CAID Services That Require Prior Auth List 10-01-2018.Xlsx

Effective: 9/13/2018 Revised: 10/01/2018

Medicaid Services that require Prior Authorization List

HAP must be notified when the member is admitted for all inpatient hospitalizations, even if you have obtained a prior authorization for the procedure to be performed.

• HAP members must receive care from contracted providers. • Any service listed below, when provided by a non-contracted provider, requires prior authorization from HAP.

To determine if a procedure is a covered benefit and meets criteria, providers must utilize HAP's online Member Eligibility Application (MEA) and the Benefit Administration Manual (BAM). It is imperative that you verify benefit coverage prior to rendering service, as failure to do so may result in denial of payment and Members must be held harmless.

The information contained in the Services that require Prior Authorization List is protected by copyright laws. Duplication should occur only with permission from the HAP Corporate Office.

Providers shall not modify, translate, decompile, disclose, create nor attempt to create any derivative work in the Services that require Prior Authorization List.

Treating providers are solely responsible for medical advice and treatment of Members.

HAP’s Benefit Coverage Policies and Procedure Reference Lists apply to all HAP lines of business offered through any HAP affiliate including insured and self-funded plans except for the following: These Benefit Coverage Policies and Procedure Reference Lists do not apply to lines of business offered through HAP affiliates ASR and Midwest Health Plan.

HAP continuously reviews and monitors all procedures to determine any potential changes of coverage that would affect current procedure lists. Otherwise, the Services that require Prior Authorization list will be reviewed and updated on a monthly basis. Always check the list on the HAP website, as it is the most current list and printed copies may be incomplete or outdated. If you would like to suggest additional services to be added to the Services that require Prior Authorization list, please contact us and we will take your request into consideration for the next scheduled revision. Any suggestions or questions should be directed in writing to:

Sr Project Consultant (T14 - 4th floor) EMAIL to: [email protected] Health Alliance Plan or 2850 West Grand Boulevard Detroit, MI 48202

Key: * Specific coverage criteria or limitations/restrictions apply. Refer to BAM for more information. Services that are “carved out” of the Genesys delegation. All other services that are indicated as "ExGEN" are processed by the HAP Referral Management Team. For services that require a prior authorization contact RMT directly by calling 313-664-8950 option #1 or submit the request online ExGEN via Care Affiliate. INFO Informational/reporting code - code not separately payable Submit request for authorization via CareAffiliate. Please select appropriate Request Type based on the type of service/place of service that care is RMT being provided.

Product Line Key: CAID Medicaid plan

Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING 00100 BIOPSY No MEDICAID ANESTHESIA FOR PROCEDURES INVOLVING PLASTIC REPAIR OF 00102 CLEFT LIP No MEDICAID ANESTHESIA FOR RECONSTRUCTIVE PROCEDURES OF EYELID (eg, 00103 blepharoplasty, No MEDICAID ANESTHESIA FOR 00104 ELECTROCONVULSIVE THERAPY No MEDICAID

1 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE AND INNER EAR 00120 INCLUDING No MEDICAID ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE AND INNER EAR 00124 INCLUDING No MEDICAID ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE AND INNER EAR 00126 INCLUDING No MEDICAID ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED 00140 No MEDICAID ANESTHESIA FOR PROCEDURES ON 00142 EYE; LENS SURGERY No MEDICAID ANESTHESIA FOR PROCEDURES ON 00144 EYE; CORNEAL TRANSPLANT No MEDICAID ANESTHESIA FOR PROCEDURES ON EYE, VITREORETINAL SURGERY 00145 No MEDICAID ANESTHESIA FOR PROCEDURES ON 00147 EYE; IRIDECTOMY No MEDICAID ANESTHESIA FOR PROCEDURE ON 00148 EYE; OPHTHALMOSCOPY No MEDICAID ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; not 00160 otherwise No MEDICAID ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; 00162 radical No MEDICAID ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; 00164 biopsy, soft No MEDICAID ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED (UNITS: 00170 5) No MEDICAID ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; 00172 repair of cleft palate No MEDICAID ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; 00174 EXCISION OF No MEDICAID ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; 00176 RADICAL SURGERY No MEDICAID ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; not 00190 otherwise No MEDICAID ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; radical 00192 surgery No MEDICAID ANESTHESIA FOR INTRACRANIAL PROCEDURES; not otherwise specified 00210 No MEDICAID Anesthia for intracranial procedures; craniotomy or craniectomy for evacuation 00211 of hematoma No MEDICAID Anesthesia for intracranial procedures; 00212 subdural taps No MEDICAID Anesthesia for intracranial procedures; 00214 burr holes, including No MEDICAID Anesthesia for intracranial procedures; cranioplasty or elevation of 00215 No MEDICAID Anesthesia for intracranial procedures; 00216 vascular procedures No MEDICAID Anesthesia for intracranial procedures; procedures in sitting position 00218 No MEDICAID

2 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for intracranial procedures; cerebrospinal fluid shunting 00220 No MEDICAID Anesthesia for intracranial procedures; 00222 electrocoagulation of No MEDICAID Anesthesia for all procedures on the 00300 integumentary system, muscles and No MEDICAID Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and 00320 No MEDICAID Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and 00322 No MEDICAID Anesthesia for all procedures on the 00326 larynx and trachea in children less No MEDICAID Anesthesia for procedures on major 00350 vessels of neck; not otherwise No MEDICAID Anesthesia for procedures on major 00352 vessels of neck; simple ligation No MEDICAID Anesthesia for procedures on the 00400 integumentary system on the No MEDICAID extremities, anterior trunk and perineum; reconstructive procedures on 00402 No MEDICAID extremities, anterior trunk and perineum; 00404 radical or modified radical No MEDICAID Anesthesia for procedures on the 00406 integumentary system on the No MEDICAID Anesthesia for procedures on the 00410 integumentary system on the No MEDICAID Anesthesia for procedures on clavicle and 00450 scapula; not otherwise No MEDICAID Anesthesia for procedures on clavicle and scapula; biopsy of clavicle 00454 No MEDICAID Anesthesia for partial rib resection; not 00470 otherwise specified No MEDICAID Anesthesia for partial rib resection; 00472 thoracoplasty (any type) No MEDICAID Anesthesia for partial rib resection; radical 00474 procedures (eg, pectus No MEDICAID Anesthesia for all procedures on 00500 esophagus No MEDICAID Anesthesia for closed chest procedures; (including bronchoscopy) not 00520 No MEDICAID Anesthesia for closed chest procedures; 00522 needle biopsy of pleura No MEDICAID Anesthesia for closed chest procedures; 00524 pneumocentesis No MEDICAID Anesthesia for closed chest procedures; mediastinoscopy and diagnostic 00528 No MEDICAID Anesthesia for closed chest procedures; mediastinoscopy and diagnostic 00529 No MEDICAID Anesthesia for permanent transvenous 00530 pacemaker insertion No MEDICAID Anesthesia for access to central venous 00532 circulation No MEDICAID Anesthesia for transvenous insertion or 00534 replacement of pacing No MEDICAID Anesthesia for cardiac electrophysiologic procedures including 00537 No MEDICAID Anesthesia for tracheobronchial 00539 reconstruction No MEDICAID Anesthesia for thoracotomy procedures 00540 involving lungs, pleura, No MEDICAID Anesthesia for thoracotomy procedures 00541 involving lungs, pleura, No MEDICAID

3 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for thoracotomy procedures 00542 involving lungs, pleura, No MEDICAID Anesthesia for thoracotomy procedures 00546 involving lungs, pleura, No MEDICAID Anesthesia for thoracotomy procedures 00548 involving lungs, pleura, No MEDICAID 00550 Anesthesia for sternal debridement No MEDICAID 00560 of chest; without pump oxygenator No MEDICAID Anesthesia for procedures on heart, 00561 pericardial sac, and great vessels No MEDICAID Anesthesia for procedures on heart, 00562 pericardial sac, and great vessels No MEDICAID Anesthesia for procedures on heart, 00563 pericardial sac, and great vessels No MEDICAID Anesthesia for direct coronary artery 00566 bypass grafting without pump No MEDICAID Anesthesia for direct coronary artery bypass grafting; with pump oxygenator 00567 No MEDICAID Anesthesia for heart transplant or 00580 heart/lung transplant No MEDICAID Anesthesia for procedures on cervical spine and cord; not otherwise 00600 No MEDICAID Anesthesia for procedures on cervical spine and cord; procedures with 00604 No MEDICAID Anesthesia for procedures on thoracic spine and cord; not otherwise 00620 No MEDICAID ANESTHESIA FOR PROCEDURES ON THE THORACIC SPINE AND CORD,2- 00625 LUNG No MEDICAID ANESTHESIA FOR PROCEDURES ON THE THORACIC SPINE AND CORD,1- 00626 LUNG No MEDICAID Anesthesia for procedures in lumbar 00630 region; not otherwise specified No MEDICAID Anesthesia for procedures in lumbar 00632 region; lumbar sympathectomy No MEDICAID Anesthesia for procedures in lumbar 00635 region; diagnostic or therapeutic No MEDICAID Anesthesia for manipulation of the spine 00640 or for closed procedures on the No MEDICAID Anesthesia for extensive spine and spinal 00670 cord procedures (eg, spinal No MEDICAID Anesthesia for procedures on upper 00700 anterior abdominal wall; not No MEDICAID Anesthesia for procedures on upper 00702 anterior abdominal wall; No MEDICAID Anesthesia for procedures on upper 00730 posterior abdominal wall No MEDICAID Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified termed code 00740 00731 No MEDICAID Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP) termed 00732 code 00740 No MEDICAID Anesthesia for hernia repairs in upper abdomen; not otherwise specified 00750 No MEDICAID Anesthesia for hernia repairs in upper 00752 abdomen; lumbar and ventral No MEDICAID Anesthesia for hernia repairs in upper 00754 abdomen; omphalocele No MEDICAID

4 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for hernia repairs in upper abdomen; transabdominal repair of 00756 No MEDICAID Anesthesia for all procedures on major 00770 abdominal blood vessels No MEDICAID Anesthesia for intraperitoneal procedures in upper abdomen including 00790 No MEDICAID Anesthesia for intraperitoneal procedures in upper abdomen including 00792 No MEDICAID Anesthesia for intraperitoneal procedures in upper abdomen including 00794 No MEDICAID Anesthesia for intraperitoneal procedures in upper abdomen including 00796 No MEDICAID ANESTHESIA FOR SURGERY FOR 00797 MORBID OBESITY No * MEDICAID Anesthesia for procedures on lower 00800 anterior abdominal wall; not No MEDICAID Anesthesia for procedures on lower 00802 anterior abdominal wall; No MEDICAID Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified termed code 00810 add to colonoscopy config? Could this be used in any screening scenarios? When a screening turns to a diagnostic 00811 No MEDICAID Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy termed code 00810 add to colonoscopy 00812 config No MEDICAID Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum termed code 00810 add to colonoscopy config? Could this be used in any screening scenarios? When a screening turns to a diagnostic

00813 No MEDICAID Anesthesia for procedures on lower 00820 posterior abdominal wall No MEDICAID Anesthesia for hernia repairs in lower abdomen; not otherwise specified 00830 No MEDICAID Anesthesia for hernia repairs in lower abdomen; ventral and incisional 00832 No MEDICAID Anesthesia for hernia repairs in the lower 00834 abdomen not otherwise No MEDICAID Anesthesia for hernia repairs in the lower 00836 abdomen not otherwise No MEDICAID Anesthesia for intraperitoneal procedures in lower abdomen including 00840 No MEDICAID Anesthesia for intraperitoneal procedures in lower abdomen including 00842 No MEDICAID Anesthesia for intraperitoneal procedures in lower abdomen including 00844 No MEDICAID Anesthesia for intraperitoneal procedures in lower abdomen including 00846 No MEDICAID

5 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for intraperitoneal procedures in lower abdomen including 00848 No MEDICAID Anesthesia for intraperitoneal procedures in lower abdomen including 00851 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00860 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00862 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00864 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00865 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00866 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00868 No MEDICAID Anesthesia for extraperitoneal procedures in lower abdomen, including 00870 No MEDICAID Anesthesia for lithotripsy, extracorporeal shock wave; with water bath 00872 No MEDICAID Anesthesia for lithotripsy, extracorporeal shock wave; without water 00873 No MEDICAID Anesthesia for procedures on major lower 00880 abdominal vessels; not No MEDICAID Anesthesia for procedures on major lower 00882 abdominal vessels; inferior No MEDICAID 00902 Anesthesia for; anorectal procedure No MEDICAID Anesthesia for; radical perineal procedure 00904 No MEDICAID 00906 Anesthesia for; vulvectomy No MEDICAID Anesthesia for; perineal prostatectomy 00908 No MEDICAID Anesthesia for transurethral procedures (including urethrocystoscopy); 00910 No MEDICAID Anesthesia for transurethral procedures (including urethrocystoscopy); 00912 No MEDICAID Anesthesia for transurethral procedures (including urethrocystoscopy); 00914 No MEDICAID Anesthesia for transurethral procedures (including urethrocystoscopy); 00916 No MEDICAID Anesthesia for transurethral procedures (including urethrocystoscopy); 00918 No MEDICAID Anesthesia for procedures on male 00920 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00921 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00922 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00924 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00926 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00928 genitalia (including open urethral No MEDICAID

6 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for procedures on male 00930 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00932 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00934 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00936 genitalia (including open urethral No MEDICAID Anesthesia for procedures on male 00938 genitalia (including open urethral No MEDICAID Anesthesia for vaginal procedures 00940 (including biopsy of labia, vagina, No MEDICAID Anesthesia for vaginal procedures 00942 (including biopsy of labia, vagina, No MEDICAID Anesthesia for vaginal procedures 00944 (including biopsy of labia, vagina, No MEDICAID Anesthesia for vaginal procedures 00948 (including biopsy of labia, vagina, No MEDICAID Anesthesia for vaginal procedures 00950 (including biopsy of labia, vagina, No MEDICAID Anesthesia for vaginal procedures 00952 (including biopsy of labia, vagina, No MEDICAID Anesthesia for bone marrow aspiration 01112 and/or biopsy, anterior or No MEDICAID Anesthesia for procedures on bony pelvis 01120 No MEDICAID Anesthesia for body cast application or 01130 revision No MEDICAID Anesthesia for interpelviabdominal 01140 (hindquarter) amputation No MEDICAID Anesthesia for radical procedures for 01150 tumor of pelvis, except No MEDICAID Anesthesia for closed procedures involving symphysis pubis or sacroiliac 01160 No MEDICAID Anesthesia for open procedures involving symphysis pubis or sacroiliac 01170 No MEDICAID Anesthesia for open repair of fracture 01173 disruption of pelvis or column No MEDICAID Anesthesia for all closed procedures 01200 involving hip joint No MEDICAID Anesthesia for arthroscopic procedures of 01202 hip joint No MEDICAID Anesthesia for open procedures involving 01210 hip joint; not otherwise No MEDICAID Anesthesia for open procedures involving 01212 hip joint; hip disarticulation No MEDICAID Anesthesia for open procedures involving 01214 hip joint; total hip No MEDICAID Anesthesia for open procedures involving 01215 hip joint; revision of total No MEDICAID Anesthesia for all closed procedures 01220 involving upper 2/3 of femur No MEDICAID Anesthesia for open procedures involving 01230 upper 2/3 of femur; not No MEDICAID Anesthesia for open procedures involving upper 2/3 of femur; amputation 01232 No MEDICAID Anesthesia for open procedures involving 01234 upper 2/3 of femur; radical No MEDICAID Anesthesia for all procedures on nerves, muscles, tendons, fascia, and 01250 No MEDICAID Anesthesia for all procedures involving 01260 veins of upper leg, including No MEDICAID Anesthesia for procedures involving 01270 arteries of upper leg, including No MEDICAID Anesthesia for procedures involving 01272 arteries of upper leg, including No MEDICAID

7 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for procedures involving 01274 arteries of upper leg, including No MEDICAID Anesthesia for all procedures on nerves, muscles, tendons, fascia, and 01320 No MEDICAID Anesthesia for all closed procedures on 01340 lower 1/3 of femur No MEDICAID Anesthesia for all open procedures on 01360 lower 1/3 of femur No MEDICAID Anesthesia for all closed procedures on 01380 knee joint No MEDICAID Anesthesia for diagnostic arthroscopic 01382 procedures of knee joint No MEDICAID Anesthesia for all closed procedures on 01390 upper ends of tibia, fibula, No MEDICAID Anesthesia for all open procedures on 01392 upper ends of tibia, fibula, No MEDICAID Anesthesia for open or surgical arthroscopic procedures on knee joint; 01400 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on knee joint; 01402 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on knee joint; 01404 No MEDICAID Anesthesia for all cast applications, 01420 removal, or repair involving knee No MEDICAID Anesthesia for procedures on veins of 01430 knee and popliteal area; not No MEDICAID Anesthesia for procedures on veins of 01432 knee and popliteal area; No MEDICAID Anesthesia for procedures on arteries of knee and popliteal area; not 01440 No MEDICAID Anesthesia for procedures on arteries of 01442 knee and popliteal area; No MEDICAID Anesthesia for procedures on arteries of 01444 knee and popliteal area; No MEDICAID Anesthesia for all closed procedures on 01462 lower leg, ankle, and foot No MEDICAID Anesthesia for arthroscopic procedures of 01464 ankle and/or foot No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, and fascia of 01470 No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, and fascia of 01472 No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, and fascia of 01474 No MEDICAID Anesthesia for open procedures on bones 01480 of lower leg, ankle, and foot; No MEDICAID Anesthesia for open procedures on bones 01482 of lower leg, ankle, and foot; No MEDICAID Anesthesia for open procedures on bones 01484 of lower leg, ankle, and foot; No MEDICAID Anesthesia for open procedures on bones 01486 of lower leg, ankle, and foot; No MEDICAID Anesthesia for lower leg cast application, 01490 removal, or repair No MEDICAID Anesthesia for procedures on arteries of lower leg, including bypass 01500 No MEDICAID Anesthesia for procedures on arteries of lower leg, including bypass 01502 No MEDICAID Anesthesia for procedures on veins of 01520 lower leg; not otherwise specified No MEDICAID

8 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for procedures on veins of 01522 lower leg; venous thrombectomy, No MEDICAID Anesthesia for all procedures on nerves, muscles, tendons, fascia, and 01610 No MEDICAID Anesthesia for all closed procedures on 01620 humeral head and neck, No MEDICAID Anesthesia for diagnostic arthroscopic procedures of shoulder joint 01622 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on humeral head 01630 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on humeral head 01634 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on humeral head 01636 No MEDICAID Anesthesia for open or surgical arthroscopic procedures on humeral head 01638 No MEDICAID Anesthesia for procedures on arteries of 01650 shoulder and axilla; not No MEDICAID Anesthesia for procedures on arteries of 01652 shoulder and axilla; No MEDICAID Anesthesia for procedures on arteries of shoulder and axilla; bypass 01654 No MEDICAID Anesthesia for procedures on arteries of 01656 shoulder and axilla; No MEDICAID Anesthesia for all procedures on veins of 01670 shoulder and axilla No MEDICAID Anesthesia for shoulder cast application, 01680 removal or repair; not No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, fascia, and 01710 No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, fascia, and 01712 No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, fascia, and 01714 No MEDICAID Anesthesia for procedures on nerves, muscles, tendons, fascia, and 01716 No MEDICAID Anesthesia for all closed procedures on 01730 humerus and elbow No MEDICAID Anesthesia for diagnostic arthroscopic procedures of elbow joint 01732 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01740 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01742 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01744 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01756 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01758 No MEDICAID Anesthesia for open or surgical arthroscopic procedures of the elbow; 01760 No MEDICAID

9 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for procedures on arteries of 01770 upper arm and elbow; not No MEDICAID Anesthesia for procedures on arteries of 01772 upper arm and elbow; No MEDICAID Anesthesia for procedures on veins of 01780 upper arm and elbow; not No MEDICAID Anesthesia for procedures on veins of 01782 upper arm and elbow; No MEDICAID Anesthesia for all procedures on nerves, muscles, tendons, fascia, and 01810 No MEDICAID Anesthesia for all closed procedures on 01820 radius, ulna, wrist, or hand No MEDICAID Anesthesia for diagnostic arthroscopic 01829 procedures on the wrist No MEDICAID Anesthesia for open or surgical arthroscopic/endoscopic procedures on 01830 No MEDICAID Anesthesia for open or surgical arthroscopic/endoscopic procedures on 01832 No MEDICAID Anesthesia for procedures on arteries of forearm, wrist, and hand; not 01840 No MEDICAID Anesthesia for procedures on arteries of 01842 forearm, wrist, and hand; No MEDICAID Anesthesia for vascular shunt, or shunt 01844 revision, any type (eg, No MEDICAID Anesthesia for procedures on veins of 01850 forearm, wrist, and hand; not No MEDICAID Anesthesia for procedures on veins of 01852 forearm, wrist, and hand; No MEDICAID Anesthesia for forearm, wrist, or hand 01860 cast application, removal, or No MEDICAID Anesthesia for diagnostic 01916 arteriography/venography No MEDICAID Anesthesia for cardiac catheterization 01920 including coronary angiography No MEDICAID Anesthesia for non-invasive imaging or 01922 radiation therapy No MEDICAID Anesthesia for therapeutic interventional 01924 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01925 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01926 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01930 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01931 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01932 radiologic procedures No MEDICAID Anesthesia for therapeutic interventional 01933 radiologic procedures No MEDICAID ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; 01935 DIAGNOSTIC No MEDICAID ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON THE SPINE AND SPINAL CORD; 01936 THERAPEUTIC No MEDICAID Anesthesia for second and third degree burn excision or debridement with 01951 No MEDICAID Anesthesia for second and third degree burn excision or debridement with 01952 No MEDICAID Anesthesia for second and third degree burn excision or debridement with 01953 No MEDICAID

10 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anesthesia for external cephalic version 01958 procedure No MEDICAID 01960 Anesthesia for vaginal delivery only No MEDICAID 01961 Anesthesia for cesarean delivery only No MEDICAID Anesthesia for urgent hysterectomy 01962 following delivery No MEDICAID Anesthesia for cesarean hysterectomy 01963 without any labor No MEDICAID ANESTHESIA FOR INCOMPLETE OR 01965 MISSED ABORTION PROCEDURES No MEDICAID ANESTHESIA FOR INDUCED 01966 ABORTION PROCEDURES No MEDICAID Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this 01967 No MEDICAID Anesthesia for cesarean delivery following 01968 neuraxial labor No MEDICAID Anesthesia for cesarean hysterectomy following neuraxial labor 01969 No MEDICAID PHYSIOLOGICAL SUPPORT FOR 01990 HARVESTING OF ORGAN(S) FROM No BRAIN- DEAD PATIENT (UNITS: 7) MEDICAID Anesthesia for diagnostic or therapeutic nerve blocks and injections 01991 Yes MEDICAID Anesthesia for diagnostic or therapeutic nerve blocks and injections 01992 Yes MEDICAID Daily hospital management of epidural or subarachnoid continuous drug 01996 No MEDICAID 01999 Unlisted anesthesia procedure(s) Yes MEDICAID FINE NEEDLE ASPIRATION, WITHOUT 10021 IMAGING GUIDANCE No MEDICAID Fine needle aspiration; with imaging 10022 guidance No MEDICAID 10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous No MEDICAID Placement of soft tissue localization device(s) (e.g.. Clip, metallic pellet, wire/ needle, radioactive seeds), percutaneous, including 10035 imaging guidance; first lesion No MEDICAID Placement of soft tissue localization device(s) (e.g.. Clip, metallic pellet, wire/ needle, radioactive seeds), percutaneous, including imaging guidance; Each additional lesion (List separately in addition to code for primary procedure) 10036 No MEDICAID Acne surgery (eg, marsupialization, 10040 opening or removal of multiple No MEDICAID Incision and drainage of abscess (eg, 10060 carbuncle, suppurative No MEDICAID Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, 10061 No MEDICAID Incision and drainage of pilonidal cyst; 10080 simple No MEDICAID Incision and drainage of pilonidal cyst; 10081 complicated No MEDICAID Incision and removal of foreign body, 10120 subcutaneous tissues; simple No MEDICAID Incision and removal of foreign body, 10121 subcutaneous tissues; complicated No MEDICAID Incision and drainage of hematoma, 10140 seroma or fluid collection No MEDICAID Puncture aspiration of abscess, 10160 hematoma, bulla, or cyst No MEDICAID

11 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Incision and drainage, complex, 10180 postoperative wound infection No MEDICAID Debridement of extensive eczematous or infected skin; up to 10% of 11000 No MEDICAID Debridement of extensive eczematous or infected skin; each additional 11001 No MEDICAID Debridement of skin, subcutaneous 11004 tissue, muscle and fascia for No MEDICAID Debridement of skin, subcutaneous 11005 tissue, muscle and fascia for No MEDICAID Debridement of skin, subcutaneous 11006 tissue, muscle and fascia for n No MEDICAID Removal of prosthetic material or mesh, 11008 abdominal wall for necrotizing No MEDICAID Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous 11010 tissues No MEDICAID Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle 11011 No MEDICAID Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone 11012 No MEDICAID Debridement, subcutaneous tissue (includes epidermis and dermis, if 11042 performed); first 20 sq cm or less No MEDICAID Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 11043 20 sq cm or less No MEDICAID Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm 11044 or less No MEDICAID 11045 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) No MEDICAID 11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) No MEDICAID 11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) No MEDICAID Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 11055 No * MEDICAID Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 11056 No * MEDICAID

12 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 11057 No * MEDICAID Biopsy of skin, subcutaneous tissue 11100 and/or mucous membrane (including No MEDICAID Biopsy of skin, subcutaneous tissue 11101 and/or mucous membrane (including No MEDICAID Removal of skin tags, multiple 11200 fibrocutaneous tags, any area; up to and Yes MEDICAID Removal of skin tags, multiple 11201 Yes fibrocutaneous tags, any area; each MEDICAID Shaving of epidermal or dermal lesion, 11300 Yes single lesion, trunk, arms or MEDICAID Shaving of epidermal or dermal lesion, 11301 Yes single lesion, trunk, arms or MEDICAID Shaving of epidermal or dermal lesion, 11302 Yes single lesion, trunk, arms or MEDICAID Shaving of epidermal or dermal lesion, 11303 Yes single lesion, trunk, arms or MEDICAID Shaving of epidermal or dermal lesion, 11305 Yes single lesion, scalp, neck, MEDICAID Shaving of epidermal or dermal lesion, 11306 Yes single lesion, scalp, neck, MEDICAID Shaving of epidermal or dermal lesion, 11307 Yes single lesion, scalp, neck, MEDICAID Shaving of epidermal or dermal lesion, 11308 Yes single lesion, scalp, neck, MEDICAID Shaving of epidermal or dermal lesion, 11310 Yes single lesion, face, ears, MEDICAID Shaving of epidermal or dermal lesion, 11311 Yes single lesion, face, ears, MEDICAID Shaving of epidermal or dermal lesion, 11312 single lesion, face, ears,eyelids, Yes MEDICAID Shaving of epidermal or dermal lesion, 11313 Yes single lesion, face, ears, MEDICAID Excision, benign lesion including margins, 11400 except skin tag (unless listed Yes MEDICAID Excision, benign lesion including margins, 11401 except skin tag (unless listed Yes MEDICAID Excision, benign lesion including margins, 11402 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11403 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11404 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11406 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11420 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11421 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11422 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11423 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11424 Yes except skin tag (unless MEDICAID Excision, benign lesion including margins, 11426 Yes except skin tag (unless MEDICAID Excision, other benign lesion including 11440 margins (unless listed elsewhere), Yes MEDICAID Excision, other benign lesion including 11441 Yes margins (unless listed MEDICAID Excision, other benign lesion including 11442 Yes margins (unless listed MEDICAID

13 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision, other benign lesion including 11443 margins (unless listed elsewhere), Yes MEDICAID EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, 11444 EARS, EYELIDS, NOSE, LIPS, MUCOUS Yes MEMBRANE; EXCISED DIAMETER 3.1 T MEDICAID EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, 11446 EARS, EYELIDS, NOSE, LIPS, MUCOUS Yes MEMBRANE; EXCISED DIAMETER OVER MEDICAID Excision of skin and subcutaneous tissue 11450 Yes for hidradenitis, axillary; MEDICAID Excision of skin and subcutaneous tissue 11451 Yes for hidradenitis, axillary; MEDICAID Excision of skin and subcutaneous tissue 11462 Yes for hidradenitis, inguinal; MEDICAID Excision of skin and subcutaneous tissue 11463 Yes for hidradenitis, inguinal; MEDICAID Excision of skin and subcutaneous tissue 11470 Yes for hidradenitis, perianal, MEDICAID Excision of skin and subcutaneous tissue 11471 Yes for hidradenitis, perianal, MEDICAID Excision, malignant lesion including 11600 margins, trunk, arms, or legs; No MEDICAID Excision, malignant lesion including 11601 margins, trunk, arms, or legs; No MEDICAID EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; EXCISED 11602 DIAMETER 1.1 TO 2.0 CM No MEDICAID EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; EXCISED 11603 DIAMETER 2.1 TO 3.0 CM No MEDICAID EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; EXCISED 11604 DIAMETER 3.1 TO 4.0 CM No MEDICAID EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; EXCISED 11606 DIAMETER OVER 4.0 CM No MEDICAID Excision, malignant lesion including 11620 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11621 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11622 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11623 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11624 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11626 margins, scalp, neck, hands, feet, No MEDICAID Excision, malignant lesion including 11640 margins, face, ears, eyelids, nose, No MEDICAID Excision, malignant lesion including 11641 margins, face, ears, eyelids, nose, No MEDICAID Excision, malignant lesion including 11642 margins, face, ears, eyelids, nose, No MEDICAID Excision, malignant lesion including 11643 margins, face, ears, eyelids, nose, No MEDICAID Excision, malignant lesion including 11644 margins, face, ears, eyelids, nose, No MEDICAID Excision, malignant lesion including 11646 margins, face, ears, eyelids, nose, No MEDICAID Trimming of nondystrophic nails, any 11719 number No * MEDICAID Debridement of nail(s) by any method(s); 11720 one to five No * MEDICAID Debridement of nail(s) by any method(s); 11721 six or more No * MEDICAID

14 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Avulsion of nail plate, partial or complete, 11730 simple; single No MEDICAID Avulsion of nail plate, partial or complete, 11732 simple; each additional No MEDICAID 11740 Evacuation of subungual hematoma No MEDICAID Excision of nail and nail matrix, partial or 11750 complete, (eg, ingrown or No MEDICAID Biopsy of nail unit (eg, plate, bed, matrix, 11755 hyponychium, proximal and No MEDICAID 11760 Repair of nail bed No MEDICAID 11762 Reconstruction of nail bed with graft No MEDICAID Wedge excision of skin of nail fold (eg, for 11765 ingrown toenail) No MEDICAID EXCISION OF PILONIDAL CYST OR 11770 SINUS; SIMPLE No MEDICAID Excision of pilonidal cyst or sinus; 11771 extensive No MEDICAID Excision of pilonidal cyst or sinus; 11772 complicated No MEDICAID Injection, intralesional; up to and including 11900 seven lesions No MEDICAID Injection, intralesional; more than seven 11901 lesions No MEDICAID TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT 11920 COLOR DEFECTS OF SKIN, Yes INCLUDING MICROPIGMENTATION; 6. MEDICAID TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT 11921 COLOR DEFECTS OF SKIN, Yes INCLUDING MICROPIGMENTATION; 6. MEDICAID TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT 11922 COLOR DEFECTS OF SKIN, Yes INCLUDING MICROPIGMENTATION; EA MEDICAID SUBCUTANEOUS INJECTION OF "FILLING" MATERIAL (EG, COLLAGEN); 11950 1 CC OR LESS Yes MEDICAID SUBCUTANEOUS INJECTION OF "FILLING" MATERIAL (EG, COLLAGEN); 11951 1.1 TO 5.0 CC Yes MEDICAID SUBCUTANEOUS INJECTION OF "FILLING" MATERIAL (EG, COLLAGEN); 11952 5.1 TO 10.0 CC Yes MEDICAID SUBCUTANEOUS INJECTION OF "FILLING" MATERIAL (EG, COLLAGEN); 11954 OVER 10.0 CC Yes MEDICAID INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, 11960 Yes INCLUDING SUBSEQUENT EXPANSION MEDICAID Replacement of tissue expander with 11970 Yes permanent prosthesis MEDICAID Removal of tissue expander(s) without 11971 Yes insertion of prosthesis MEDICAID Removal, implantable contraceptive 11976 capsules No MEDICAID Subcutaneous hormone pellet implantation (implantation of estradiol 11980 No MEDICAID Insertion, non-biodegradable drug delivery 11981 implant No MEDICAID Removal, non-biodegradable drug 11982 delivery implant No MEDICAID

15 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Removal with reinsertion, non- 11983 biodegradable drug delivery implant No MEDICAID Simple repair of superficial wounds of 12001 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12002 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12004 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12005 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12006 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12007 scalp, neck, axillae, external No MEDICAID Simple repair of superficial wounds of 12011 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12013 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12014 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12015 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12016 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12017 face, ears, eyelids, nose, lips No MEDICAID Simple repair of superficial wounds of 12018 face, ears, eyelids, nose, lips No MEDICAID Treatment of superficial wound 12020 dehiscence; simple closure No MEDICAID Treatment of superficial wound 12021 dehiscence; with packing No MEDICAID Layer closure of wounds of scalp, axillae, 12031 trunk and/or extremities No MEDICAID Layer closure of wounds of scalp, axillae, 12032 trunk and/or extremities No MEDICAID Layer closure of wounds of scalp, axillae, 12034 trunk and/or extremities No MEDICAID Layer closure of wounds of scalp, axillae, 12035 trunk and/or extremities No MEDICAID Layer closure of wounds of scalp, axillae, 12036 trunk and/or extremities No MEDICAID Layer closure of wounds of scalp, axillae, 12037 trunk and/or extremities No MEDICAID Layer closure of wounds of neck, hands, 12041 feet and/or external genitalia; No MEDICAID Layer closure of wounds of neck, hands, 12042 feet and/or external genitalia; No MEDICAID Layer closure of wounds of neck, hands, 12044 feet and/or external genitalia; No MEDICAID Layer closure of wounds of neck, hands, 12045 feet and/or external genitalia; No MEDICAID Layer closure of wounds of neck, hands, 12046 feet and/or external genitalia; No MEDICAID Layer closure of wounds of neck, hands, 12047 feet and/or external genitalia; No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12051 No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12052 No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12053 No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12054 No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12055 No MEDICAID

16 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12056 No MEDICAID Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous 12057 No MEDICAID Repair, complex, trunk; 1.1 cm to 2.5 cm 13100 No MEDICAID Repair, complex, trunk; 2.6 cm to 7.5 cm 13101 No MEDICAID Repair, complex, trunk; each additional 5 cm or less (List separately in 13102 No MEDICAID Repair, complex, scalp, arms, and/or legs; 13120 1.1 cm to 2.5 cm No MEDICAID Repair, complex, scalp, arms, and/or legs; 13121 2.6 cm to 7.5 cm No MEDICAID Repair, complex, scalp, arms, and/or legs; 13122 each additional 5 cm or less No MEDICAID Repair, complex, forehead, cheeks, chin, 13131 mouth, neck, axillae, No MEDICAID Repair, complex, forehead, cheeks, chin, 13132 mouth, neck, axillae, No MEDICAID Repair, complex, forehead, cheeks, chin, 13133 mouth, neck, axillae, No MEDICAID REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM 13151 No MEDICAID REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM 13152 No MEDICAID REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH 13153 ADDITIONAL 5 CM No MEDICAID Secondary closure of surgical wound or 13160 dehiscence, extensive or No MEDICAID Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or 14000 No MEDICAID Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 14001 No MEDICAID Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; 14020 No MEDICAID Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; 14021 No MEDICAID ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR 14040 FEET; DEFECT 10 S No MEDICAID ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR 14041 FEET; DEFECT 10.1 No MEDICAID ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ 14060 CM OR LESS No MEDICAID ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ 14061 CM TO 30.0 SQ CM No MEDICAID ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; 14301 DEFECT 30.1 TO 60.0 SQ CM No MEDICAID

17 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EA ADDL 30.0 SQ CM OR PART THEREOF 14302 (ADD-ON TO 14301) No MEDICAID Filleted finger or toe flap, including 14350 preparation of recipient site No MEDICAID SURG PREP OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS/BURN ESCHAR/SCAR, TRUNK/EXTREMITIES, FIRST 100 SQ CM OR 1% PED 15002 No MEDICAID SURG PREP/CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS/BURN ESCHAR/SCAR, TRUNK/EXTREMITIES, EA ADDL 100 SQ CM OR 1% PED 15003 No MEDICAID SURG PREP/CREATION OF RECIPIENT SITE BY EXCISION OPEN WOUNDS, BURN ESCHAR, SCAR, HEAD AREA, EXTREMITIES, GENITALIA, 1ST 100 SQ 15004 CM No MEDICAID SURG PREP/CREATION OF RECIPIENT SITE BY EXCISION OPEN WOUNDS, BURN ESCHAR, SCAR, HEAD AREA, EXTREMITIES, GENITALIA, 1ST 100 SQ 15005 CM No MEDICAID HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ 15040 CM OR LESS No MEDICAID Pinch graft, single or multiple, to cover 15050 small ulcer, tip of digit, or No MEDICAID SPLIT THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15100 15050) No MEDICAID SPLIT GRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND 15101 CHILDREN, OR No MEDICAID EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LES, OR ONE PERCENT OF BODY 15110 AREA OF INFANTS AND CHILDREN No MEDICAID EDPDERMAL AUTOGRAFT, TRUNK, ARMS LEGS; EACH ADDITONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF 15111 INFANTS AND CHILDR No MEDICAID EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; 1ST 15115 100 SQ CM No MEDICAID EPIDERMAL AUTOGRAFT FACE,SCALP, EYELIDS, MOUTH NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EA 15116 ADDL 100 SQ No MEDICAID SPLIT THICKNESS AUTOGRAFT FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FT AND/OR MTLP DIGITS; 1ST 15120 100 SQ CM No MEDICAID

18 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 15121 100 S No MEDICAID DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1 % OF BODY AREA OF INFANTS & 15130 CHILDREN No MEDICAID DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EA ADDL 100 SQ CN OR EA ADDL 1% OF BODY AREA OF INFANTS & CHILDREN, OR PART THEREOF 15131 (LIST SEP No MEDICAID DERMAL AUTOGRAFT FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HAND, FEET, AND/OR MTLP DIGITS; 1ST 100 SQ CM 15135 OR LESS No MEDICAID DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MLTP DIGITS; EA ADDL 100 15136 SQ CM O No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUCK, ARMS, LEGS; 15150 FIRST 25 SQ CM OR LESS No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT TRUNK, ARMS LEGS; ADDL 1 SQ CM TO 75 CM (LIST SEPARATELY IN ADDITION TO CODE 15151 FOR PRIMARY PROC No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT TRUNK, ARMS, LEGS; EA ADDL 100 SQ CM, OR EA ADDL 1% OF BODY AREA OF INFANTS & 15152 CHILDREN, OR PA No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR 15155 MULTIPLE DIGI No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK., EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR 15156 MULTIPLE DIGI No MEDICAID TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITX, GENITALIA, HANDS, FEET AND/OR 15157 MLTP DIGITS; E No MEDICAID Full thickness graft, free, including direct 15200 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15201 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15220 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15221 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15240 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15241 closure of donor site, No MEDICAID Full thickness graft, free, including direct 15260 closure of donor site, nose, No MEDICAID Full thickness graft, free, including direct 15261 closure of donor site, No MEDICAID

19 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or 15271 less wound surface area No MEDICAID Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 15272 No MEDICAID Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children 15273 No MEDICAID Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

15274 No MEDICAID Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 15275 surface area No MEDICAID Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 15276 No MEDICAID Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children 15277 No MEDICAID Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

15278 No MEDICAID Formation of direct or tubed pedicle, with 15570 or without transfer; trunk No MEDICAID Formation of direct or tubed pedicle, with 15572 or without transfer; No MEDICAID Formation of direct or tubed pedicle, with 15574 or without transfer; No MEDICAID Formation of direct or tubed pedicle, with 15576 or without transfer; No MEDICAID

20 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Delay of flap or sectioning of flap (division 15600 and inset); at trunk No MEDICAID Delay of flap or sectioning of flap (division 15610 and inset); at scalp, No MEDICAID Delay of flap or sectioning of flap (division 15620 and inset); at forehead, No MEDICAID Delay of flap or sectioning of flap (division 15630 and inset); at eyelids, No MEDICAID Transfer, intermediate, of any pedicle flap 15650 (eg, abdomen to wrist, No MEDICAID Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) 15730 No MEDICAID FOREHEAD FLAP WITH PRESERVATION OF VASCULAR 15731 PEDICLE No MEDICAID Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) termed code 15732 15733 No MEDICAID Muscle, myocutaneous, or 15734 fasciocutaneous flap; trunk No MEDICAID Muscle, myocutaneous, or 15736 fasciocutaneous flap; upper extremity No MEDICAID Muscle, myocutaneous, or 15738 fasciocutaneous flap; lower extremity No MEDICAID 15740 Flap; island pedicle No MEDICAID 15750 Flap; neurovascular pedicle No MEDICAID Free muscle or myocutaneous flap with 15756 microvascular anastomosis No MEDICAID Free skin flap with microvascular 15757 anastomosis No MEDICAID Free fascial flap with microvascular 15758 anastomosis No MEDICAID Graft; composite (eg, full thickness of 15760 external ear or nasal ala), No MEDICAID 15770 Graft; derma-fat-fascia No MEDICAID PUNCH GRAFT FOR HAIR 15775 TRANSPLANT; 1 TO 15 PUNCH Yes GRAFTS MEDICAID PUNCH GRAFT FOR HAIR 15776 TRANSPLANT; MORE THAN 15 PUNCH Yes GRAFTS MEDICAID Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue 15777 reinforcement (eg, breast, trunk) (List Yes separately in addition to code for primary procedure) MEDICAID DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL 15780 KERATOSIS) Yes MEDICAID DERMABRASION; SEGMENTAL, FACE 15781 Yes MEDICAID DERMABRASION; REGIONAL, OTHER 15782 THAN FACE Yes MEDICAID DERMABRASION; SUPERFICIAL, ANY 15783 SITE, (EG, TATTOO REMOVAL) Not Covered MEDICAID ABRASION; SINGLE LESION (EG, 15786 Yes KERATOSIS, SCAR) MEDICAID ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY 15787 Yes IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MEDICAID CHEMICAL PEEL, FACIAL; EPIDERMAL 15788 Yes MEDICAID 15789 CHEMICAL PEEL, FACIAL; DERMAL Yes MEDICAID

21 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CHEMICAL PEEL, NONFACIAL; 15792 EPIDERMAL Yes MEDICAID CHEMICAL PEEL, NONFACIAL; 15793 DERMAL Yes MEDICAID 15819 CERVICOPLASTY Yes MEDICAID BLEPHAROPLASTY, LOWER EYELID; 15820 Yes MEDICAID BLEPHAROPLASTY, LOWER EYELID; 15821 WITH EXTENSIVE HERNIATED FAT Yes PAD MEDICAID BLEPHAROPLASTY, UPPER EYELID; 15822 Yes MEDICAID BLEPHAROPLASTY, UPPER EYELID; 15823 WITH EXCESSIVE SKIN WEIGHTING Yes DOWN LID MEDICAID 15824 RHYTIDECTOMY; FOREHEAD Yes MEDICAID RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING 15825 (PLATYSMAL FLAP, "P-FLAP") Yes MEDICAID RHYTIDECTOMY; GLABELLAR FROWN 15826 Yes LINES MEDICAID RHYTIDECTOMY; CHEEK, CHIN, AND 15828 NECK Yes MEDICAID RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM 15829 (SMAS) FLAP Yes MEDICAID EXCISION, EXCESSIVE SKIN & SUBCUT TISS (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY 15830 Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15832 LIPECTOMY); THIGH Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15833 LIPECTOMY); LEG Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15834 LIPECTOMY); HIP Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); BUTTOCK 15835 Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15836 LIPECTOMY); ARM Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); FOREARM OR HAND 15837 Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); SUBMENTAL FAT PAD 15838 Yes MEDICAID EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); OTHER AREA 15839 Yes MEDICAID Graft for facial nerve paralysis; free fascia 15840 graft (including obtaining No MEDICAID Graft for facial nerve paralysis; free 15841 muscle graft (including obtaining No MEDICAID Graft for facial nerve paralysis; free 15842 muscle flap by microsurgical No MEDICAID Graft for facial nerve paralysis; regional 15845 muscle transfer No MEDICAID

22 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EXCISION, EXCESSIVE SKIN & SUBCUTANEOUS TISSUE (INCL LIPECTOMY), ABDOMEN 15847 (ABDOMINOPLASTY) (INCL UMBILICAL Yes TRANSPORTATION & FASCIAL MEDICAID Removal of sutures under anesthesia (other than local), same surgeon 15850 No MEDICAID Removal of sutures under anesthesia (other than local), other surgeon 15851 No MEDICAID Dressing change (for other than burns) 15852 under anesthesia (other than No MEDICAID Intravenous injection of agent (eg, 15860 fluorescein) to test vascular flow No MEDICAID SUCTION ASSISTED LIPECTOMY; 15876 Yes HEAD AND NECK MEDICAID SUCTION ASSISTED LIPECTOMY; 15877 TRUNK Not Covered MEDICAID SUCTION ASSISTED LIPECTOMY; 15878 UPPER EXTREMITY Not Covered MEDICAID SUCTION ASSISTED LIPECTOMY; 15879 LOWER EXTREMITY Not Covered MEDICAID Excision, coccygeal pressure ulcer, with 15920 coccygectomy; with primary No MEDICAID Excision, coccygeal pressure ulcer, with 15922 coccygectomy; with flap closure No MEDICAID Excision, sacral pressure ulcer, with 15931 primary suture; No MEDICAID Excision, sacral pressure ulcer, with 15933 primary suture; with ostectomy No MEDICAID Excision, sacral pressure ulcer, with skin 15934 flap closure; No MEDICAID Excision, sacral pressure ulcer, with skin 15935 flap closure; with ostectomy No MEDICAID Excision, sacral pressure ulcer, in 15936 preparation for muscle or No MEDICAID Excision, sacral pressure ulcer, in 15937 preparation for muscle or No MEDICAID Excision, ischial pressure ulcer, with 15940 primary suture; No MEDICAID Excision, ischial pressure ulcer, with 15941 primary suture; with ostectomy No MEDICAID Excision, ischial pressure ulcer, with skin 15944 flap closure; No MEDICAID Excision, ischial pressure ulcer, with skin 15945 flap closure; with ostectomy No MEDICAID Excision, ischial pressure ulcer, with 15946 ostectomy, in preparation for No MEDICAID Excision, trochanteric pressure ulcer, with 15950 primary suture; No MEDICAID Excision, trochanteric pressure ulcer, with 15951 primary suture; with No MEDICAID Excision, trochanteric pressure ulcer, with 15952 skin flap closure; No MEDICAID Excision, trochanteric pressure ulcer, with 15953 skin flap closure; with No MEDICAID Excision, trochanteric pressure ulcer, in 15956 preparation for muscle or No MEDICAID Excision, trochanteric pressure ulcer, in 15958 preparation for muscle or No MEDICAID UNLISTED PROCEDURE, EXCISION 15999 PRESSURE ULCER Yes MEDICAID Initial treatment, first degree burn, when 16000 no more than local treatment No MEDICAID Dressings and/or debridement, initial or 16020 subsequent; without anesthesia, No MEDICAID Dressings and/or debridement, initial or 16025 subsequent; without anesthesia, No MEDICAID

23 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Dressings and/or debridement, initial or 16030 subsequent; without anesthesia, No MEDICAID 16035 Escharotomy; initial incision No MEDICAID Escharotomy; each additional incision 16036 (List separately in addition to No MEDICAID Destruction (eg, laser surgery, 17000 electrosurgery, cryosurgery, No MEDICAID Destruction (eg, laser surgery, 17003 electrosurgery, cryosurgery, No MEDICAID Destruction (eg, laser surgery, 17004 electrosurgery, cryosurgery, No MEDICAID DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS THAN 17106 10 SQ CM No MEDICAID DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); 10.0 - 50.0 17107 SQ CM No MEDICAID DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); OVER 50.0 17108 SQ CM No MEDICAID Destruction (eg, laser surgery, 17110 electrosurgery, cryosurgery, No MEDICAID Destruction (eg, laser surgery, 17111 electrosurgery, cryosurgery, No MEDICAID Chemical cauterization of granulation 17250 tissue (proud flesh, sinus or No MEDICAID Destruction, malignant lesion (eg, laser 17260 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17261 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17262 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17263 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17264 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17266 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17270 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17271 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17272 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17273 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17274 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17276 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17280 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17281 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17282 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17283 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17284 surgery, electrosurgery, No MEDICAID Destruction, malignant lesion (eg, laser 17286 surgery, electrosurgery, No MEDICAID 17311 MOHS GROSS TUMOR PROC, < 5 No MEDICAID 17312 MOHS GROSS TUMOR RMVL, STG 2 No MEDICAID 17313 MOHS GROSS TUMOR RMVL, < 5 No MEDICAID 17314 MOHS GROSS TUMOR RMVL, < 5 No MEDICAID 17315 MOHS GROSS TUMOR RMVL, ADDL No MEDICAID

24 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CRYOTHERAPY (CO2 SLUSH, LIQUID 17340 Yes N2) FOR ACNE MEDICAID CHEMICAL EXFOLIATION FOR ACNE 17360 Yes (EG, ACNE PASTE, ACID) MEDICAID ELECTROLYSIS EPILATION, EACH 1/2 17380 Yes HOUR MEDICAID UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND 17999 SUBCUTANEOUS TISSUE Yes MEDICAID 19000 Puncture aspiration of cyst of breast; No MEDICAID Puncture aspiration of cyst of breast; each 19001 additional cyst (List No MEDICAID Mastotomy with exploration or drainage of 19020 abscess, deep No MEDICAID Injection procedure only for mammary 19030 ductogram or galactogram No MEDICAID 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance No MEDICAID 19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) No MEDICAID 19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance No MEDICAID 19084 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) No MEDICAID 19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance No MEDICAID 19086 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure) No MEDICAID Biopsy of breast; percutaneous, needle core, not using imaging guidance 19100 No MEDICAID 19101 Biopsy of breast; open, incisional No MEDICAID

25 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ABLATION, CRYOSURGICAL, OF FIBROADEMONA, INCLUDING 19105 No ULTRASOUND GUIDANCE, EACH FIBROADENOMA MEDICAID Nipple exploration, with or without 19110 excision of a solitary lactiferous No MEDICAID 19112 Excision of lactiferous duct fistula No MEDICAID Excision of cyst, fibroadenoma, or other 19120 benign or malignant tumor, No MEDICAID Excision of breast lesion identified by 19125 preoperative placement of No MEDICAID Excision of breast lesion identified by 19126 preoperative placement of No MEDICAID Excision of chest wall tumor including ribs 19260 No MEDICAID Excision of chest wall tumor involving ribs, 19271 with plastic No MEDICAID Excision of chest wall tumor involving ribs, 19272 with plastic No MEDICAID 19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance No MEDICAID 19282 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure) No MEDICAID 19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance No MEDICAID 19284 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) No MEDICAID 19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance No MEDICAID 19286 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) No MEDICAID 19287 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance No MEDICAID 19288 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

No MEDICAID

26 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure) 19294 No MEDICAID Placement of radiotherapy afterloading balloon catheter into the breast 19296 No MEDICAID Placement of radiotherapy afterloading balloon catheter into the breast 19297 No MEDICAID Placement of radiotherapy afterloading brachytherapy catheters (multiple 19298 No MEDICAID 19300 MASTECTOMY FOR GYNECOMASTIA Yes MEDICAID 19301 MASTECTOMY, PARTIAL No MEDICAID MASTECTOMY, PARTIAL; WITH 19302 AXILLARY LYMPHADENECTOMY No MEDICAID 19303 MASTECTOMY, SIMPLE; COMPLETE No MEDICAID 19304 MASTECTOMY, SUBCUTANEOUS No MEDICAID MASTECTOMY, RADICAL, AXILLARY 19305 LYMPH NODES No MEDICAID MASTECTOMY, RADICAL, AXILLARY AND INTERNAL MAMMARY LYMPH 19306 NODES No MEDICAID 19307 MASTECTOMY, MODIFIED RADICAL No MEDICAID 19316 MASTOPEXY Yes MEDICAID 19318 REDUCTION MAMMAPLASTY Yes MEDICAID MAMMAPLASTY, AUGMENTATION; 19324 WITHOUT PROSTHETIC IMPLANT Yes MEDICAID MAMMAPLASTY, AUGMENTATION; 19325 WITH PROSTHETIC IMPLANT Yes MEDICAID REMOVAL OF INTACT MAMMARY 19328 IMPLANT Yes MEDICAID REMOVAL OF MAMMARY IMPLANT 19330 Yes MATERIAL MEDICAID Immediate insertion of breast prosthesis 19340 Yes following mastopexy, MEDICAID DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING 19342 Yes MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION MEDICAID NIPPLE/AREOLA RECONSTRUCTION 19350 Yes MEDICAID 19355 Correction of inverted nipples Yes MEDICAID Breast reconstruction, immediate or 19357 Yes delayed, with tissue MEDICAID Breast reconstruction with latissimus dorsi 19361 Yes flap, with or without MEDICAID BREAST RECONSTRUCTION WITH 19364 Yes FREE FLAP MEDICAID BREAST RECONSTRUCTION WITH 19366 Yes OTHER TECHNIQUE MEDICAID Breast reconstruction with transverse 19367 Yes rectus abdominis MEDICAID BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 19368 MYOCUTANEOUS FLAP (TRAM), Yes SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; MEDICAID Breast reconstruction with transverse 19369 Yes rectus abdominis MEDICAID Open periprosthetic capsulotomy, breast 19370 Yes MEDICAID PERIPROSTHETIC CAPSULECTOMY, 19371 Yes BREAST MEDICAID REVISION OF RECONSTRUCTED 19380 Yes BREAST MEDICAID

27 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PREPARATION OF MOULAGE FOR 19396 CUSTOM BREAST IMPLANT Yes MEDICAID 19499 UNLISTED PROCEDURE, BREAST Yes MEDICAID Incision and drainage of soft tissue abscess, subfascial (ie, involves the soft 20005 tissue below the deep fascia) No MEDICAID Exploration of penetrating wound 20100 (separate procedure); neck No MEDICAID Exploration of penetrating wound 20101 (separate procedure); chest No MEDICAID Exploration of penetrating wound 20102 (separate procedure); No MEDICAID Exploration of penetrating wound 20103 (separate procedure); extremity No MEDICAID Excision of epiphyseal bar, with or without 20150 autogenous soft tissue graft No MEDICAID 20200 Biopsy, muscle; superficial No MEDICAID 20205 Biopsy, muscle; deep No MEDICAID Biopsy, muscle, percutaneous needle 20206 No MEDICAID Biopsy, bone, trocar, or needle; superficial 20220 (eg, ilium, sternum, No MEDICAID Biopsy, bone, trocar, or needle; deep (eg, 20225 vertebral body, femur) No MEDICAID Biopsy, bone, open; superficial (eg, ilium, 20240 sternum, spinous process, No MEDICAID Biopsy, bone, open; deep (eg, humerus, 20245 ischium, femur) No MEDICAID 20250 Biopsy, vertebral body, open; thoracic No MEDICAID Biopsy, vertebral body, open; lumbar or 20251 cervical No MEDICAID Injection of sinus tract; therapeutic 20500 (separate procedure) No MEDICAID Injection of sinus tract; diagnostic 20501 (sinogram) No MEDICAID Removal of foreign body in muscle or 20520 tendon sheath; simple No MEDICAID Removal of foreign body in muscle or 20525 tendon sheath; deep or complicated No MEDICAID Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel 20526 No MEDICAID Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's 20527 contracture) No MEDICAID Injection(s); single tendon sheath, or 20550 ligament, aponeurosis (eg, No MEDICAID Injection(s); single tendon origin/insertion 20551 No MEDICAID Injection(s); single or multiple trigger 20552 point(s), one or two muscle(s) No MEDICAID Injection(s); single or multiple trigger 20553 point(s), three or more No MEDICAID PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR SOFT TISSUE FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION (AT THE TIME OF OR SUBSEQUENT TO THE PROCEDURE) 20555 No MEDICAID Arthrocentesis, aspiration and/or injection; 20600 small joint or bursa (eg, No MEDICAID Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting 20604 No MEDICAID Arthrocentesis, aspiration and/or injection; 20605 intermediate joint or bursa No * MEDICAID

28 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20606 No MEDICAID Arthrocentesis, aspiration and/or injection; 20610 major joint or bursa (eg, No MEDICAID Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting 20611 No MEDICAID Aspiration and/or injection of ganglion 20612 cyst(s) any location No MEDICAID Aspiration and injection for treatment of 20615 bone cyst No MEDICAID Insertion of wire or pin with application of 20650 skeletal traction, No MEDICAID Application of cranial tongs, caliper, or 20660 stereotactic frame, including No MEDICAID Application of halo, including removal; 20661 cranial No MEDICAID Application of halo, including removal; 20662 pelvic No MEDICAID Application of halo, including removal; 20663 femoral No MEDICAID Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta) 20664 No MEDICAID Removal of tongs or halo applied by 20665 another physician No MEDICAID Removal of implant; superficial, (eg, 20670 buried wire, pin or rod) (separate No MEDICAID Removal of implant; deep (eg, buried 20680 wire, pin, screw, metal band, nail, No MEDICAID Application of a uniplane (pins or wires in 20690 one plane), unilateral, No MEDICAID Application of a multiplane (pins or wires 20692 in more than one plane), No MEDICAID Adjustment or revision of external fixation 20693 system requiring anesthesia No MEDICAID Removal, under anesthesia, of external 20694 fixation system No MEDICAID Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer- assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment[s], assessment[s], and computation[s] o 20696 No MEDICAID Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer- assisted adjustment (eg, spatial frame), including imaging; exchange (ie, removal and replacement ) of strut, each

20697 No MEDICAID Replantation, arm (includes surgical neck 20802 of humerus through No MEDICAID Replantation, forearm (includes radius 20805 and ulna to radial carpal No MEDICAID Replantation, hand (includes hand 20808 through metacarpophalangeal No MEDICAID

29 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Replantation, digit, excluding thumb 20816 (includes No MEDICAID Replantation, digit, excluding thumb 20822 (includes distal tip to sublimis No MEDICAID Replantation, thumb (includes 20824 carpometacarpal joint to MP joint), No MEDICAID Replantation, thumb (includes distal tip to 20827 MP joint), complete No MEDICAID Replantation, foot, complete amputation 20838 No MEDICAID Bone graft, any donor area; minor or small 20900 (eg, dowel or button) No MEDICAID Bone graft, any donor area; major or large 20902 No MEDICAID 20910 Cartilage graft; costochondral No MEDICAID 20912 Cartilage graft; nasal septum No MEDICAID 20920 Fascia lata graft; by stripper No MEDICAID Fascia lata graft; by incision and area 20922 exposure, complex or sheet No MEDICAID Tendon graft, from a distance (eg, 20924 palmaris, toe extensor, plantaris) No MEDICAID Tissue grafts, other (eg, paratenon, fat, 20926 dermis) No MEDICAID Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 20930 No MEDICAID Allograft, structural, for spine surgery only (List separately in addition to code for 20931 primary procedure) No MEDICAID Autograft for spine surgery only (includes 20936 harvesting the graft); local No MEDICAID Autograft for spine surgery only (includes 20937 harvesting the graft); No MEDICAID Autograft for spine surgery only (includes 20938 harvesting the graft); No MEDICAID Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) 20939 No MEDICAID Monitoring of interstitial fluid pressure (includes insertion of device, 20950 No MEDICAID Bone graft with microvascular 20955 anastomosis; fibula No MEDICAID BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; ILIAC CREST 20956 No MEDICAID Bone graft with microvascular 20957 anastomosis; metatarsal No MEDICAID Bone graft with microvascular 20962 anastomosis; other than fibula, iliac No MEDICAID Free osteocutaneous flap with 20969 microvascular anastomosis; other No MEDICAID Free osteocutaneous flap with 20970 microvascular anastomosis; iliac No MEDICAID Free osteocutaneous flap with 20972 microvascular anastomosis; No MEDICAID Free osteocutaneous flap with 20973 microvascular anastomosis; great No MEDICAID Electrical stimulation to aid bone healing; 20974 noninvasive (nonoperative) No MEDICAID Electrical stimulation to aid bone healing; 20975 invasive (operative) No MEDICAID Low intensity ultrasound stimulation to aid 20979 bone healing, noninvasive No MEDICAID

30 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ABLATION, BONE TUMOR(S), EG (OSTEOID, OSTEOMA, METATASTIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE 20982 No MEDICAID Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation 20983 No MEDICAID COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES; 20985 IMAGE-LESS (LIST SEPARATELY IN No ADDITION TO CODE FOR PRIMARY PROCEDURE) MEDICAID UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, 20999 GENERAL Yes MEDICAID ARTHROTOMY, 21010 Yes TEMPOROMANDIBULAR JOINT MEDICAID EXCISION, TUMOR, SOFT TISSUE OF 21011 FACE OR SCALP, SUBCUTANEOUS; Yes LESS THAN 2 CM MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 21012 Yes CM OR GREATER MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); LESS THAN 2 CM 21013 No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER 21014 No MEDICAID Radical resection of tumor (eg, malignant 21015 neoplasm), soft tissue of No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FACE OR SCALP; 2 CM OR 21016 GREATER No MEDICAID Excision of bone (eg, for osteomyelitis or bone abscess); mandible 21025 No MEDICAID Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) 21026 No MEDICAID Removal by contouring of benign tumor of 21029 facial bone (eg, fibrous No MEDICAID Excision of benign tumor or cyst of maxilla 21030 or zygoma by enucleation and No MEDICAID EXCISION OF TORUS MANDIBULARIS 21031 No MEDICAID EXCISION OF MAXILLARY TORUS 21032 No PALATINUS MEDICAID Excision of malignant tumor of maxilla or 21034 zygoma No MEDICAID Excision of benign tumor or cyst of 21040 mandible, by enucleation and/or No MEDICAID Excision of malignant tumor of mandible; 21044 No MEDICAID Excision of malignant tumor of mandible; 21045 radical resection No MEDICAID

31 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTEOTOMY(EG, 21046 LOCALLY AGGRESSIVE OR No MEDICAID REQUIRING EXTRA-ORAL OSTETOMY AND PARTIAL MANDIBULECTOMY(EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESIONS 21047 No MEDICAID EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA- ORAL OSTEOTOMY(EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE 21048 LESION(S) No MEDICAID REQUIRING EXTRA-ORAL OSTEOTOMY AND PARTIAL MAXILLECTOMY (EG, LOCALLY AND 21049 DESTRUCTIVE LESION(S) No MEDICAID CONDYLECTOMY, TEMPOROMANDIBULAR JOINT 21050 (SEPARATE PROCEDURE) Yes MEDICAID MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 21060 Yes MEDICAID CORONOIDECTOMY (SEPARATE 21070 PROCEDURE) No MEDICAID MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE) 21073 Yes MEDICAID IMPRESSION AND CUSTOM PREPARATION; SURGICAL 21076 OBTURATOR PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; ORBITAL 21077 PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; INTERIM OBTURATOR 21079 PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; DEFINITIVE 21080 OBTURATOR PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; MANDIBULAR 21081 RESECTION PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; PALATAL 21082 AUGMENTATION PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; PALATAL LIFT 21083 PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; SPEECH AID 21084 PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; ORAL SURGICAL 21085 SPLINT No MEDICAID IMPRESSION AND CUSTOM PREPARATION; AURICULAR 21086 PROSTHESIS No MEDICAID IMPRESSION AND CUSTOM PREPARATION; NASAL PROSTHESIS 21087 No MEDICAID IMPRESSION AND CUSTOM 21088 PREPARATION; FACIAL PROSTHESIS Yes MEDICAID UNLISTED MAXILLOFACIAL 21089 PROSTHETIC PROCEDURE Yes MEDICAID

32 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL FIXATION, INCLUDES REMOVAL 21100 (SEPARATE PROCEDURE) No MEDICAID APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL 21110 Yes MEDICAID INJECTION PROCEDURE FOR 21116 TEMPOROMANDIBULAR JOINT Yes ARTHROGRAPHY MEDICAID GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, 21120 PROSTHETIC MATERIAL) Yes MEDICAID GENIOPLASTY; SLIDING OSTEOTOMY, 21121 SINGLE PIECE Yes MEDICAID GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL 21122 CHIN) Yes MEDICAID GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21123 Yes MEDICAID AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 21125 Yes MEDICAID AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) 21127 Yes MEDICAID REDUCTION FOREHEAD; 21137 CONTOURING ONLY Yes MEDICAID REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING 21138 AUTOGRAFT) Yes MEDICAID REDUCTION FOREHEAD; CONTOURING AND SETBACK OF 21139 ANTERIOR FRONTAL SINUS WALL Yes MEDICAID RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, 21141 FOR LONG FACE SYNDROME), Yes WITHOUT BONE GRAFT MEDICAID RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT 21142 Yes MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT MEDICAID RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, 21143 SEGMENT MOVEMENT IN ANY Yes DIRECTION, WITHOUT BONE GRAFT MEDICAID RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, 21145 REQUIRING BONE GRAFTS Yes (INCLUDES OBTAINING AUTOG MEDICAID

33 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS 21146 (INCLUDES OBTAINING AUTOGRA Yes MEDICAID RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE 21147 GRAFTS (INCLUDES OBTAINI Yes MEDICAID RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, 21150 Yes TREACHER-COLLINS SYNDROME) MEDICAID RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, 21151 REQUIRING BONE GRAFTS Yes (INCLUDES OBTAINING AUTOGRAFTS) MEDICAID RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY 21154 TYPE, REQUIRING BONE GRAFTS Yes (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT MEDICAID RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY 21155 TYPE, REQUIRING BONE GRAFTS Yes (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I MEDICAID RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), 21159 REQUIRING BONE GRAFTS (INCL Yes MEDICAID RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), 21160 REQUIRING BONE GRAFTS (INCL Yes MEDICAID RECONSTRUCTION SUPERIOR- LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT 21172 GRAFTS (INCLUDES OBTAIN Yes MEDICAID RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION (EG, 21175 PLAGIOCEPHALY, TRIGONO Yes MEDICAID RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH GRAFTS (ALLOGRAFT OR PROSTHETIC 21179 MATERIAL) Yes MEDICAID RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH AUTOGRAFT (INCLUDES OBTAINING 21180 GRAFTS) Yes MEDICAID RECONSTRUCTION BY CONTOURING OF BENIGN TUMOR OF CRANIAL BONES (EG, FIBROUS DYSPLASIA), 21181 EXTRACRANIAL Yes MEDICAID RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN 21182 TUMOR OF Yes MEDICAID

34 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN 21183 TUMOR OF Yes MEDICAID RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN 21184 TUMOR OF Yes MEDICAID RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21188 Yes MEDICAID RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; WITHOUT BONE 21193 GRAFT Yes MEDICAID RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", 21194 OR "L" OSTEOTOMY; WITH BONE Yes GRAFT (INCLUDES OBTAINING GRAFT) MEDICAID RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; 21195 Yes WITHOUT INTERNAL RIGID FIXATION MEDICAID RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; 21196 Yes WITH INTERNAL RIGID FIXATION MEDICAID OSTEOTOMY, MANDIBLE, 21198 SEGMENTAL Yes MEDICAID OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS 21199 ADVANCEMENT Yes MEDICAID OSTEOTOMY, MAXILLA, SEGMENTAL 21206 (EG, WASSMUND OR SCHUCHARD) Yes MEDICAID OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC 21208 IMPLANT) Yes MEDICAID OSTEOPLASTY, FACIAL BONES; 21209 REDUCTION Yes MEDICAID GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING 21210 GRAFT) Yes MEDICAID GRAFT, BONE; MANDIBLE (INCLUDES 21215 OBTAINING GRAFT) Yes MEDICAID GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAINING 21230 GRAFT) Yes MEDICAID GRAFT; EAR CARTILAGE, 21235 AUTOGENOUS, TO NOSE OR EAR Yes (INCLUDES OBTAINING GRAFT) MEDICAID ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH 21240 Yes OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT) MEDICAID ARTHROPLASTY, 21242 TEMPOROMANDIBULAR JOINT, WITH Yes ALLOGRAFT MEDICAID ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH 21243 Yes PROSTHETIC JOINT REPLACEMENT MEDICAID

35 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL 21244 Yes BONE PLATE (EG, MANDIBULAR STAPLE BONE PLATE) MEDICAID RECONSTRUCTION OF MANDIBLE OR 21245 MAXILLA, SUBPERIOSTEAL IMPLANT; Yes PARTIAL MEDICAID RECONSTRUCTION OF MANDIBLE OR 21246 MAXILLA, SUBPERIOSTEAL IMPLANT; Yes COMPLETE MEDICAID RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL MICROSOMIA 21247 Yes MEDICAID RECONSTRUCTION OF MANDIBLE OR 21248 MAXILLA, ENDOSTEAL IMPLANT (EG, Yes BLADE, CYLINDER); PARTIAL MEDICAID RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, 21249 Yes BLADE, CYLINDER); COMPLETE MEDICAID RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE (INCLUDES 21255 OBTAINING AUTOGRAFTS) Yes MEDICAID RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND WITH BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, MICRO- OPHTHALMI 21256 Yes MEDICAID PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; EXTRACRANIAL 21260 APPROACH Yes MEDICAID PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; COMBINED INTRA- 21261 AND EXTRACRANIAL APPROACH Yes MEDICAID PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; WITH FOREHEAD 21263 ADVANCEMENT Yes MEDICAID ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, WITH BONE GRAFTS; 21267 EXTRACRANIAL APPROACH Yes MEDICAID ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, WITH BONE GRAFTS; COMBINED INTRA- AND 21268 EXTRACRANIAL APPROACH Yes MEDICAID MALAR AUGMENTATION, 21270 Yes PROSTHETIC MATERIAL MEDICAID Secondary revision of orbitocraniofacial 21275 Yes reconstruction MEDICAID MEDIAL CANTHOPEXY (SEPARATE 21280 Yes PROCEDURE) MEDICAID 21282 LATERAL CANTHOPEXY Yes MEDICAID Reduction of masseter muscle and bone 21295 Yes (eg, for treatment of benign MEDICAID Reduction of masseter muscle and bone 21296 Yes (eg, for treatment of benign MEDICAID UNLISTED CRANIOFACIAL AND 21299 MAXILLOFACIAL PROCEDURE Yes MEDICAID Closed treatment of nasal bone fracture 21310 without manipulation No MEDICAID Closed treatment of nasal bone fracture; 21315 without stabilization No MEDICAID

36 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of nasal bone fracture; 21320 with stabilization No MEDICAID Open treatment of nasal fracture; 21325 uncomplicated No MEDICAID Open treatment of nasal fracture; 21330 complicated, with internal and/or No MEDICAID Open treatment of nasal fracture; with 21335 concomitant open treatment of No MEDICAID Open treatment of nasal septal fracture, 21336 with or without stabilization No MEDICAID Closed treatment of nasal septal fracture, 21337 with or without stabilization No MEDICAID Open treatment of nasoethmoid fracture; 21338 without external fixation No MEDICAID Open treatment of nasoethmoid fracture; 21339 with external fixation No MEDICAID Percutaneous treatment of nasoethmoid complex fracture, with splint, 21340 No MEDICAID Open treatment of depressed frontal sinus 21343 fracture No MEDICAID Open treatment of complicated (eg, 21344 comminuted or involving No MEDICAID CLOSED TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE), WITH INTERDENTAL WIRE FIXATION OR 21345 FIXATION OF DENTURE OR SPLI No MEDICAID OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH 21346 WIRING AND/OR LOCAL FIXATION No MEDICAID OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); REQUIRING MULTIPLE OPEN 21347 APPROACHES No MEDICAID OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH BONE GRAFTING (INCLUDES 21348 OBTAINING GRAFT) No MEDICAID Percutaneous treatment of fracture of 21355 malar area, including zygomatic No MEDICAID Open treatment of depressed zygomatic 21356 arch fracture (eg, Gillies No MEDICAID Open treatment of depressed malar 21360 fracture, including zygomatic No MEDICAID Open treatment of complicated (eg, 21365 comminuted or involving No MEDICAID Open treatment of complicated (eg, 21366 comminuted or involving No MEDICAID Open treatment of orbital floor blowout 21385 fracture; transantral No MEDICAID Open treatment of orbital floor blowout 21386 fracture; periorbital No MEDICAID Open treatment of orbital floor blowout 21387 fracture; combined No MEDICAID Open treatment of orbital floor blowout 21390 fracture; periorbital No MEDICAID Open treatment of orbital floor blowout 21395 fracture; periorbital No MEDICAID Closed treatment of fracture of orbit, 21400 except blowout; without No MEDICAID Closed treatment of fracture of orbit, 21401 except blowout; with manipulation No MEDICAID Open treatment of fracture of orbit, except 21406 blowout; without No MEDICAID Open treatment of fracture of orbit, except 21407 blowout; with implant No MEDICAID

37 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open treatment of fracture of orbit, except 21408 blowout; with bone No MEDICAID Closed treatment of palatal or maxillary 21421 fracture (LeFort I type), with No MEDICAID Open treatment of palatal or maxillary 21422 fracture (LeFort I type); No MEDICAID Open treatment of palatal or maxillary 21423 fracture (LeFort I type); No MEDICAID CLOSED TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) USING INTERDENTAL WIRE FIXATION OF 21431 DENTURE OR SPLINT No MEDICAID OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); WITH WIRING AND/OR INTERNAL FIXATION 21432 No MEDICAID OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE 21433 FORAMINA), MUL No MEDICAID OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, UTILIZING INTERNAL AND/OR EXTERNAL FIXATION TECHNIQUES ( 21435 No MEDICAID OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE SURGICAL APPROACHES, INTERNAL FIXATION, WITH BO 21436 No MEDICAID Closed treatment of mandibular or 21440 maxillary alveolar ridge fracture No MEDICAID Open treatment of mandibular or maxillary 21445 alveolar ridge fracture No MEDICAID Closed treatment of mandibular fracture; 21450 without manipulation No MEDICAID Closed treatment of mandibular fracture; 21451 with manipulation No MEDICAID Percutaneous treatment of mandibular fracture, with external fixation 21452 No MEDICAID Closed treatment of mandibular fracture 21453 with interdental fixation No MEDICAID Open treatment of mandibular fracture 21454 with external fixation No MEDICAID Open treatment of mandibular fracture; 21461 without interdental No MEDICAID Open treatment of mandibular fracture; 21462 with interdental fixation No MEDICAID Open treatment of mandibular condylar 21465 fracture No MEDICAID Open treatment of complicated 21470 mandibular fracture by multiple No MEDICAID Closed treatment of temporomandibular dislocation; initial or subsequent 21480 No MEDICAID Closed treatment of temporomandibular dislocation; complicated (eg, 21485 No MEDICAID Open treatment of temporomandibular 21490 dislocation No MEDICAID INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 21497 Not Covered MEDICAID UNLISTED MUSCULOSKELETAL 21499 PROCEDURE, HEAD Yes MEDICAID

38 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Incision and drainage, deep abscess or 21501 hematoma, soft tissues of neck No MEDICAID Incision and drainage, deep abscess or 21502 hematoma, soft tissues of neck No MEDICAID Incision, deep, with opening of bone 21510 cortex (eg, for osteomyelitis or No MEDICAID 21550 Biopsy, soft tissue of neck or thorax No MEDICAID EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; SUBCUTANEOUS; 21552 Yes 3 CM OR GREATER MEDICAID EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; DEEP, SUBFASCIAL, INTRAMUSCULAR; 5 CM 21554 OR GREATER No MEDICAID Excision tumor, soft tissue of neck or 21555 Yes thorax; subcutaneous MEDICAID Excision tumor, soft tissue of neck or 21556 thorax; deep, subfascial, No MEDICAID Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck ot thorax 21557 No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF NECK OR THORAX; 5 CM 21558 OR GREATER No MEDICAID 21600 Excision of rib, partial No MEDICAID Costotransversectomy (separate 21610 procedure) No MEDICAID 21615 Excision first and/or cervical rib; No MEDICAID Excision first and/or cervical rib; with 21616 sympathectomy No MEDICAID 21620 Ostectomy of sternum, partial No MEDICAID 21627 Sternal debridement No MEDICAID 21630 Radical resection of sternum; No MEDICAID Radical resection of sternum; with 21632 mediastinal lymphadenectomy No MEDICAID HYOID MYOTOMY AND SUSPENSION 21685 No MEDICAID Division of scalenus anticus; without 21700 resection of cervical rib No MEDICAID Division of scalenus anticus; with 21705 resection of cervical rib No MEDICAID Division of sternocleidomastoid for 21720 torticollis, open operation; without No MEDICAID Division of sternocleidomastoid for 21725 torticollis, open operation; with No MEDICAID Reconstructive repair of pectus 21740 excavatum or carinatum; open Yes MEDICAID MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT 21742 THORACOSCOPY Yes MEDICAID MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH 21743 THORACOSCOPY Yes MEDICAID Closure of median sternotomy separation 21750 with or without No MEDICAID Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1- 21811 3 ribs No MEDICAID Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4- 21812 6 ribs No MEDICAID Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 21813 or more ribs No MEDICAID 21820 Closed treatment of sternum fracture No MEDICAID

39 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open treatment of sternum fracture with 21825 or without skeletal No MEDICAID UNLISTED PROCEDURE, NECK OR 21899 THORAX Yes MEDICAID Biopsy, soft tissue of back or flank; 21920 Yes superficial MEDICAID Biopsy, soft tissue of back or flank; deep 21925 Yes MEDICAID Excision, tumor, soft tissue of back or 21930 Yes flank MEDICAID EXCISION, TUMOR, SOFT TISSUE OF 21931 BACK OR FLANK; 3 CM OR GREATER Yes MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK; LESS 21932 THAN 5 CM No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK; 5 CM OR 21933 GREATER No MEDICAID Radical resection of tumor (eg, malignant 21935 neoplasm), soft tissue of No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK; 5 CM OR 21936 GREATER No MEDICAID 22010 I&d, p-spine, c/t/cerv-thor No MEDICAID 22015 I&d, p-spine, l/s/ls No MEDICAID Partial excision of posterior vertebral 22100 component (eg, spinous No MEDICAID Partial excision of posterior vertebral 22101 component (eg, spinous No MEDICAID Partial excision of posterior vertebral 22102 component (eg, spinous No MEDICAID Partial excision of posterior vertebral 22103 component (eg, spinous No MEDICAID Partial excision of vertebral body, for 22110 intrinsic bony lesion, without No MEDICAID Partial excision of vertebral body, for 22112 intrinsic bony lesion, without No MEDICAID Partial excision of vertebral body, for 22114 intrinsic bony lesion, without No MEDICAID Partial excision of vertebral body, for 22116 intrinsic bony lesion, without No MEDICAID OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONEVERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); THORACIC 22206 No MEDICAID OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONEVERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR 22207 No MEDICAID OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONEVERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 22208 No MEDICAID Osteotomy of spine, posterior or 22210 posterolateral approach, one No MEDICAID Osteotomy of spine, posterior or 22212 posterolateral approach, one No MEDICAID

40 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Osteotomy of spine, posterior or 22214 posterolateral approach, one No MEDICAID Osteotomy of spine, posterior or 22216 posterolateral approach, one No MEDICAID Osteotomy of spine, including diskectomy, 22220 anterior approach, No MEDICAID Osteotomy of spine, including diskectomy, 22222 anterior approach, No MEDICAID Osteotomy of spine, including diskectomy, 22224 anterior approach, No MEDICAID Osteotomy of spine, including diskectomy, 22226 anterior approach, No MEDICAID Closed treatment of vertebral body 22310 fracture(s), without manipulation, No MEDICAID Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction 22315 No MEDICAID Open treatment and/or reduction of 22318 odontoid fracture(s) and or No MEDICAID Open treatment and/or reduction of 22319 odontoid fracture(s) and or No MEDICAID Open treatment and/or reduction of 22325 vertebral fracture(s) and/or No MEDICAID Open treatment and/or reduction of 22326 vertebral fracture(s) and/or No MEDICAID Open treatment and/or reduction of 22327 vertebral fracture(s) and/or No MEDICAID Open treatment and/or reduction of 22328 vertebral fracture(s) and/or No MEDICAID Manipulation of spine requiring 22505 No anesthesia, any region MEDICAID Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; 22510 cervicothoracic No MEDICAID Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; 22511 lumbosacral No MEDICAID Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

22512 No MEDICAID Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

22513 No MEDICAID Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

22514 No MEDICAID

41 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

22515 No MEDICAID PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL 22526 INCLUDING FLUROSCOPIC No GUIDANCE; SINGLE LEVEL MEDICAID PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL 22527 INCLUDING FLUROSCOPIC No GUIDANCE; 1 OR MORE ADD'L LVLS MEDICAID ARTHRODESIS, LATERAL EXTRACAVITY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN 22532 FOR DECOMPRESSION); THO No MEDICAID Arthrodesis, anterior interbody technique, 22556 including minimal No MEDICAID Arthrodesis, anterior interbody technique, 22558 including minimal No MEDICAID 22585 Additional spinal fusion No MEDICAID Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior 22586 instrumentation, with image guidance, No includes bone graft when performed, L5- S1 interspace MEDICAID Arthrodesis, posterior technique, 22590 craniocervical (occiput-C2) No MEDICAID Arthrodesis, posterior technique, atlas- 22595 axis (C1-C2) No MEDICAID Arthrodesis, posterior or posterolateral 22600 technique, single level; No MEDICAID Arthrodesis, posterior or posterolateral 22610 technique, single level; No MEDICAID Arthrodesis, posterior or posterolateral 22612 technique, single level; No MEDICAID Arthrodesis, posterior or posterolateral 22614 technique, single level; No MEDICAID Arthrodesis, posterior interbody 22630 technique, including laminectomy No MEDICAID Arthrodesis, posterior interbody 22632 technique, including laminectomy No MEDICAID Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar 22633 No MEDICAID

42 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22634 No MEDICAID Arthrodesis, posterior, for spinal 22800 deformity, with or without cast; up No MEDICAID Arthrodesis, posterior, for spinal 22802 deformity, with or without cast; 7 No MEDICAID Arthrodesis, posterior, for spinal 22804 deformity, with or without cast; 13 No MEDICAID Arthrodesis, anterior, for spinal deformity, 22808 with or without cast; 2 to No MEDICAID Arthrodesis, anterior, for spinal deformity, 22810 with or without cast; 4 to No MEDICAID Arthrodesis, anterior, for spinal deformity, 22812 with or without cast; 8 or No MEDICAID Kyphectomy, circumferential exposure of 22818 spine and resection of No MEDICAID Kyphectomy, circumferential exposure of 22819 spine and resection of No MEDICAID 22830 Exploration of spinal fusion No MEDICAID Posterior non-segmental instrumentation (eg, Harrington rod technique, 22840 No MEDICAID Internal spinal fixation by wiring of spinous 22841 processes No MEDICAID Posterior segmental instrumentation (eg, 22842 pedicle fixation, dual No MEDICAID Posterior segmental instrumentation (eg, 22843 pedicle fixation, dual No MEDICAID Posterior segmental instrumentation (eg, 22844 pedicle fixation, dual No MEDICAID Anterior instrumentation; 2 to 3 vertebral 22845 segments No MEDICAID Anterior instrumentation; 4 to 7 vertebral 22846 segments No MEDICAID Anterior instrumentation; 8 or more 22847 vertebral segments No MEDICAID Pelvic fixation (attachment of caudal end 22848 of instrumentation to No MEDICAID 22849 Reinsertion of spinal fixation device No MEDICAID Removal of posterior nonsegmental 22850 instrumentation (eg, No MEDICAID Removal of posterior segmental 22852 instrumentation No MEDICAID Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)

22853 No MEDICAID

43 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

22854 No MEDICAID 22855 Removal of anterior instrumentation No MEDICAID Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical

22856 No MEDICAID TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCL DISCECTOMY TO PREPARE INTERSPACE, LUMBAR, 22857 SINGLE INTERSPACE No MEDICAID Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

22858 No MEDICAID Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

22859 No MEDICAID Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical 22861 No MEDICAID REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTERIOR APPROACH, LUMBAR, SINGLE 22862 No MEDICAID Removal of total disc arthroplasty (artificial disc), anterior approach, single 22864 interspace; cervical No MEDICAID REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, LUMBAR, 22865 SINGLE INTERSPACE No MEDICAID Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level 22867 No MEDICAID

44 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) 22868 No MEDICAID Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when 22869 performed, lumbar; single level No MEDICAID Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary 22870 procedure) No MEDICAID 22899 UNLISTED PROCEDURE, SPINE Yes MEDICAID Excision, abdominal wall tumor, subfascial 22900 (eg, desmoid) No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); GREATER THAN 5 22901 CM No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF 22902 ABDOMINAL WALL, SUBCUTANEOUS; Yes LESS THAN 3 CM MEDICAID EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 22903 Yes GREATER THAN 3 CM MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF ABDOMINAL WALL, LESS 22904 THAN 5 CM No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF ABDOMINAL WALL, 22905 GREATER THAN 5 CM No MEDICAID UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM 22999 Yes MEDICAID Removal of subdeltoid calcareous 23000 deposits, open No MEDICAID Capsular contracture release (eg, Sever 23020 type procedure) No MEDICAID Incision and drainage, shoulder area; 23030 deep abscess or hematoma No MEDICAID Incision and drainage, shoulder area; 23031 infected bursa No MEDICAID Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area 23035 No MEDICAID Arthrotomy, glenohumeral joint, including 23040 exploration, drainage, or No MEDICAID Arthrotomy, acromioclavicular, 23044 sternoclavicular joint, including No MEDICAID Biopsy, soft tissue of shoulder area; 23065 Yes superficial MEDICAID Biopsy, soft tissue of shoulder area; deep 23066 No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 23071 Yes GREATER THAN 3 CM MEDICAID

45 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); GREATER THAN 5 23073 CM No MEDICAID Excision, soft tissue tumor, shoulder area; 23075 Yes subcutaneous MEDICAID Excision, soft tissue tumor, shoulder area; 23076 deep, subfascial, or No MEDICAID Radical resection of tumor (eg, malignant 23077 neoplasm), soft tissue of No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF SHOULDER AREA; 23078 GREATER THAN 5 CM No MEDICAID Arthrotomy, glenohumeral joint, including 23100 biopsy No MEDICAID Arthrotomy, acromioclavicular joint or 23101 sternoclavicular joint, including No MEDICAID Arthrotomy; glenohumeral joint, with 23105 synovectomy, with or without biopsy No MEDICAID Arthrotomy; sternoclavicular joint, with 23106 synovectomy, with or without No MEDICAID Arthrotomy, glenohumeral joint, with joint 23107 exploration, with or without No MEDICAID 23120 Claviculectomy; partial No MEDICAID 23125 Claviculectomy; total No MEDICAID Acromioplasty or acromionectomy, partial, with or without coracoacromial 23130 No MEDICAID Excision or curettage of bone cyst or 23140 benign tumor of clavicle or No MEDICAID Excision or curettage of bone cyst or 23145 benign tumor of clavicle or No MEDICAID Excision or curettage of bone cyst or 23146 benign tumor of clavicle or No MEDICAID Excision or curettage of bone cyst or 23150 benign tumor of proximal humerus; No MEDICAID Excision or curettage of bone cyst or 23155 benign tumor of proximal humerus; No MEDICAID Excision or curettage of bone cyst or 23156 benign tumor of proximal humerus; No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle 23170 No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula 23172 No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head 23174 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 23180 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 23182 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 23184 No MEDICAID Ostectomy of scapula, partial (eg, 23190 superior medial angle) No MEDICAID 23195 Resection, humeral head No MEDICAID 23200 Radical resection for tumor; clavicle No MEDICAID 23210 Radical resection for tumor; scapula No MEDICAID Radical resection of bone tumor, proximal 23220 humerus; No MEDICAID Removal of foreign body, shoulder; 23330 subcutaneous No MEDICAID 23333 Removal of foreign body, shoulder; deep (subfascial or intramuscular) No MEDICAID

46 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 23334 Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component No MEDICAID 23335 Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder) No MEDICAID Injection procedure for shoulder 23350 arthrography or enhanced CT/MRI No MEDICAID Muscle transfer, any type, shoulder or 23395 upper arm; single No MEDICAID Muscle transfer, any type, shoulder or 23397 upper arm; multiple No MEDICAID Scapulopexy (eg, Sprengels deformity or 23400 for paralysis) No MEDICAID Tenotomy, shoulder area; single tendon 23405 No MEDICAID Tenotomy, shoulder area; multiple 23406 tendons through same incision No MEDICAID Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute 23410 No MEDICAID Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 23412 No MEDICAID Coracoacromial ligament release, with or 23415 without acromioplasty No MEDICAID Reconstruction of complete shoulder 23420 (rotator) cuff avulsion, chronic No MEDICAID 23430 Tenodesis of long tendon of biceps No MEDICAID Resection or transplantation of long 23440 tendon of biceps No MEDICAID Capsulorrhaphy, anterior; Putti-Platt 23450 procedure or Magnuson type No MEDICAID Capsulorrhaphy, anterior; with labral 23455 repair (eg, Bankart procedure) No MEDICAID Capsulorrhaphy, anterior, any type; with 23460 bone block No MEDICAID Capsulorrhaphy, anterior, any type; with 23462 coracoid process transfer No MEDICAID Capsulorrhaphy, glenohumeral joint, 23465 posterior, with or without bone No MEDICAID Capsulorrhaphy, glenohumeral joint, any 23466 type multi-directional No MEDICAID Arthroplasty, glenohumeral joint; 23470 hemiarthroplasty No MEDICAID Arthroplasty, glenohumeral joint; total 23472 shoulder (glenoid and No MEDICAID Revision of total shoulder arthroplasty, including allograft when performed; 23473 humeral or glenoid component No MEDICAID Revision of total shoulder arthroplasty, including allograft when performed; 23474 humeral and glenoid component No MEDICAID Osteotomy, clavicle, with or without 23480 internal fixation; No MEDICAID Osteotomy, clavicle, with or without 23485 internal fixation; with bone graft No MEDICAID Prophylactic treatment (nailing, pinning, 23490 plating or wiring) with or No MEDICAID Prophylactic treatment (nailing, pinning, 23491 plating or wiring) with or No MEDICAID Closed treatment of clavicular fracture; 23500 without manipulation No MEDICAID Closed treatment of clavicular fracture; 23505 with manipulation No MEDICAID Open treatment of clavicular fracture, with 23515 or without internal or No MEDICAID

47 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of sternoclavicular 23520 dislocation; without manipulation No MEDICAID Closed treatment of sternoclavicular 23525 dislocation; with manipulation No MEDICAID Open treatment of sternoclavicular 23530 dislocation, acute or chronic; No MEDICAID Open treatment of sternoclavicular 23532 dislocation, acute or chronic; with No MEDICAID Closed treatment of acromioclavicular dislocation; without manipulation 23540 No MEDICAID Closed treatment of acromioclavicular dislocation; with manipulation 23545 No MEDICAID Open treatment of acromioclavicular 23550 dislocation, acute or chronic; No MEDICAID Open treatment of acromioclavicular 23552 dislocation, acute or chronic; with No MEDICAID Closed treatment of scapular fracture; 23570 without manipulation No MEDICAID Closed treatment of scapular fracture; 23575 with manipulation, with or No MEDICAID Open treatment of scapular fracture 23585 (body, glenoid or acromion) with or No MEDICAID Closed treatment of proximal humeral (surgical or anatomical neck) 23600 No MEDICAID Closed treatment of proximal humeral (surgical or anatomical neck) 23605 No MEDICAID Open treatment of proximal humeral 23615 (surgical or anatomical neck) No MEDICAID Open treatment of proximal humeral 23616 (surgical or anatomical neck) No MEDICAID 23620 Treat great humeral tuberosity fx No MEDICAID Closed treatment of greater humeral 23625 tuberosity fracture; with No MEDICAID Open treatment of greater humeral 23630 tuberosity fracture, with or without No MEDICAID Closed treatment of shoulder dislocation, with manipulation; without 23650 No MEDICAID Closed treatment of shoulder dislocation, with manipulation; requiring 23655 No MEDICAID Open treatment of acute shoulder 23660 dislocation No MEDICAID Closed treatment of shoulder dislocation, 23665 with fracture of greater No MEDICAID Open treatment of shoulder dislocation, with fracture of greater humeral 23670 No MEDICAID Closed treatment of shoulder dislocation, with surgical or anatomical 23675 No MEDICAID Open treatment of shoulder dislocation, with surgical or anatomical neck 23680 No MEDICAID Manipulation under anesthesia, shoulder joint, including application of 23700 No MEDICAID 23800 Arthrodesis, glenohumeral joint; No MEDICAID Arthrodesis, glenohumeral joint; with 23802 autogenous graft (includes No MEDICAID Interthoracoscapular amputation 23900 (forequarter) No MEDICAID 23920 Disarticulation of shoulder; No MEDICAID Disarticulation of shoulder; secondary 23921 closure or scar revision No MEDICAID UNLISTED PROCEDURE, SHOULDER 23929 Yes MEDICAID

48 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Incision and drainage, upper arm or elbow 23930 area; deep abscess or No MEDICAID Incision and drainage, upper arm or elbow 23931 area; bursa No MEDICAID Incision, deep, with opening of bone 23935 cortex (eg, for osteomyelitis or No MEDICAID Arthrotomy, elbow, including exploration, 24000 drainage, or removal of No MEDICAID Arthrotomy of the elbow, with capsular excision for capsular release 24006 No MEDICAID Biopsy, soft tissue of upper arm or elbow 24065 Yes area; superficial MEDICAID Biopsy, soft tissue of upper arm or elbow 24066 area; deep (subfascial or No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, 24071 Yes SUBCUTANEOUS; GREATER THAN 3 CM MEDICAID EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); GREATER THAN 5 CM 24073 No MEDICAID Excision, tumor, soft tissue of upper arm 24075 Yes or elbow area; subcutaneous MEDICAID Excision, tumor, soft tissue of upper arm 24076 or elbow area; deep No MEDICAID Radical resection of tumor (eg, malignant 24077 neoplasm), soft tissue of No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF UPPER ARM OR ELBOW 24079 AREA; GREATER THAN 5 CM No MEDICAID Arthrotomy, elbow; with synovial biopsy 24100 only No MEDICAID Arthrotomy, elbow; with joint exploration, with or without biopsy, with 24101 No MEDICAID 24102 Arthrotomy, elbow; with synovectomy No MEDICAID 24105 Excision, olecranon bursa No MEDICAID Excision or curettage of bone cyst or 24110 benign tumor, humerus; No MEDICAID Excision or curettage of bone cyst or 24115 benign tumor, humerus; with No MEDICAID Excision or curettage of bone cyst or 24116 benign tumor, humerus; with No MEDICAID Excision or curettage of bone cyst or 24120 benign tumor of head or neck of No MEDICAID Excision or curettage of bone cyst or 24125 benign tumor of head or neck of No MEDICAID Excision or curettage of bone cyst or 24126 benign tumor of head or neck of No MEDICAID 24130 Excision, radial head No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal 24134 No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or 24136 No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon 24138 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 24140 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 24145 No MEDICAID

49 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Partial excision (craterization, saucerization, or diaphysectomy) bone 24147 No MEDICAID Radical resection of capsule, soft tissue, 24149 and heterotopic bone, elbow, No MEDICAID Radical resection for tumor, shaft or distal 24150 humerus; No MEDICAID Radical resection for tumor, radial head or 24152 neck; No MEDICAID Resection of elbow joint (arthrectomy) 24155 No MEDICAID 24160 Implant removal; elbow joint No MEDICAID 24164 Implant removal; radial head No MEDICAID Removal of foreign body, upper arm or 24200 elbow area; subcutaneous No MEDICAID Removal of foreign body, upper arm or 24201 elbow area; deep (subfascial or No MEDICAID Injection procedure for elbow arthrography 24220 No MEDICAID Manipulation, elbow, under anesthesia 24300 No MEDICAID Muscle or tendon transfer, any type, 24301 upper arm or elbow, single No MEDICAID Tendon lengthening, upper arm or elbow, 24305 each tendon No MEDICAID Tenotomy, open, elbow to shoulder, each 24310 tendon No MEDICAID Tenoplasty, with muscle transfer, with or 24320 without free graft, elbow to No MEDICAID Flexor-plasty, elbow (eg, Steindler type 24330 advancement); No MEDICAID Flexor-plasty, elbow (eg, Steindler type 24331 advancement); with extensor No MEDICAID 24332 Tenolysis, triceps No MEDICAID Tenodesis of biceps tendon at elbow 24340 (separate procedure) No MEDICAID Repair, tendon or muscle, upper arm or 24341 elbow, each tendon or muscle, No MEDICAID Reinsertion of ruptured biceps or triceps 24342 tendon, distal, with or No MEDICAID Repair lateral collateral ligament, elbow, 24343 with local tissue No MEDICAID Reconstruction lateral collateral ligament, 24344 elbow, with tendon graft No MEDICAID Repair medial collateral ligament, elbow, 24345 with local tissue No MEDICAID Reconstruction medial collateral ligament, 24346 elbow, with tendon graft No MEDICAID TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); 24357 PERCUTANEOUS No MEDICAID TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR 24358 BONE, OPEN No MEDICAID TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT 24359 No MEDICAID Arthroplasty, elbow; with membrane (eg, 24360 fascial) No MEDICAID Arthroplasty, elbow; with distal humeral 24361 prosthetic replacement No MEDICAID Arthroplasty, elbow; with implant and 24362 fascia lata ligament No MEDICAID

50 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic 24363 No MEDICAID 24365 Arthroplasty, radial head; No MEDICAID 24366 Arthroplasty, radial head; with implant No MEDICAID Revision of total elbow arthroplasty, 24370 including allograft when performed; humeral or ulnar component No MEDICAID Revision of total elbow arthroplasty, 24371 including allograft when performed; humeral and ulnar component No MEDICAID Osteotomy, humerus, with or without 24400 internal fixation No MEDICAID Multiple osteotomies with realignment on 24410 intramedullary rod, No MEDICAID Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) 24420 No MEDICAID Repair of nonunion or malunion, humerus; without graft (eg, compression 24430 No MEDICAID Repair of nonunion or malunion, humerus; 24435 with iliac or other autograft No MEDICAID Hemiepiphyseal arrest (eg, cubitus varus 24470 or valgus, distal humerus) No MEDICAID Decompression fasciotomy, forearm, with 24495 brachial artery exploration No MEDICAID Prophylactic treatment (nailing, pinning, 24498 plating or wiring), with or No MEDICAID Closed treatment of humeral shaft 24500 fracture; without manipulation No MEDICAID Closed treatment of humeral shaft 24505 fracture; with manipulation, with or No MEDICAID Open treatment of humeral shaft fracture 24515 with plate/screws, with or No MEDICAID Treatment of humeral shaft fracture, with 24516 insertion of intramedullary No MEDICAID Closed treatment of supracondylar or 24530 transcondylar humeral fracture, No MEDICAID Closed treatment of supracondylar or 24535 transcondylar humeral fracture, No MEDICAID Percutaneous skeletal fixation of supracondylar or transcondylar humeral 24538 No MEDICAID Open treatment of humeral supracondylar or transcondylar fracture, with 24545 No MEDICAID Open treatment of humeral supracondylar or transcondylar fracture, with 24546 No MEDICAID Closed treatment of humeral epicondylar fracture, medial or lateral; 24560 No MEDICAID Closed treatment of humeral epicondylar fracture, medial or lateral; 24565 No MEDICAID Percutaneous skeletal fixation of humeral 24566 epicondylar fracture, medial No MEDICAID Open treatment of humeral epicondylar fracture, medial or lateral, with 24575 No MEDICAID Closed treatment of humeral condylar 24576 fracture, medial or lateral; No MEDICAID Closed treatment of humeral condylar fracture, medial or lateral; with 24577 No MEDICAID Open treatment of humeral condylar 24579 fracture, medial or lateral, with or No MEDICAID Percutaneous skeletal fixation of humeral 24582 condylar fracture, medial or No MEDICAID

51 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open treatment of periarticular fracture and/or dislocation of the elbow 24586 No MEDICAID Open treatment of periarticular fracture and/or dislocation of the elbow 24587 No MEDICAID Treatment of closed elbow dislocation; 24600 without anesthesia No MEDICAID Treatment of closed elbow dislocation; 24605 requiring anesthesia No MEDICAID Open treatment of acute or chronic elbow 24615 dislocation No MEDICAID Closed treatment of Monteggia type of 24620 fracture dislocation at elbow No MEDICAID Open treatment of Monteggia type of 24635 fracture dislocation at elbow No MEDICAID Closed treatment of radial head subluxation in child, nursemaid elbow, 24640 No MEDICAID Closed treatment of radial head or neck 24650 fracture; without manipulation No MEDICAID Closed treatment of radial head or neck 24655 fracture; with manipulation No MEDICAID Open treatment of radial head or neck 24665 fracture, with or without internal No MEDICAID Open treatment of radial head or neck 24666 fracture, with or without internal No MEDICAID Closed treatment of ulnar fracture, 24670 proximal end (olecranon process); No MEDICAID Closed treatment of ulnar fracture, 24675 proximal end (olecranon process); No MEDICAID Open treatment of ulnar fracture proximal end (olecranon process), with 24685 No MEDICAID 24800 Arthrodesis, elbow joint; local No MEDICAID Arthrodesis, elbow joint; with autogenous 24802 graft (includes obtaining No MEDICAID Amputation, arm through humerus; with 24900 primary closure No MEDICAID Amputation, arm through humerus; open, 24920 circular (guillotine) No MEDICAID Amputation, arm through humerus; 24925 secondary closure or scar No MEDICAID Amputation, arm through humerus; re- 24930 amputation No MEDICAID Amputation, arm through humerus; with 24931 implant No MEDICAID 24935 Stump elongation, upper extremity No MEDICAID Cineplasty, upper extremity, complete 24940 procedure No MEDICAID UNLISTED PROCEDURE, HUMERUS 24999 OR ELBOW Yes MEDICAID Incision, extensor tendon sheath, wrist 25000 (eg, deQuervains disease) No MEDICAID Incision, flexor tendon sheath, wrist (eg, 25001 flexor carpi radialis) No MEDICAID Decompression fasciotomy, forearm 25020 and/or wrist, flexor OR extensor No MEDICAID Decompression fasciotomy, forearm 25023 and/or wrist, flexor OR extensor No MEDICAID Decompression fasciotomy, forearm 25024 and/or wrist, flexor AND extensor No MEDICAID Decompression fasciotomy, forearm 25025 and/or wrist, flexor AND extensor No MEDICAID Incision and drainage, forearm and/or wrist; deep abscess or hematoma 25028 No MEDICAID Incision and drainage, forearm and/or 25031 wrist; bursa No MEDICAID Incision, deep, bone cortex, forearm 25035 and/or wrist (eg, osteomyelitis or No MEDICAID

52 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthrotomy, radiocarpal or midcarpal joint, 25040 with exploration, drainage, No MEDICAID Biopsy, soft tissue of forearm and/or wrist; 25065 Yes superficial MEDICAID Biopsy, soft tissue of forearm and/or wrist; 25066 deep (subfascial or No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, 25071 Yes SUBCUTANEOUS; GREATER THAN 3 CM MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER (REVISED 010110) 25073 No MEDICAID Excision, tumor, soft tissue of forearm 25075 and/or wrist area; subcutaneous Yes MEDICAID Excision, tumor, soft tissue of forearm 25076 and/or wrist area; deep No MEDICAID Radical resection of tumor (eg, malignant 25077 neoplasm), soft tissue of No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FOREARM AND/OR WRIST 25078 AREA; 3 CM OR GREATER No MEDICAID 25085 Capsulotomy, wrist (eg, contracture) No MEDICAID 25100 Arthrotomy, wrist joint; with biopsy No MEDICAID Arthrotomy, wrist joint; with joint 25101 exploration, with or without biopsy, No MEDICAID Arthrotomy, wrist joint; with synovectomy 25105 No MEDICAID Arthrotomy, distal radioulnar joint 25107 including repair of triangular No MEDICAID EXCISION OF TENDON, FOREARM AND/OR WRIST, FLEXOR OR 25109 EXTENSOR, EACH No MEDICAID Excision, lesion of tendon sheath, forearm 25110 and/or wrist No MEDICAID Excision of ganglion, wrist (dorsal or 25111 volar); primary No MEDICAID Excision of ganglion, wrist (dorsal or 25112 volar); recurrent No MEDICAID Radical excision of bursa, synovia of 25115 wrist, or forearm tendon sheaths No MEDICAID Radical excision of bursa, synovia of 25116 wrist, or forearm tendon sheaths No MEDICAID Synovectomy, extensor tendon sheath, 25118 wrist, single compartment; No MEDICAID Synovectomy, extensor tendon sheath, wrist, single compartment; with 25119 No MEDICAID Excision or curettage of bone cyst or 25120 benign tumor of radius or ulna No MEDICAID Excision or curettage of bone cyst or 25125 benign tumor of radius or ulna No MEDICAID Excision or curettage of bone cyst or 25126 benign tumor of radius or ulna No MEDICAID Excision or curettage of bone cyst or 25130 benign tumor of carpal bones; No MEDICAID Excision or curettage of bone cyst or 25135 benign tumor of carpal bones; with No MEDICAID Excision or curettage of bone cyst or 25136 benign tumor of carpal bones; with No MEDICAID Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or 25145 No MEDICAID Partial excision (craterization, 25150 saucerization, or diaphysectomy) of No MEDICAID Partial excision (craterization, 25151 saucerization, or diaphysectomy) of No MEDICAID

53 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radical resection for tumor, radius or ulna 25170 No MEDICAID 25210 Carpectomy; one bone No MEDICAID Carpectomy; all bones of proximal row 25215 No MEDICAID Radial styloidectomy (separate procedure) 25230 No MEDICAID Excision distal ulna partial or complete (eg, Darrach type or matched 25240 No MEDICAID Injection procedure for wrist arthrography 25246 No MEDICAID Exploration with removal of deep foreign 25248 body, forearm or wrist No MEDICAID Removal of wrist prosthesis; (separate 25250 procedure) No MEDICAID Removal of wrist prosthesis; complicated, 25251 including total wrist No MEDICAID Manipulation, wrist, under anesthesia 25259 No MEDICAID Repair, tendon or muscle, flexor, forearm 25260 and/or wrist; primary, single, No MEDICAID Repair, tendon or muscle, flexor, forearm 25263 and/or wrist; secondary, No MEDICAID Repair, tendon or muscle, flexor, forearm 25265 and/or wrist; secondary, with No MEDICAID Repair, tendon or muscle, extensor, 25270 forearm and/or wrist; primary, No MEDICAID Repair, tendon or muscle, extensor, 25272 forearm and/or wrist; secondary, No MEDICAID Repair, tendon or muscle, extensor, 25274 forearm and/or wrist; secondary, No MEDICAID Repair, tendon sheath, extensor, forearm 25275 and/or wrist, with free graft No MEDICAID Lengthening or shortening of flexor or 25280 extensor tendon, forearm and/or No MEDICAID Tenotomy, open, flexor or extensor 25290 tendon, forearm and/or wrist, single, No MEDICAID Tenolysis, flexor or extensor tendon, 25295 forearm and/or wrist, single, each No MEDICAID 25300 Tenodesis at wrist; flexors of fingers No MEDICAID Tenodesis at wrist; extensors of fingers 25301 No MEDICAID Tendon transplantation or transfer, flexor 25310 or extensor, forearm and/or No MEDICAID Tendon transplantation or transfer, flexor 25312 or extensor, forearm and/or No MEDICAID Flexor origin slide (eg, for cerebral palsy, 25315 Volkmann contracture), No MEDICAID Flexor origin slide (eg, for cerebral palsy, 25316 Volkmann contracture), No MEDICAID Capsulorrhaphy or reconstruction, wrist, 25320 open (eg, capsulodesis, No MEDICAID Arthroplasty, wrist, with or without 25332 interposition, with or without No MEDICAID Centralization of wrist on ulna (eg, radial 25335 club hand) No MEDICAID Reconstruction for stabilization of 25337 unstable distal ulna or distal No MEDICAID 25350 Osteotomy, radius; distal third No MEDICAID Osteotomy, radius; middle or proximal 25355 third No MEDICAID 25360 Osteotomy; ulna No MEDICAID 25365 Osteotomy; radius AND ulna No MEDICAID Multiple osteotomies, with realignment on intramedullary rod (Sofield 25370 No MEDICAID Multiple osteotomies, with realignment on intramedullary rod (Sofield 25375 No MEDICAID

54 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Osteoplasty, radius OR ulna; shortening 25390 No MEDICAID Osteoplasty, radius OR ulna; lengthening 25391 with autograft No MEDICAID Osteoplasty, radius AND ulna; shortening 25392 (excluding 64876) No MEDICAID Osteoplasty, radius AND ulna; 25393 lengthening with autograft No MEDICAID 25394 Osteoplasty, carpal bone, shortening No MEDICAID Repair of nonunion or malunion, radius 25400 OR ulna; without graft (eg, No MEDICAID Repair of nonunion or malunion, radius OR ulna; with autograft (includes 25405 No MEDICAID Repair of nonunion or malunion, radius 25415 AND ulna; without graft (eg, No MEDICAID Repair of nonunion or malunion, radius 25420 AND ulna; with autograft No MEDICAID Repair of defect with autograft; radius OR 25425 ulna No MEDICAID Repair of defect with autograft; radius 25426 AND ulna No MEDICAID Insertion of vascular pedicle into carpal 25430 bone (eg, Hori procedure) No MEDICAID Repair of nonunion of carpal bone 25431 (excluding carpal scaphoid No MEDICAID Repair of nonunion, scaphoid carpal 25440 (navicular) bone, with or without No MEDICAID Arthroplasty with prosthetic replacement; 25441 distal radius No MEDICAID Arthroplasty with prosthetic replacement; 25442 distal ulna No MEDICAID Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) 25443 No MEDICAID Arthroplasty with prosthetic replacement; 25444 lunate No MEDICAID Arthroplasty with prosthetic replacement; 25445 trapezium No MEDICAID Arthroplasty with prosthetic replacement; distal radius and partial or 25446 No MEDICAID Arthroplasty, interposition, intercarpal or 25447 carpometacarpal joints No MEDICAID Revision of arthroplasty, including 25449 removal of implant, wrist joint No MEDICAID Epiphyseal arrest by epiphysiodesis or 25450 stapling; distal radius OR ulna No MEDICAID Epiphyseal arrest by epiphysiodesis or 25455 stapling; distal radius AND ulna No MEDICAID Prophylactic treatment (nailing, pinning, 25490 plating or wiring) with or No MEDICAID Prophylactic treatment (nailing, pinning, 25491 plating or wiring) with or No MEDICAID Prophylactic treatment (nailing, pinning, 25492 plating or wiring) with or No MEDICAID Closed treatment of radial shaft fracture; 25500 without manipulation No MEDICAID Closed treatment of radial shaft fracture; 25505 with manipulation No MEDICAID Open treatment of radial shaft fracture, 25515 with or without internal or No MEDICAID Closed treatment of radial shaft fracture 25520 and closed treatment of No MEDICAID Open treatment of radial shaft fracture, 25525 with internal and/ or external No MEDICAID Open treatment of radial shaft fracture, 25526 with internal and/or external No MEDICAID Closed treatment of ulnar shaft fracture; 25530 without manipulation No MEDICAID

55 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of ulnar shaft fracture; 25535 with manipulation No MEDICAID Open treatment of ulnar shaft fracture, 25545 with or without internal or No MEDICAID Closed treatment of radial and ulnar shaft 25560 fractures; without No MEDICAID Closed treatment of radial and ulnar shaft 25565 fractures; with manipulation No MEDICAID Open treatment of radial AND ulnar shaft 25574 fractures, with internal or No MEDICAID Open treatment of radial AND ulnar shaft 25575 fractures, with internal or No MEDICAID Closed treatment of distal radial fracture 25600 (eg, Colles or Smith type) or No MEDICAID Closed treatment of distal radial fracture 25605 (eg, Colles or Smith type) or No MEDICAID 25606 TREAT DISTAL RADIAL FRACTURE No MEDICAID EPIPHYSEAL SEPARATION, WITH 25607 INTERNAL FIXATION No MEDICAID OPEN TREATMENT DISTAL RADIAL 25608 FRACTURE No MEDICAID OPEN TREATMENT DISTAL 25609 FRACTURE 3 OR > FRAGMENTS No MEDICAID CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; WITHOUT MANIPULATION 25622 No MEDICAID Closed treatment of carpal scaphoid 25624 (navicular) fracture; with No MEDICAID Open treatment of carpal scaphoid 25628 (navicular) fracture, with or without No MEDICAID Closed treatment of carpal bone fracture 25630 (excluding carpal scaphoid No MEDICAID Closed treatment of carpal bone fracture 25635 (excluding carpal scaphoid No MEDICAID Open treatment of carpal bone fracture 25645 (other than carpal scaphoid No MEDICAID Closed treatment of ulnar styloid fracture 25650 No MEDICAID Percutaneous skeletal fixation of ulnar 25651 styloid fracture No MEDICAID Open treatment of ulnar styloid fracture 25652 No MEDICAID Closed treatment of radiocarpal or 25660 intercarpal dislocation, one or more No MEDICAID Open treatment of radiocarpal or 25670 intercarpal dislocation, one or more No MEDICAID Percutaneous skeletal fixation of distal 25671 radioulnar dislocation No MEDICAID Closed treatment of distal radioulnar 25675 dislocation with manipulation No MEDICAID Open treatment of distal radioulnar 25676 dislocation, acute or chronic No MEDICAID Closed treatment of trans-scaphoperilunar type of fracture dislocation, 25680 No MEDICAID Open treatment of trans-scaphoperilunar type of fracture dislocation 25685 No MEDICAID Closed treatment of lunate dislocation, 25690 with manipulation No MEDICAID 25695 Open treatment of lunate dislocation No MEDICAID Arthrodesis, wrist; complete, without bone 25800 graft (includes radiocarpal No MEDICAID 25805 Arthrodesis, wrist; with sliding graft No MEDICAID Arthrodesis, wrist; with iliac or other 25810 autograft (includes obtaining No MEDICAID Arthrodesis, wrist; limited, without bone 25820 graft (eg, intercarpal or No MEDICAID Arthrodesis, wrist; with autograft (includes 25825 obtaining graft) No MEDICAID

56 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthrodesis, distal radioulnar joint with 25830 segmental resection of ulna, No MEDICAID Amputation, forearm, through radius and 25900 ulna; No MEDICAID Amputation, forearm, through radius and 25905 ulna; open, circular No MEDICAID Amputation, forearm, through radius and 25907 ulna; secondary closure No MEDICAID Amputation, forearm, through radius and 25909 ulna; re-amputation No MEDICAID 25915 Krukenberg procedure No MEDICAID 25920 Disarticulation through wrist; No MEDICAID Disarticulation through wrist; secondary 25922 closure or scar revision No MEDICAID Disarticulation through wrist; re- 25924 amputation No MEDICAID 25927 Transmetacarpal amputation; No MEDICAID Transmetacarpal amputation; secondary 25929 closure or scar revision No MEDICAID Transmetacarpal amputation; re- 25931 amputation No MEDICAID UNLISTED PROCEDURE, FOREARM 25999 OR WRIST Yes MEDICAID 26010 Drainage of finger abscess; simple No MEDICAID Drainage of finger abscess; complicated 26011 (eg, felon) No MEDICAID Drainage of tendon sheath, digit and/or 26020 palm, each No MEDICAID Drainage of palmar bursa; single, bursa 26025 No MEDICAID Drainage of palmar bursa; multiple bursa 26030 No MEDICAID Incision, bone cortex, hand or finger (eg, 26034 osteomyelitis or bone No MEDICAID Decompression fingers and/or hand, 26035 injection injury (eg, grease gun) No MEDICAID Decompressive fasciotomy, hand 26037 (excludes 26035) No MEDICAID Fasciotomy, palmar (eg, Dupuytren's 26040 contracture); percutaneous No MEDICAID Fasciotomy, palmar (eg, Dupuytren's 26045 contracture); open, partial No MEDICAID Tendon sheath incision (eg, for trigger 26055 finger) No MEDICAID Tenotomy, percutaneous, single, each 26060 digit No MEDICAID Arthrotomy, with exploration, drainage, or removal of loose or foreign 26070 No MEDICAID Arthrotomy, with exploration, drainage, or removal of loose or foreign 26075 No MEDICAID Arthrotomy, with exploration, drainage, or removal of loose or foreign 26080 No MEDICAID Arthrotomy with biopsy; carpometacarpal 26100 joint, each No MEDICAID Arthrotomy with biopsy; 26105 metacarpophalangeal joint, each No MEDICAID Arthrotomy with biopsy; interphalangeal 26110 joint, each No MEDICAID EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF 26111 HAND OR FINGER, SUBCUTANEOUS; Yes 1.5 CM OR GREATER MEDICAID EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); 1.5 CM OR 26113 GREATER No MEDICAID

57 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision, tumor or vascular malformation, 26115 soft tissue of hand or finger; Yes MEDICAID Excision, tumor or vascular malformation, soft tissue of hand or finger; 26116 No MEDICAID Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand 26117 No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF HAND OR FINGER; 3 CM 26118 OR GREATER No MEDICAID Fasciectomy, palm only, with or without Z- 26121 plasty, other local tissue No MEDICAID Fasciectomy, partial palmar with release 26123 of single digit including No MEDICAID Fasciectomy, partial palmar with release 26125 of single digit including No MEDICAID 26130 Synovectomy, carpometacarpal joint No MEDICAID Synovectomy, metacarpophalangeal joint 26135 including intrinsic release and No MEDICAID Synovectomy, proximal interphalangeal joint, including extensor 26140 No MEDICAID Synovectomy, tendon sheath, radical 26145 (tenosynovectomy), flexor tendon, No MEDICAID Excision of lesion of tendon sheath or joint 26160 capsule (eg, cyst, mucous No MEDICAID Excision of tendon, palm, flexor, single 26170 (separate procedure), each No MEDICAID Excision of tendon, finger, flexor 26180 (separate procedure), each tendon No MEDICAID Sesamoidectomy, thumb or finger 26185 (separate procedure) No MEDICAID Excision or curettage of bone cyst or 26200 benign tumor of metacarpal; No MEDICAID Excision or curettage of bone cyst or 26205 benign tumor of metacarpal; with No MEDICAID Excision or curettage of bone cyst or 26210 benign tumor of proximal, middle, No MEDICAID Excision or curettage of bone cyst or 26215 benign tumor of proximal, middle, No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 26230 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 26235 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 26236 No MEDICAID Radical resection, metacarpal (eg, tumor); 26250 No MEDICAID Radical resection, proximal or middle 26260 phalanx of finger (eg, tumor); No MEDICAID Radical resection, distal phalanx of finger 26262 (eg, tumor) No MEDICAID Removal of implant from finger or hand 26320 No MEDICAID Manipulation, finger joint, under 26340 anesthesia, each joint No MEDICAID Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord 26341 No MEDICAID Repair or advancement, flexor tendon, not 26350 in zone 2 digital flexor No MEDICAID Repair or advancement, flexor tendon, not 26352 in zone 2 digital flexor No MEDICAID

58 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair or advancement, flexor tendon, in 26356 zone 2 digital flexor tendon No MEDICAID Repair or advancement, flexor tendon, in 26357 zone 2 digital flexor tendon No MEDICAID Repair or advancement, flexor tendon, in 26358 zone 2 digital flexor tendon No MEDICAID Repair or advancement of profundus 26370 tendon, with intact superficialis No MEDICAID Repair or advancement of profundus 26372 tendon, with intact superficialis No MEDICAID Repair or advancement of profundus 26373 tendon, with intact superficialis No MEDICAID Excision flexor tendon, with implantation of synthetic rod for delayed 26390 No MEDICAID Removal of synthetic rod and insertion of flexor tendon graft, hand or 26392 No MEDICAID Repair, extensor tendon, hand, primary or secondary; without free graft, 26410 No MEDICAID Repair, extensor tendon, hand, primary or 26412 secondary; with free graft No MEDICAID Excision of extensor tendon, with 26415 implantation of synthetic rod for No MEDICAID Removal of synthetic rod and insertion of 26416 extensor tendon graft No MEDICAID Repair, extensor tendon, finger, primary 26418 or secondary; without free No MEDICAID Repair, extensor tendon, finger, primary 26420 or secondary; with free graft No MEDICAID Repair of extensor tendon, central slip, 26426 secondary (eg, boutonniere No MEDICAID Repair of extensor tendon, central slip, 26428 secondary (eg, boutonniere No MEDICAID Closed treatment of distal extensor 26432 tendon insertion, with or without No MEDICAID Repair of extensor tendon, distal insertion, 26433 primary or secondary; No MEDICAID Repair of extensor tendon, distal insertion, 26434 primary or secondary; with No MEDICAID Realignment of extensor tendon, hand, 26437 each tendon No MEDICAID Tenolysis, flexor tendon; palm OR finger, 26440 each tendon No MEDICAID Tenolysis, flexor tendon; palm AND finger, 26442 each tendon No MEDICAID Tenolysis, extensor tendon, hand OR 26445 finger, each tendon No MEDICAID Tenolysis, complex, extensor tendon, 26449 finger, including forearm, each No MEDICAID Tenotomy, flexor, palm, open, each 26450 tendon No MEDICAID Tenotomy, flexor, finger, open, each 26455 tendon No MEDICAID Tenotomy, extensor, hand or finger, open, 26460 each tendon No MEDICAID Tenodesis; of proximal interphalangeal 26471 joint, each joint No MEDICAID 26474 Tenodesis; of distal joint, each joint No MEDICAID Lengthening of tendon, extensor, hand or 26476 finger, each tendon No MEDICAID Shortening of tendon, extensor, hand or 26477 finger, each tendon No MEDICAID Lengthening of tendon, flexor, hand or 26478 finger, each tendon No MEDICAID Shortening of tendon, flexor, hand or 26479 finger, each tendon No MEDICAID Transfer or transplant of tendon, 26480 carpometacarpal area or dorsum of No MEDICAID

59 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Transfer or transplant of tendon, 26483 carpometacarpal area or dorsum of No MEDICAID Transfer or transplant of tendon, palmar; 26485 without free tendon graft, No MEDICAID Transfer or transplant of tendon, palmar; 26489 with free tendon graft No MEDICAID Opponensplasty; superficialis tendon 26490 transfer type, each tendon No MEDICAID Opponensplasty; tendon transfer with 26492 graft (includes obtaining graft), No MEDICAID Opponensplasty; hypothenar muscle 26494 transfer No MEDICAID 26496 Opponensplasty; other methods No MEDICAID Transfer of tendon to restore intrinsic 26497 function; ring and small finger No MEDICAID Transfer of tendon to restore intrinsic 26498 function; all four fingers No MEDICAID Correction claw finger, other methods 26499 No MEDICAID Reconstruction of tendon pulley, each 26500 tendon; with local tissues No MEDICAID Reconstruction of tendon pulley, each 26502 tendon; with tendon or fascial No MEDICAID Release of thenar muscle(s) (eg, thumb 26508 contracture) No MEDICAID 26510 Cross intrinsic transfer, each tendon No MEDICAID Capsulodesis, metacarpophalangeal joint; single digit 26516 No MEDICAID Capsulodesis, metacarpophalangeal joint; two digits 26517 No MEDICAID Capsulodesis, metacarpophalangeal joint; three or four digits 26518 No MEDICAID Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint 26520 No MEDICAID Capsulectomy or capsulotomy; 26525 interphalangeal joint, each joint No MEDICAID Arthroplasty, metacarpophalangeal joint; 26530 each joint No MEDICAID Arthroplasty, metacarpophalangeal joint; 26531 with prosthetic implant, each No MEDICAID Arthroplasty, interphalangeal joint; each 26535 joint No MEDICAID Arthroplasty, interphalangeal joint; with 26536 prosthetic implant, each joint No MEDICAID Repair of collateral ligament, metacarpophalangeal or interphalangeal 26540 No MEDICAID Reconstruction, collateral ligament, 26541 metacarpophalangeal joint, single; No MEDICAID Reconstruction, collateral ligament, 26542 metacarpophalangeal joint, single; No MEDICAID Reconstruction, collateral ligament, 26545 interphalangeal joint, single, No MEDICAID Repair non-union, metacarpal or phalanx, (includes obtaining bone graft 26546 No MEDICAID Repair and reconstruction, finger, volar 26548 plate, interphalangeal joint No MEDICAID 26550 Pollicization of a digit No MEDICAID Transfer, toe-to-hand with microvascular anastomosis; great toe 26551 No MEDICAID Transfer, toe-to-hand with microvascular anastomosis; other than 26553 No MEDICAID

60 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Transfer, toe-to-hand with microvascular anastomosis; other than 26554 No MEDICAID Transfer, finger to another position 26555 without microvascular anastomosis No MEDICAID Transfer, free toe joint, with microvascular 26556 anastomosis No MEDICAID Repair of syndactyly (web finger) each 26560 web space; with skin flaps No MEDICAID Repair of syndactyly (web finger) each 26561 web space; with skin flaps and No MEDICAID Repair of syndactyly (web finger) each web space; complex (eg, involving 26562 No MEDICAID 26565 Osteotomy; metacarpal, each No MEDICAID 26567 Osteotomy; phalanx of finger, each No MEDICAID Osteoplasty, lengthening, metacarpal or 26568 phalanx No MEDICAID 26580 Repair cleft hand No MEDICAID Reconstruction of polydactylous digit, soft 26587 tissue and bone No MEDICAID 26590 Repair macrodactylia, each digit No MEDICAID Repair, intrinsic muscles of hand, each 26591 muscle No MEDICAID Release, intrinsic muscles of hand, each 26593 muscle No MEDICAID Excision of constricting ring of finger, with 26596 multiple Z-plasties No MEDICAID Closed treatment of metacarpal fracture, 26600 single; without manipulation, No MEDICAID Closed treatment of metacarpal fracture, single; with manipulation, each 26605 No MEDICAID Closed treatment of metacarpal fracture, 26607 with manipulation, with No MEDICAID Percutaneous skeletal fixation of 26608 metacarpal fracture, each bone No MEDICAID Open treatment of metacarpal fracture, single, with or without internal 26615 No MEDICAID Closed treatment of carpometacarpal 26641 dislocation, thumb, with No MEDICAID Closed treatment of carpometacarpal 26645 fracture dislocation, thumb (Bennett No MEDICAID Percutaneous skeletal fixation of 26650 carpometacarpal fracture dislocation, No MEDICAID Open treatment of carpometacarpal 26665 fracture dislocation, thumb (Bennett No MEDICAID Closed treatment of carpometacarpal 26670 dislocation, other than thumb, with No MEDICAID Closed treatment of carpometacarpal 26675 dislocation, other than thumb, with No MEDICAID Percutaneous skeletal fixation of 26676 carpometacarpal dislocation, other No MEDICAID Open treatment of carpometacarpal 26685 dislocation, other than thumb; with or No MEDICAID Open treatment of carpometacarpal 26686 dislocation, other than thumb; No MEDICAID Closed treatment of metacarpophalangeal dislocation, single, with 26700 No MEDICAID Closed treatment of metacarpophalangeal dislocation, single, with 26705 No MEDICAID Percutaneous skeletal fixation of 26706 metacarpophalangeal dislocation, No MEDICAID Open treatment of metacarpophalangeal dislocation, single, with or 26715 No MEDICAID Closed treatment of phalangeal shaft 26720 fracture, proximal or middle No MEDICAID

61 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of phalangeal shaft 26725 fracture, proximal or middle No MEDICAID Percutaneous skeletal fixation of unstable 26727 phalangeal shaft fracture, No MEDICAID Open treatment of phalangeal shaft 26735 fracture, proximal or middle phalanx, No MEDICAID Closed treatment of articular fracture, 26740 involving metacarpophalangeal or No MEDICAID Closed treatment of articular fracture, 26742 involving metacarpophalangeal or No MEDICAID Open treatment of articular fracture, 26746 involving metacarpophalangeal or No MEDICAID Closed treatment of distal phalangeal fracture, finger or thumb; without 26750 No MEDICAID Closed treatment of distal phalangeal fracture, finger or thumb; with 26755 No MEDICAID Percutaneous skeletal fixation of distal 26756 phalangeal fracture, finger or No MEDICAID Open treatment of distal phalangeal 26765 fracture, finger or thumb, with or No MEDICAID Closed treatment of interphalangeal joint 26770 dislocation, single, with No MEDICAID Closed treatment of interphalangeal joint 26775 dislocation, single, with No MEDICAID Percutaneous skeletal fixation of 26776 interphalangeal joint dislocation, No MEDICAID Open treatment of interphalangeal joint 26785 dislocation, with or without No MEDICAID Fusion in opposition, thumb, with 26820 autogenous graft (includes obtaining No MEDICAID Arthrodesis, carpometacarpal joint, 26841 thumb, with or without internal No MEDICAID Arthrodesis, carpometacarpal joint, 26842 thumb, with or without internal No MEDICAID Arthrodesis, carpometacarpal joint, digit, 26843 other than thumb, each; No MEDICAID Arthrodesis, carpometacarpal joint, digit, 26844 other than thumb, each; with No MEDICAID Arthrodesis, metacarpophalangeal joint, 26850 with or without internal No MEDICAID Arthrodesis, metacarpophalangeal joint, 26852 with or without internal No MEDICAID Arthrodesis, interphalangeal joint, with or 26860 without internal fixation; No MEDICAID Arthrodesis, interphalangeal joint, with or 26861 without internal fixation; No MEDICAID Arthrodesis, interphalangeal joint, with or 26862 without internal fixation; No MEDICAID Arthrodesis, interphalangeal joint, with or 26863 without internal fixation; No MEDICAID Amputation, metacarpal, with finger or 26910 thumb (ray amputation), single, No MEDICAID Amputation, finger or thumb, primary or 26951 secondary, any joint or phalanx, No MEDICAID Amputation, finger or thumb, primary or 26952 secondary, any joint or phalanx, No MEDICAID UNLISTED PROCEDURE, HANDS OR 26989 FINGERS Yes MEDICAID Incision and drainage, pelvis or hip joint 26990 area; deep abscess or No MEDICAID Incision and drainage, pelvis or hip joint 26991 area; infected bursa No MEDICAID Incision, bone cortex, pelvis and/or hip 26992 joint (eg, osteomyelitis or No MEDICAID Tenotomy, adductor of hip, percutaneous 27000 (separate procedure) No MEDICAID 27001 Tenotomy, adductor of hip, open No MEDICAID Tenotomy, adductor, subcutaneous, open, 27003 with obturator neurectomy No MEDICAID

62 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Tenotomy, hip flexor(s), open (separate 27005 procedure) No MEDICAID Tenotomy, abductors and/or extensor(s) 27006 of hip, open (separate No MEDICAID 27025 Fasciotomy, hip or thigh, any type No MEDICAID Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata 27027 muscle), unilateral No MEDICAID Arthrotomy, hip, with drainage (eg, 27030 infection) No MEDICAID Arthrotomy, hip, including exploration or 27033 removal of loose or foreign No MEDICAID Denervation, hip joint, intrapelvic or 27035 extrapelvic intra-articular No MEDICAID Capsulectomy or capsulotomy, hip, with or 27036 without excision of No MEDICAID Biopsy, soft tissue of pelvis and hip area; 27040 Yes superficial MEDICAID Biopsy, soft tissue of pelvis and hip area; 27041 deep, subfascial or No MEDICAID EXCISION, TUMOR,SOF T TISSUE OF PELVIS AND HIP AREA; 27043 Yes SUBCUTANEOUS; 3 CM OR GREATER MEDICAID EXCISION, TUMOR, SOF T TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER 27045 No MEDICAID Excision, tumor, pelvis and hip area; 27047 Yes subcutaneous tissue MEDICAID Excision, tumor, pelvis and hip area; 27048 deep, subfascial, intramuscular No MEDICAID Radical resection of tumor, soft tissue of 27049 pelvis and hip area (eg, No MEDICAID Arthrotomy, with biopsy; sacroiliac joint 27050 No MEDICAID 27052 Arthrotomy, with biopsy; hip joint No MEDICAID Arthrotomy with synovectomy, hip joint 27054 No MEDICAID Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable 27057 muscle, unilateral No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF PELVIS AND HIP AREA; 5 27059 CM OR GREATER No MEDICAID 27060 Excision; ischial bursa No MEDICAID Excision; trochanteric bursa or 27062 calcification No MEDICAID Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed 27065 No MEDICAID Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed 27066 No MEDICAID Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incision 27067 No MEDICAID

63 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur (craterization, saucerization) (eg, osteomyelitis or bone abscess); 27070 superficial No MEDICAID Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular) 27071 No MEDICAID Radical resection of tumor or infection; 27075 wing of ilium, one pubic or No MEDICAID Radical resection of tumor or infection; 27076 ilium, including No MEDICAID Radical resection of tumor or infection; 27077 innominate bone, total No MEDICAID Radical resection of tumor or infection; 27078 ischial tuberosity and No MEDICAID 27080 Coccygectomy, primary No MEDICAID Removal of foreign body, pelvis or hip; 27086 subcutaneous tissue No MEDICAID Removal of foreign body, pelvis or hip; 27087 deep (subfascial or No MEDICAID Removal of hip prosthesis; (separate 27090 procedure) No MEDICAID Removal of hip prosthesis; complicated, 27091 including total hip No MEDICAID Injection procedure for hip arthrography; 27093 without anesthesia No MEDICAID Injection procedure for hip arthrography; 27095 with anesthesia No MEDICAID Injection procedure for sacroiliac joint, 27096 arthrography and/or No MEDICAID Release or recession, hamstring, proximal 27097 No MEDICAID 27098 Transfer, adductor to ischium No MEDICAID Transfer external oblique muscle to 27100 greater trochanter including fascial No MEDICAID Transfer paraspinal muscle to hip 27105 (includes fascial or tendon extension No MEDICAID Transfer iliopsoas; to greater trochanter of 27110 femur No MEDICAID 27111 Transfer iliopsoas; to femoral neck No MEDICAID Acetabuloplasty; (eg, Whitman, Colonna, 27120 Haygroves, or cup type) No MEDICAID Acetabuloplasty; resection, femoral head 27122 (eg, Girdlestone procedure) No MEDICAID Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) 27125 No MEDICAID 27130 Total hip arthroplasty No MEDICAID (total hip arthroplasty), with or without 27132 autograft or allograft No MEDICAID Revision of total hip arthroplasty; both 27134 components, with or No MEDICAID Revision of total hip arthroplasty; 27137 acetabular component only, with No MEDICAID Revision of total hip arthroplasty; femoral 27138 component only, with or No MEDICAID Osteotomy and transfer of greater 27140 trochanter of femur (separate No MEDICAID Osteotomy, iliac, acetabular or innominate 27146 bone; No MEDICAID Osteotomy, iliac, acetabular or innominate 27147 bone; with open No MEDICAID Osteotomy, iliac, acetabular or innominate 27151 bone; with femoral No MEDICAID Osteotomy, iliac, acetabular or innominate 27156 bone; with femoral No MEDICAID

64 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Osteotomy, pelvis, bilateral (eg, 27158 congenital malformation) No MEDICAID Osteotomy, femoral neck (separate 27161 procedure) No MEDICAID Osteotomy, intertrochanteric or 27165 subtrochanteric including internal No MEDICAID Bone graft, femoral head, neck, 27170 intertrochanteric or subtrochanteric No MEDICAID Treatment of slipped femoral epiphysis; by traction, without reduction 27175 No MEDICAID Treatment of slipped femoral epiphysis; by single or multiple pinning, 27176 No MEDICAID Open treatment of slipped femoral 27177 epiphysis; single or multiple pinning No MEDICAID Open treatment of slipped femoral 27178 epiphysis; closed manipulation with No MEDICAID Open treatment of slipped femoral 27179 epiphysis; osteoplasty of No MEDICAID Open treatment of slipped femoral 27181 epiphysis; osteotomy and No MEDICAID Epiphyseal arrest by epiphysiodesis or 27185 stapling, greater trochanter No MEDICAID Prophylactic treatment (nailing, pinning, 27187 plating or wiring) with or No MEDICAID Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation 27197 No MEDICAID Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural) 27198 No MEDICAID Closed treatment of coccygeal fracture 27200 No MEDICAID 27202 Open treatment of coccygeal fracture No MEDICAID Open treatment of iliac spine(s), 27215 tuberosity avulsion, or iliac wing No MEDICAID dislocation (includes ilium, sacroiliac joint 27216 and/or sacrum) No MEDICAID Open treatment of anterior ring fracture 27217 and/or dislocation with No MEDICAID Open treatment of posterior ring fracture 27218 and/or dislocation with No MEDICAID Closed treatment of acetabulum (hip 27220 socket) fracture(s); without No MEDICAID Closed treatment of acetabulum (hip 27222 socket) fracture(s); with No MEDICAID Open treatment of posterior or anterior 27226 acetabular wall fracture, No MEDICAID Open treatment of acetabular fracture(s) 27227 involving anterior or No MEDICAID Open treatment of acetabular fracture(s) 27228 involving anterior and No MEDICAID Closed treatment of femoral fracture, 27230 proximal end, neck; without No MEDICAID

65 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of femoral fracture, 27232 proximal end, neck; with No MEDICAID Percutaneous skeletal fixation of femoral 27235 fracture, proximal end, neck No MEDICAID Open treatment of femoral fracture, 27236 proximal end, neck, internal No MEDICAID Closed treatment of intertrochanteric, 27238 pertrochanteric, or No MEDICAID Closed treatment of intertrochanteric, 27240 pertrochanteric, or No MEDICAID Treatment of intertrochanteric, 27244 pertrochanteric, or subtrochanteric No MEDICAID Treatment of intertrochanteric, 27245 pertrochanteric, or subtrochanteric No MEDICAID Closed treatment of greater trochanteric fracture, without manipulation 27246 No MEDICAID Open treatment of greater trochanteric 27248 fracture, with or without No MEDICAID Closed treatment of hip dislocation, 27250 traumatic; without anesthesia No MEDICAID Closed treatment of hip dislocation, 27252 traumatic; requiring anesthesia No MEDICAID Open treatment of hip dislocation, 27253 traumatic, without internal No MEDICAID Open treatment of hip dislocation, 27254 traumatic, with acetabular wall No MEDICAID Treatment of spontaneous hip dislocation 27256 (developmental, including No MEDICAID Treatment of spontaneous hip dislocation 27257 (developmental, including No MEDICAID Open treatment of spontaneous hip 27258 dislocation (developmental, No MEDICAID Open treatment of spontaneous hip 27259 dislocation (developmental, No MEDICAID Closed treatment of post hip arthroplasty 27265 dislocation; without No MEDICAID Closed treatment of post hip arthroplasty 27266 dislocation; requiring No MEDICAID CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 27267 WITHOUT MANIPULATION No MEDICAID CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 27268 WITH MANIPULATION No MEDICAID OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; INCLUDES INTERNAL FIXATION, 27269 WHEN PERFORMED No MEDICAID Manipulation, hip joint, requiring general 27275 anesthesia No MEDICAID Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing 27279 device Not Covered MEDICAID Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, 27279 includes obtaining bone graft when No performed, and placement of transfixing device MEDICAID Arthrodesis, sacroiliac joint (including 27280 obtaining graft) No MEDICAID Arthrodesis, symphysis pubis (including 27282 obtaining graft) No MEDICAID Arthrodesis, hip joint (including obtaining 27284 graft); No MEDICAID Arthrodesis, hip joint (including obtaining 27286 graft); with No MEDICAID

66 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interpelviabdominal amputation 27290 (hindquarter amputation) No MEDICAID 27295 Disarticulation of hip No MEDICAID UNLISTED PROCEDURE, PELVIS OR 27299 HIP JOINT Yes MEDICAID Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee 27301 No MEDICAID Incision, deep, with opening of bone 27303 cortex, femur or knee (eg, No MEDICAID Fasciotomy, iliotibial (tenotomy), open 27305 No MEDICAID Tenotomy, percutaneous, adductor or 27306 hamstring; single tendon (separate No MEDICAID Tenotomy, percutaneous, adductor or 27307 hamstring; multiple tendons No MEDICAID Arthrotomy, knee, with exploration, 27310 drainage, or removal of foreign body No MEDICAID Biopsy, soft tissue of thigh or knee area; 27323 Yes superficial MEDICAID Biopsy, soft tissue of thigh or knee area; 27324 deep (subfascial or No MEDICAID NEURECTOMY, HAMSTRING MUSCLE 27325 No MEDICAID NEURECTOMY, POPLITEAL 27326 (GASTROCNEMIUS) No MEDICAID Excision, tumor, thigh or knee area; 27327 Yes subcutaneous MEDICAID Excision, tumor, thigh or knee area; deep, 27328 subfascial, or intramuscular No MEDICAID Radical resection of tumor (eg, malignant 27329 neoplasm), soft tissue of No MEDICAID ARTHROTOMY, KNEE; WITH 27330 SYNOVIAL BIOPSY ONLY No MEDICAID ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN 27331 BODIES No MEDICAID ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL OR 27332 LATERAL No MEDICAID ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL AND 27333 LATERAL No MEDICAID ARTHROTOMY, WITH SYNOVECTOMY KNEE; ANTERIOR OR POSTERIOR 27334 No MEDICAID ARTHROTOMY, WITH SYNOVECTOMY KNEE; ANTERIOR AND POSTERIOR INCLUDING POPLITEAL AREA 27335 No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, 27337 Yes SUBCUTANEOUS; 3 CM OR GREATER MEDICAID EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER 27339 No MEDICAID 27340 Excision, prepatellar bursa No MEDICAID Excision of synovial cyst of popliteal 27345 space (eg, Baker's cyst) No MEDICAID Excision of lesion of meniscus or capsule 27347 (eg, cyst, ganglion), knee No MEDICAID 27350 Patellectomy or hemipatellectomy No MEDICAID Excision or curettage of bone cyst or 27355 benign tumor of femur; No MEDICAID

67 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision or curettage of bone cyst or 27356 benign tumor of femur; with No MEDICAID Excision or curettage of bone cyst or 27357 benign tumor of femur; with No MEDICAID Excision or curettage of bone cyst or 27358 benign tumor of femur; with No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone, 27360 No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF THIGH OR KNEE AREA; 5 27364 CM OR GREATER No MEDICAID Radical resection of tumor, bone, femur or 27365 knee No MEDICAID Injection procedure for knee arthrography 27370 No MEDICAID Removal of foreign body, deep, thigh 27372 region or knee area No MEDICAID Suture of infrapatellar tendon; primary 27380 No MEDICAID Suture of infrapatellar tendon; secondary 27381 reconstruction, including No MEDICAID Suture of quadriceps or hamstring muscle 27385 rupture; primary No MEDICAID Suture of quadriceps or hamstring muscle 27386 rupture; secondary No MEDICAID Tenotomy, open, hamstring, knee to hip; 27390 single tendon No MEDICAID Tenotomy, open, hamstring, knee to hip; 27391 multiple tendons, one leg No MEDICAID Tenotomy, open, hamstring, knee to hip; 27392 multiple tendons, bilateral No MEDICAID Lengthening of hamstring tendon; single 27393 tendon No MEDICAID Lengthening of hamstring tendon; multiple 27394 tendons, one leg No MEDICAID Lengthening of hamstring tendon; multiple 27395 tendons, bilateral No MEDICAID Transplant, hamstring tendon to patella; 27396 single tendon No MEDICAID Transplant, hamstring tendon to patella; 27397 multiple tendons No MEDICAID Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type 27400 No MEDICAID Arthrotomy with meniscus repair, knee 27403 No MEDICAID Repair, primary, torn ligament and/or 27405 capsule, knee; collateral No MEDICAID Repair, primary, torn ligament and/or 27407 capsule, knee; cruciate No MEDICAID Repair, primary, torn ligament and/or 27409 capsule, knee; collateral and No MEDICAID AUTOLOGOUS CHONDROCYTE 27412 IMPLANTATION, KNEE No MEDICAID OSTEOCHONDRAL ALLOGRAFT, 27415 KNEE, OPEN No MEDICAID OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF 27416 AUTOGRAFT(S)) No MEDICAID Anterior tibial tubercleplasty (eg, Maquet 27418 type procedure) No MEDICAID Reconstruction of dislocating patella; (eg, 27420 Hauser type procedure) No MEDICAID Reconstruction of dislocating patella; with 27422 extensor realignment and/or No MEDICAID Reconstruction of dislocating patella; with 27424 patellectomy No MEDICAID 27425 Lateral retinacular release, open No MEDICAID

68 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ligamentous reconstruction 27427 (augmentation), knee; extra-articular No MEDICAID Ligamentous reconstruction (augmentation), knee; intra-articular 27428 (open) No MEDICAID Ligamentous reconstruction (augmentation), knee; intra-articular 27429 (open) No MEDICAID Quadricepsplasty (eg, Bennett or 27430 Thompson type) No MEDICAID Capsulotomy, posterior capsular release, 27435 knee No MEDICAID Arthroplasty, patella; without prosthesis 27437 No MEDICAID 27438 Arthroplasty, patella; with prosthesis No MEDICAID 27440 Arthroplasty, knee, tibial plateau; No MEDICAID Arthroplasty, knee, tibial plateau; with 27441 debridement and partial No MEDICAID Arthroplasty, femoral condyles or tibial 27442 plateau(s), knee; No MEDICAID Arthroplasty, femoral condyles or tibial 27443 plateau(s), knee; with No MEDICAID Arthroplasty, knee, hinge prosthesis (eg, 27445 Walldius type) No MEDICAID Arthroplasty, knee, condyle and plateau; 27446 medial OR lateral No MEDICAID Arthroplasty, knee, condyle and plateau; 27447 medial AND lateral No MEDICAID Osteotomy, femur, shaft or supracondylar; 27448 without fixation No MEDICAID Osteotomy, femur, shaft or supracondylar; 27450 with fixation No MEDICAID Osteotomy, multiple, with realignment on 27454 intramedullary rod, No MEDICAID Osteotomy, proximal tibia, including fibular 27455 excision or osteotomy No MEDICAID Osteotomy, proximal tibia, including fibular 27457 excision or osteotomy No MEDICAID Osteoplasty, femur; shortening (excluding 27465 64876) No MEDICAID 27466 Osteoplasty, femur; lengthening No MEDICAID Osteoplasty, femur; combined, 27468 lengthening and shortening with No MEDICAID Repair, nonunion or malunion, femur, 27470 distal to head and neck; No MEDICAID Repair, nonunion or malunion, femur, 27472 distal to head and neck; No MEDICAID Arrest, epiphyseal, any method (eg, 27475 epiphysiodesis); distal femur No MEDICAID Arrest, epiphyseal, any method (eg, 27477 epiphysiodesis); tibia and fibula, No MEDICAID Arrest, epiphyseal, any method (eg, 27479 epiphysiodesis); combined distal No MEDICAID Arrest, hemiepiphyseal, distal femur or 27485 proximal tibia or fibula (eg, No MEDICAID Revision of total knee arthroplasty, with or 27486 without allograft; one No MEDICAID Revision of total knee arthroplasty, with or 27487 without allograft; No MEDICAID Removal of prosthesis, including total 27488 knee prosthesis, No MEDICAID Prophylactic treatment (nailing, pinning, 27495 plating or wiring) with or No MEDICAID 27496 extensor or adductor); No MEDICAID Decompression fasciotomy, thigh and/or 27497 knee, one compartment (flexor No MEDICAID Decompression fasciotomy, thigh and/or 27498 knee, multiple compartments; No MEDICAID Decompression fasciotomy, thigh and/or 27499 knee, multiple compartments; No MEDICAID

69 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closed treatment of femoral shaft 27500 fracture, without manipulation No MEDICAID Closed treatment of supracondylar or 27501 transcondylar femoral fracture with No MEDICAID Closed treatment of femoral shaft 27502 fracture, with manipulation, with or No MEDICAID Closed treatment of supracondylar or 27503 transcondylar femoral fracture with No MEDICAID Open treatment of femoral shaft fracture, 27506 with or without external No MEDICAID Open treatment of femoral shaft fracture 27507 with plate/screws, with or No MEDICAID Closed treatment of femoral fracture, 27508 distal end, medial or lateral No MEDICAID Percutaneous skeletal fixation of femoral 27509 fracture, distal end, No MEDICAID Closed treatment of femoral fracture, 27510 distal end, medial or lateral No MEDICAID Open treatment of femoral supracondylar or transcondylar fracture 27511 No MEDICAID Open treatment of femoral supracondylar or transcondylar fracture 27513 No MEDICAID Open treatment of femoral fracture, distal 27514 end, medial or lateral No MEDICAID Closed treatment of distal femoral 27516 epiphyseal separation; without No MEDICAID Closed treatment of distal femoral 27517 epiphyseal separation; with No MEDICAID Open treatment of distal femoral 27519 epiphyseal separation, with or No MEDICAID Closed treatment of patellar fracture, 27520 without manipulation No MEDICAID Open treatment of patellar fracture, with 27524 internal fixation and/or No MEDICAID Closed treatment of tibial fracture, 27530 proximal (plateau); without No MEDICAID Closed treatment of tibial fracture, 27532 proximal (plateau); with or without No MEDICAID Open treatment of tibial fracture, proximal 27535 (plateau); unicondylar, with No MEDICAID Open treatment of tibial fracture, proximal 27536 (plateau); bicondylar, with No MEDICAID Closed treatment of intercondylar spine(s) 27538 and/or tuberosity fracture(s) No MEDICAID Open treatment of intercondylar spine(s) 27540 and/or tuberosity fracture(s) No MEDICAID Closed treatment of knee dislocation; 27550 without anesthesia No MEDICAID Closed treatment of knee dislocation; 27552 requiring anesthesia No MEDICAID Open treatment of knee dislocation, with 27556 or without internal or external No MEDICAID Open treatment of knee dislocation, with 27557 or without internal or external No MEDICAID Open treatment of knee dislocation, with 27558 or without internal or external No MEDICAID Closed treatment of patellar dislocation; 27560 without anesthesia No MEDICAID Closed treatment of patellar dislocation; 27562 requiring anesthesia No MEDICAID Open treatment of patellar dislocation, with or without partial or total 27566 No MEDICAID Manipulation of knee joint under general 27570 anesthesia (includes No MEDICAID 27580 Arthrodesis, knee, any technique No MEDICAID Amputation, thigh, through femur, any 27590 level; No MEDICAID

70 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Amputation, thigh, through femur, any 27591 level; immediate fitting No MEDICAID Amputation, thigh, through femur, any 27592 level; open, circular No MEDICAID Amputation, thigh, through femur, any 27594 level; secondary closure or No MEDICAID Amputation, thigh, through femur, any 27596 level; re-amputation No MEDICAID 27598 Disarticulation at knee No MEDICAID UNLISTED PROCEDURE, FEMUR OR 27599 KNEE Yes MEDICAID Decompression fasciotomy, leg; anterior 27600 and/or lateral compartments No MEDICAID Decompression fasciotomy, leg; posterior 27601 compartment(s) only No MEDICAID Decompression fasciotomy, leg; anterior 27602 and/or lateral, and posterior No MEDICAID Incision and drainage, leg or ankle; deep 27603 abscess or hematoma No MEDICAID Incision and drainage, leg or ankle; 27604 infected bursa No MEDICAID Tenotomy, percutaneous, Achilles tendon 27605 (separate procedure); local No MEDICAID Tenotomy, percutaneous, Achilles tendon (separate procedure); general 27606 No MEDICAID Incision (eg, osteomyelitis or bone 27607 abscess), leg or ankle No MEDICAID Arthrotomy, ankle, including exploration, 27610 drainage, or removal of No MEDICAID Arthrotomy, posterior capsular release, ankle, with or without Achilles 27612 No MEDICAID Biopsy, soft tissue of leg or ankle area; 27613 Yes superficial MEDICAID Biopsy, soft tissue of leg or ankle area; 27614 deep (subfascial or No MEDICAID Radical resection of tumor (eg, malignant neoplasm), soft tissue of leg 27615 No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF LEG OR ANKLE AREA; 5 27616 CM OR GREATER No MEDICAID Excision, tumor, leg or ankle area; 27618 Yes subcutaneous tissue MEDICAID Excision, tumor, leg or ankle area; deep 27619 (subfascial or intramuscular) No MEDICAID Arthrotomy, ankle, with joint exploration, with or without biopsy, with 27620 No MEDICAID 27625 Arthrotomy, with synovectomy, ankle; No MEDICAID Arthrotomy, with synovectomy, ankle; 27626 including tenosynovectomy No MEDICAID Excision of lesion of tendon sheath or 27630 capsule (eg, cyst or ganglion), No MEDICAID EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, 27632 Yes SUBCUTANEOUS; 3 CM OR GREATER MEDICAID EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER 27634 No MEDICAID Excision or curettage of bone cyst or 27635 benign tumor, tibia or fibula; No MEDICAID Excision or curettage of bone cyst or 27637 benign tumor, tibia or fibula; No MEDICAID Excision or curettage of bone cyst or 27638 benign tumor, tibia or fibula; No MEDICAID

71 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Partial excision (craterization, saucerization, or diaphysectomy) bone 27640 No MEDICAID Partial excision (craterization, saucerization, or diaphysectomy) bone 27641 No MEDICAID Radical resection of tumor, bone; tibia 27645 No MEDICAID Radical resection of tumor, bone; fibula 27646 No MEDICAID Radical resection of tumor, bone; talus or 27647 calcaneus No MEDICAID Injection procedure for ankle arthrography 27648 No MEDICAID Repair, primary, open or percutaneous, ruptured Achilles tendon; 27650 No MEDICAID Repair, primary, open or percutaneous, ruptured Achilles tendon; with 27652 No MEDICAID Repair, secondary, Achilles tendon, with 27654 or without graft No MEDICAID 27656 Repair, fascial defect of leg No MEDICAID Repair, flexor tendon, leg; primary, 27658 without graft, each tendon No MEDICAID Repair, flexor tendon, leg; secondary, with 27659 or without graft, each No MEDICAID Repair, extensor tendon, leg; primary, 27664 without graft, each tendon No MEDICAID Repair, extensor tendon, leg; secondary, 27665 with or without graft, each No MEDICAID Repair, dislocating peroneal tendons; 27675 without fibular osteotomy No MEDICAID Repair, dislocating peroneal tendons; with 27676 fibular osteotomy No MEDICAID Tenolysis, flexor or extensor tendon, leg 27680 and/or ankle; single, each No MEDICAID Tenolysis, flexor or extensor tendon, leg 27681 and/or ankle; multiple tendons No MEDICAID Lengthening or shortening of tendon, leg 27685 or ankle; single tendon No MEDICAID Lengthening or shortening of tendon, leg 27686 or ankle; multiple tendons No MEDICAID Gastrocnemius recession (eg, Strayer 27687 procedure) No MEDICAID Transfer or transplant of single tendon 27690 (with muscle redirection or No MEDICAID Transfer or transplant of single tendon 27691 (with muscle redirection or No MEDICAID Transfer or transplant of single tendon 27692 (with muscle redirection or No MEDICAID Repair, primary, disrupted ligament, 27695 ankle; collateral No MEDICAID Repair, primary, disrupted ligament, 27696 ankle; both collateral ligaments No MEDICAID Repair, secondary, disrupted ligament, 27698 ankle, collateral (eg, No MEDICAID 27700 Arthroplasty, ankle; No MEDICAID Arthroplasty, ankle; with implant (total 27702 ankle) No MEDICAID Arthroplasty, ankle; revision, total ankle 27703 No MEDICAID 27704 Removal of ankle implant No MEDICAID 27705 Osteotomy; tibia No MEDICAID 27707 Osteotomy; fibula No MEDICAID 27709 Osteotomy; tibia and fibula No MEDICAID Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield 27712 No MEDICAID Osteoplasty, tibia and fibula, lengthening 27715 or shortening No MEDICAID

72 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair of nonunion or malunion, tibia; 27720 without graft, (eg, compression No MEDICAID Repair of nonunion or malunion, tibia; with 27722 sliding graft No MEDICAID Repair of nonunion or malunion, tibia; with 27724 iliac or other autograft No MEDICAID Repair of nonunion or malunion, tibia; by 27725 synostosis, with fibula, any No MEDICAID REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL 27726 FIXATION No MEDICAID Repair of congenital pseudarthrosis, tibia 27727 No MEDICAID Arrest, epiphyseal (epiphysiodesis), open; 27730 distal tibia No MEDICAID Arrest, epiphyseal (epiphysiodesis), open; 27732 distal fibula No MEDICAID Arrest, epiphyseal (epiphysiodesis), open; 27734 distal tibia and fibula No MEDICAID Arrest, epiphyseal (epiphysiodesis), any 27740 method, combined, proximal No MEDICAID Arrest, epiphyseal (epiphysiodesis), any 27742 method, combined, proximal No MEDICAID Prophylactic treatment (nailing, pinning, 27745 plating or wiring) with or No MEDICAID Closed treatment of tibial shaft fracture 27750 (with or without fibular No MEDICAID Closed treatment of tibial shaft fracture 27752 (with or without fibular No MEDICAID Percutaneous skeletal fixation of tibial 27756 shaft fracture (with or without No MEDICAID Open treatment of tibial shaft fracture, 27758 (with or without fibular No MEDICAID Treatment of tibial shaft fracture (with or 27759 without fibular fracture) by No MEDICAID Closed treatment of medial malleolus fracture; without manipulation 27760 No MEDICAID Closed treatment of medial malleolus fracture; with manipulation, with 27762 No MEDICAID Open treatment of medial malleolus 27766 fracture, with or without internal or No MEDICAID CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITHOUT MANIPULATION 27767 No MEDICAID CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH 27768 MANIPULATION No MEDICAID OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN 27769 PERFORMED No MEDICAID Closed treatment of proximal fibula or 27780 shaft fracture; without No MEDICAID Closed treatment of proximal fibula or 27781 shaft fracture; with manipulation No MEDICAID Open treatment of proximal fibula or shaft 27784 fracture, with or without No MEDICAID Closed treatment of distal fibular fracture 27786 (lateral malleolus); without No MEDICAID Closed treatment of distal fibular fracture 27788 (lateral malleolus); with No MEDICAID Open treatment of distal fibular fracture 27792 (lateral malleolus), with or No MEDICAID Closed treatment of bimalleolar ankle 27808 fracture, (including Potts); No MEDICAID Closed treatment of bimalleolar ankle 27810 fracture, (including Potts); with No MEDICAID

73 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open treatment of bimalleolar ankle 27814 fracture, with or without internal No MEDICAID Closed treatment of trimalleolar ankle 27816 fracture; without manipulation No MEDICAID Closed treatment of trimalleolar ankle 27818 fracture; with manipulation No MEDICAID Open treatment of trimalleolar ankle 27822 fracture, with or without internal No MEDICAID Open treatment of trimalleolar ankle 27823 fracture, with or without internal No MEDICAID Closed treatment of fracture of weight 27824 bearing articular portion of No MEDICAID Closed treatment of fracture of weight 27825 bearing articular portion of No MEDICAID Open treatment of fracture of weight 27826 bearing articular surface/portion No MEDICAID Open treatment of fracture of weight 27827 bearing articular surface/portion No MEDICAID Open treatment of fracture of weight 27828 bearing articular surface/portion No MEDICAID Open treatment of distal tibiofibular joint 27829 (syndesmosis) disruption, No MEDICAID Closed treatment of proximal tibiofibular 27830 joint dislocation; without No MEDICAID Closed treatment of proximal tibiofibular 27831 joint dislocation; requiring No MEDICAID Open treatment of proximal tibiofibular 27832 joint dislocation, with or No MEDICAID Closed treatment of ankle dislocation; 27840 without anesthesia No MEDICAID Closed treatment of ankle dislocation; requiring anesthesia, with or 27842 No MEDICAID Open treatment of ankle dislocation, with 27846 or without percutaneous No MEDICAID Open treatment of ankle dislocation, with 27848 or without percutaneous No MEDICAID Manipulation of ankle under general 27860 anesthesia (includes application of No MEDICAID 27870 Arthrodesis, ankle, open No MEDICAID Arthrodesis, tibiofibular joint, proximal or 27871 distal No MEDICAID Amputation, leg, through tibia and fibula; 27880 No MEDICAID Amputation, leg, through tibia and fibula; 27881 with immediate fitting No MEDICAID Amputation, leg, through tibia and fibula; 27882 open, circular (guillotine) No MEDICAID Amputation, leg, through tibia and fibula; 27884 secondary closure or scar No MEDICAID Amputation, leg, through tibia and fibula; 27886 re-amputation No MEDICAID Amputation, ankle, through malleoli of 27888 tibia and fibula (eg, Syme, No MEDICAID 27889 Ankle disarticulation No MEDICAID Decompression fasciotomy, leg; anterior 27892 and/or lateral compartments No MEDICAID Decompression fasciotomy, leg; posterior 27893 compartment(s) only, with No MEDICAID Decompression fasciotomy, leg; anterior 27894 and/or lateral, and posterior No MEDICAID UNLISTED PROCEDURE, LEG OR 27899 ANKLE Yes MEDICAID 28001 Incision and drainage, bursa, foot No MEDICAID Incision and drainage below fascia, with 28002 or without tendon sheath No MEDICAID Incision and drainage below fascia, with 28003 or without tendon sheath No MEDICAID Incision, bone cortex (eg, osteomyelitis or 28005 bone abscess), foot No MEDICAID 28008 Fasciotomy, foot and/or toe No MEDICAID

74 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Tenotomy, percutaneous, toe; single 28010 tendon No MEDICAID Tenotomy, percutaneous, toe; multiple 28011 tendons No MEDICAID Arthrotomy, including exploration, 28020 drainage, or removal of loose or No MEDICAID Arthrotomy, including exploration, 28022 drainage, or removal of loose or No MEDICAID Arthrotomy, including exploration, 28024 drainage, or removal of loose or No MEDICAID Release, tarsal tunnel (posterior tibial 28035 nerve decompression) No MEDICAID EXCISION, TUMOR, SOF TISSUE OF 28039 FOOT OR TOE, SUBCUTANEOUS; 1.5 Yes CM OR GREATER MEDICAID EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBFASCIAL (EG, INTRAMUSCULAR); 1.5 CM OR 28041 GREATER No MEDICAID Excision, tumor, foot; subcutaneous 28043 Yes tissue MEDICAID Excision, tumor, foot; deep, subfascial, 28045 intramuscular No MEDICAID Radical resection of tumor (eg, malignant neoplasm), soft tissue of foot 28046 No MEDICAID RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FOOT OR TOE; 3 CM OR 28047 GREATER No MEDICAID Arthrotomy with biopsy; intertarsal or 28050 tarsometatarsal joint No MEDICAID Arthrotomy with biopsy; 28052 metatarsophalangeal joint No MEDICAID Arthrotomy with biopsy; interphalangeal 28054 joint No MEDICAID NEURECTOMY, INTRINSIC 28055 MUSCULATURE OF FOOT No MEDICAID Fasciectomy, plantar fascia; partial 28060 (separate procedure) No MEDICAID Fasciectomy, plantar fascia; radical 28062 (separate procedure) No MEDICAID Synovectomy; intertarsal or 28070 tarsometatarsal joint, each No MEDICAID Synovectomy; metatarsophalangeal joint, 28072 each No MEDICAID Excision, interdigital (Morton) neuroma, 28080 single, each No MEDICAID Synovectomy, tendon sheath, foot; flexor 28086 No MEDICAID Synovectomy, tendon sheath, foot; 28088 extensor No MEDICAID Excision of lesion, tendon, tendon sheath, 28090 or capsule (including No MEDICAID Excision of lesion, tendon, tendon sheath, 28092 or capsule (including No MEDICAID Excision or curettage of bone cyst or 28100 benign tumor, talus or calcaneus; No MEDICAID Excision or curettage of bone cyst or 28102 benign tumor, talus or calcaneus; No MEDICAID Excision or curettage of bone cyst or 28103 benign tumor, talus or calcaneus; No MEDICAID Excision or curettage of bone cyst or 28104 benign tumor, tarsal or No MEDICAID Excision or curettage of bone cyst or 28106 benign tumor, tarsal or No MEDICAID Excision or curettage of bone cyst or 28107 benign tumor, tarsal or No MEDICAID Excision or curettage of bone cyst or 28108 benign tumor, phalanges of foot No MEDICAID

75 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ostectomy, partial excision, fifth 28110 metatarsal head (bunionette) No MEDICAID Ostectomy, complete excision; first 28111 metatarsal head No MEDICAID Ostectomy, complete excision; other 28112 metatarsal head (second, third or No MEDICAID Ostectomy, complete excision; fifth 28113 metatarsal head No MEDICAID Ostectomy, complete excision; all 28114 metatarsal heads, with partial No MEDICAID Ostectomy, excision of tarsal coalition 28116 No MEDICAID 28118 Ostectomy, calcaneus; No MEDICAID Ostectomy, calcaneus; for spur, with or 28119 without plantar fascial release No MEDICAID Partial excision (craterization, 28120 saucerization, sequestrectomy, or No MEDICAID Partial excision (craterization, 28122 saucerization, sequestrectomy, or No MEDICAID Partial excision (craterization, 28124 saucerization, sequestrectomy, or No MEDICAID Resection, partial or complete, phalangeal 28126 base, each toe No MEDICAID 28130 Talectomy (astragalectomy) No MEDICAID 28140 Metatarsectomy No MEDICAID 28150 Phalangectomy, toe, each toe No MEDICAID Resection, condyle(s), distal end of 28153 phalanx, each toe No MEDICAID Hemiphalangectomy or interphalangeal joint excision, toe, proximal end 28160 No MEDICAID Radical resection of tumor, bone; tarsal 28171 (except talus or calcaneus) No MEDICAID Radical resection of tumor, bone; 28173 metatarsal No MEDICAID Radical resection of tumor, bone; phalanx 28175 of toe No MEDICAID Removal of foreign body, foot; 28190 subcutaneous No MEDICAID 28192 Removal of foreign body, foot; deep No MEDICAID Removal of foreign body, foot; 28193 complicated No MEDICAID Repair, tendon, flexor, foot; primary or 28200 secondary, without free graft, No MEDICAID Repair, tendon, flexor, foot; secondary with free graft, each tendon 28202 No MEDICAID Repair, tendon, extensor, foot; primary or 28208 secondary, each tendon No MEDICAID Repair, tendon, extensor, foot; secondary with free graft, each tendon 28210 No MEDICAID 28220 Tenolysis, flexor, foot; single tendon No MEDICAID Tenolysis, flexor, foot; multiple tendons 28222 No MEDICAID Tenolysis, extensor, foot; single tendon 28225 No MEDICAID Tenolysis, extensor, foot; multiple tendons 28226 No MEDICAID Tenotomy, open, tendon flexor; foot, 28230 single or multiple tendon(s) No MEDICAID Tenotomy, open, tendon flexor; toe, single 28232 tendon (separate procedure) No MEDICAID Tenotomy, open, extensor, foot or toe, 28234 each tendon No MEDICAID Reconstruction (advancement), posterior tibial tendon with excision of 28238 No MEDICAID Tenotomy, lengthening, or release, 28240 abductor hallucis muscle No MEDICAID

76 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Division of plantar fascia and muscle (eg, 28250 Steindler stripping) No MEDICAID Capsulotomy, midfoot; medial release 28260 only (separate procedure) No MEDICAID Capsulotomy, midfoot; with tendon 28261 lengthening No MEDICAID Capsulotomy, midfoot; extensive, 28262 including posterior talotibial No MEDICAID Capsulotomy, midtarsal (eg, Heyman type 28264 procedure) No MEDICAID Capsulotomy; metatarsophalangeal joint, 28270 with or without tenorrhaphy, No MEDICAID Capsulotomy; interphalangeal joint, each 28272 joint (separate procedure) No MEDICAID Syndactylization, toes (eg, webbing or 28280 Kelikian type procedure) No MEDICAID Correction, hammertoe (eg, 28285 interphalangeal fusion, partial or total No MEDICAID Correction, cock-up fifth toe, with plastic 28286 skin closure (eg, Ruiz-Mora No MEDICAID Ostectomy, partial, exostectomy or 28288 condylectomy, metatarsal head, No MEDICAID Hallux rigidus correction with cheilectomy, debridement and capsular 28289 No MEDICAID Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant 28291 No MEDICAID Correction, hallux valgus (bunion), with or 28292 without sesamoidectomy; No MEDICAID Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method 28295 No MEDICAID Correction, hallux valgus (bunion), with or 28296 without sesamoidectomy; with No MEDICAID Correction, hallux valgus (bunion), with or 28297 without sesamoidectomy; No MEDICAID Correction, hallux valgus (bunion), with or 28298 without sesamoidectomy; by No MEDICAID Correction, hallux valgus (bunion), with or 28299 without sesamoidectomy; by No MEDICAID Osteotomy; calcaneus (eg, Dwyer or 28300 Chambers type procedure), with or No MEDICAID 28302 Osteotomy; talus No MEDICAID Osteotomy, tarsal bones, other than 28304 calcaneus or talus; No MEDICAID Osteotomy, tarsal bones, other than 28305 calcaneus or talus; with autograft No MEDICAID Osteotomy, with or without lengthening, 28306 shortening or angular No MEDICAID Osteotomy, with or without lengthening, 28307 shortening or angular No MEDICAID Osteotomy, with or without lengthening, 28308 shortening or angular No MEDICAID Osteotomy, with or without lengthening, 28309 shortening or angular No MEDICAID Osteotomy, shortening, angular or 28310 rotational correction; proximal No MEDICAID Osteotomy, shortening, angular or 28312 rotational correction; other No MEDICAID Reconstruction, angular deformity of toe, 28313 soft tissue procedures only No MEDICAID Sesamoidectomy, first toe (separate 28315 procedure) No MEDICAID Repair, nonunion or malunion; tarsal 28320 bones No MEDICAID

77 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair, nonunion or malunion; metatarsal, 28322 with or without bone graft No MEDICAID Reconstruction, toe, macrodactyly; soft 28340 tissue resection No MEDICAID Reconstruction, toe, macrodactyly; 28341 requiring bone resection No MEDICAID 28344 Reconstruction, toe(s); polydactyly No MEDICAID Reconstruction, toe(s); syndactyly, with or 28345 without skin graft(s), each No MEDICAID 28360 Reconstruction, cleft foot No MEDICAID Closed treatment of calcaneal fracture; 28400 without manipulation No MEDICAID Closed treatment of calcaneal fracture; 28405 with manipulation No MEDICAID Percutaneous skeletal fixation of 28406 calcaneal fracture, with manipulation No MEDICAID Open treatment of calcaneal fracture, with 28415 or without internal or No MEDICAID Open treatment of calcaneal fracture, with 28420 or without internal or No MEDICAID Closed treatment of talus fracture; without 28430 manipulation No MEDICAID Closed treatment of talus fracture; with 28435 manipulation No MEDICAID Percutaneous skeletal fixation of talus 28436 fracture, with manipulation No MEDICAID Open treatment of talus fracture, with or 28445 without internal or external No MEDICAID Open osteochondral autograft, talus 28446 No (includes obtaining graft[s]) MEDICAID Treatment of tarsal bone fracture (except 28450 talus and calcaneus); without No MEDICAID Treatment of tarsal bone fracture (except 28455 talus and calcaneus); with No MEDICAID Percutaneous skeletal fixation of tarsal 28456 bone fracture (except talus and No MEDICAID Open treatment of tarsal bone fracture 28465 (except talus and calcaneus), No MEDICAID Closed treatment of metatarsal fracture; 28470 without manipulation, each No MEDICAID Closed treatment of metatarsal fracture; 28475 with manipulation, each No MEDICAID Percutaneous skeletal fixation of 28476 metatarsal fracture, with No MEDICAID Open treatment of metatarsal fracture, 28485 with or without internal or No MEDICAID Closed treatment of fracture great toe, 28490 phalanx or phalanges; without No MEDICAID Closed treatment of fracture great toe, 28495 phalanx or phalanges; with No MEDICAID Percutaneous skeletal fixation of fracture 28496 great toe, phalanx or No MEDICAID Open treatment of fracture great toe, 28505 phalanx or phalanges, with or No MEDICAID Closed treatment of fracture, phalanx or 28510 phalanges, other than great No MEDICAID Closed treatment of fracture, phalanx or 28515 phalanges, other than great No MEDICAID Open treatment of fracture, phalanx or 28525 phalanges, other than great toe, No MEDICAID Closed treatment of sesamoid fracture 28530 No MEDICAID Open treatment of sesamoid fracture, with 28531 or without internal fixation No MEDICAID Closed treatment of tarsal bone 28540 dislocation, other than talotarsal; No MEDICAID Closed treatment of tarsal bone 28545 dislocation, other than talotarsal; No MEDICAID Percutaneous skeletal fixation of tarsal 28546 bone dislocation, other than No MEDICAID

78 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open treatment of tarsal bone dislocation, 28555 with or without internal or No MEDICAID Closed treatment of talotarsal joint 28570 dislocation; without anesthesia No MEDICAID Closed treatment of talotarsal joint 28575 dislocation; requiring anesthesia No MEDICAID Percutaneous skeletal fixation of 28576 talotarsal joint dislocation, with No MEDICAID Open treatment of talotarsal joint 28585 dislocation, with or without internal No MEDICAID Closed treatment of tarsometatarsal joint 28600 dislocation; without No MEDICAID Closed treatment of tarsometatarsal joint 28605 dislocation; requiring No MEDICAID Percutaneous skeletal fixation of 28606 tarsometatarsal joint dislocation, No MEDICAID Open treatment of tarsometatarsal joint 28615 dislocation, with or without No MEDICAID Closed treatment of metatarsophalangeal joint dislocation; without 28630 No MEDICAID Closed treatment of metatarsophalangeal joint dislocation; requiring 28635 No MEDICAID Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, 28636 No MEDICAID Open treatment of metatarsophalangeal joint dislocation, with or without 28645 No MEDICAID Closed treatment of interphalangeal joint 28660 dislocation; without No MEDICAID Closed treatment of interphalangeal joint 28665 dislocation; requiring No MEDICAID Percutaneous skeletal fixation of 28666 interphalangeal joint dislocation, No MEDICAID Open treatment of interphalangeal joint 28675 dislocation, with or without No MEDICAID 28705 Arthrodesis; pantalar No MEDICAID 28715 Arthrodesis; triple No MEDICAID 28725 Arthrodesis; subtalar No MEDICAID Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; 28730 No MEDICAID Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with 28735 No MEDICAID Arthrodesis, with tendon lengthening and 28737 advancement, midtarsal, tarsal No MEDICAID Arthrodesis, midtarsal or tarsometatarsal, 28740 single joint No MEDICAID Arthrodesis, great toe; 28750 metatarsophalangeal joint No MEDICAID Arthrodesis, great toe; interphalangeal 28755 joint No MEDICAID Arthrodesis, with extensor hallucis longus 28760 transfer to first metatarsal No MEDICAID Amputation, foot; midtarsal (eg, Chopart 28800 type procedure) No MEDICAID 28805 Amputation, foot; transmetatarsal No MEDICAID Amputation, metatarsal, with toe, single 28810 No MEDICAID Amputation, toe; metatarsophalangeal 28820 joint No MEDICAID 28825 Amputation, toe; interphalangeal joint No MEDICAID EXTRACORPOREAL SHOCK WAVE, HI ENERGY, PERFORMED BY A PHYS, 28890 REQUIRING ANESTHESIA OTHER No THAN LOCA, INCLDG ULTRASOUND GUIDANCE INVOLV MEDICAID

79 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNLISTED PROCEDURE, FOOT OR 28899 TOES Yes MEDICAID Application of halo type body cast (see 29000 20661-20663 for insertion) No MEDICAID Application of Risser jacket, localizer, 29010 body; only No MEDICAID Application of Risser jacket, localizer, 29015 body; including head No MEDICAID Application of body cast, shoulder to hips; 29035 No MEDICAID Application of body cast, shoulder to hips; 29040 including head, Minerva type No MEDICAID Application of body cast, shoulder to hips; 29044 including one thigh No MEDICAID Application of body cast, shoulder to hips; 29046 including both thighs No MEDICAID 29049 Application, cast; figure-of-eight No MEDICAID 29055 Application, cast; shoulder spica No MEDICAID 29058 Application, cast; plaster Velpeau No MEDICAID Application, cast; shoulder to hand (long 29065 arm) No MEDICAID Application, cast; elbow to finger (short 29075 arm) No MEDICAID Application, cast; hand and lower forearm 29085 (gauntlet) No MEDICAID Application, cast; finger (eg, contracture) 29086 No MEDICAID Application of long arm splint (shoulder to 29105 hand) No MEDICAID Application of short arm splint (forearm to 29125 hand); static No MEDICAID Application of short arm splint (forearm to 29126 hand); dynamic No MEDICAID 29130 Application of finger splint; static No MEDICAID 29131 Application of finger splint; dynamic No MEDICAID 29200 Strapping; thorax No MEDICAID 29240 Strapping; shoulder (eg, Velpeau) No MEDICAID 29260 Strapping; elbow or wrist No MEDICAID 29280 Strapping; hand or finger No MEDICAID 29305 Application of hip spica cast; one leg No MEDICAID Application of hip spica cast; one and one- 29325 half spica or both legs No MEDICAID Application of long leg cast (thigh to toes); 29345 No MEDICAID Application of long leg cast (thigh to toes); 29355 walker or ambulatory type No MEDICAID 29358 Application of long leg cast brace No MEDICAID Application of cylinder cast (thigh to ankle) 29365 No MEDICAID Application of short leg cast (below knee 29405 to toes); No MEDICAID Application of short leg cast (below knee 29425 to toes); walking or No MEDICAID Application of patellar tendon bearing 29435 (PTB) cast No MEDICAID Adding walker to previously applied cast 29440 No MEDICAID Application of rigid total contact leg cast 29445 No MEDICAID Application of clubfoot cast with molding or manipulation, long or short 29450 No MEDICAID Application of long leg splint (thigh to 29505 ankle or toes) No MEDICAID Application of short leg splint (calf to foot) 29515 No MEDICAID 29520 Strapping; hip No MEDICAID 29530 Strapping; knee No MEDICAID 29540 Strapping; ankle and/or foot No MEDICAID 29550 Strapping; toes No MEDICAID

80 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 29580 Strapping; Unna boot No MEDICAID APPLICATION OF MULTI-LAYER VENOUS WOUND COMPRESSION 29581 SYSTEM, BELOW KNEE No MEDICAID Application of multi-layer compression system; upper arm, forearm, hand, and 29584 fingers No MEDICAID Removal or bivalving; gauntlet, boot or 29700 body cast No MEDICAID Removal or bivalving; full arm or full leg 29705 cast No MEDICAID Removal or bivalving; shoulder or hip 29710 spica, Minerva, or Risser jacket, No MEDICAID 29720 Repair of spica, body cast or jacket No MEDICAID 29730 Windowing of cast No MEDICAID Wedging of cast (except clubfoot casts) 29740 No MEDICAID 29750 Wedging of clubfoot cast No MEDICAID UNLISTED PROCEDURE, CASTING OR 29799 STRAPPING Yes MEDICAID Arthroscopy, temporomandibular joint, 29800 diagnostic, with or without No MEDICAID Arthroscopy, temporomandibular joint, 29804 surgical No MEDICAID Arthroscopy, shoulder, diagnostic, with or 29805 without synovial biopsy No MEDICAID Arthroscopy, shoulder, surgical; 29806 capsulorrhaphy No MEDICAID Arthroscopy, shoulder, surgical; repair of 29807 SLAP lesion No MEDICAID Arthroscopy, shoulder, surgical; with 29819 removal of loose body or foreign No MEDICAID Arthroscopy, shoulder, surgical; 29820 synovectomy, partial No MEDICAID Arthroscopy, shoulder, surgical; 29821 synovectomy, complete No MEDICAID Arthroscopy, shoulder, surgical; 29822 debridement, limited No MEDICAID Arthroscopy, shoulder, surgical; 29823 debridement, extensive No MEDICAID Arthroscopy, shoulder, surgical; distal 29824 claviculectomy including distal No MEDICAID Arthroscopy, shoulder, surgical; with lysis 29825 and resection of adhesions, No MEDICAID Arthroscopy, shoulder, surgical; decompression of subacromial space 29826 No MEDICAID Arthroscopy, shoulder, surgical; with 29827 rotator cuff repair No MEDICAID ARTHROSCOPY, SHOULDER, 29828 SURGICAL; BICEPS TENODESIS No MEDICAID Arthroscopy, elbow, diagnostic, with or 29830 without synovial biopsy No MEDICAID Arthroscopy, elbow, surgical; with removal 29834 of loose body or foreign body No MEDICAID Arthroscopy, elbow, surgical; 29835 synovectomy, partial No MEDICAID Arthroscopy, elbow, surgical; 29836 synovectomy, complete No MEDICAID Arthroscopy, elbow, surgical; 29837 debridement, limited No MEDICAID Arthroscopy, elbow, surgical; 29838 debridement, extensive No MEDICAID Arthroscopy, wrist, diagnostic, with or 29840 without synovial biopsy No MEDICAID Arthroscopy, wrist, surgical; for infection, 29843 lavage and drainage No MEDICAID Arthroscopy, wrist, surgical; synovectomy, 29844 partial No MEDICAID Arthroscopy, wrist, surgical; synovectomy, 29845 complete No MEDICAID

81 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthroscopy, wrist, surgical; excision 29846 and/or repair of triangular No MEDICAID Arthroscopy, wrist, surgical; internal 29847 fixation for fracture or No MEDICAID Endoscopy, wrist, surgical, with release of 29848 transverse carpal ligament No MEDICAID Arthroscopically aided treatment of 29850 intercondylar spine(s) and/or No MEDICAID Arthroscopically aided treatment of 29851 intercondylar spine(s) and/or No MEDICAID Arthroscopically aided treatment of tibial 29855 fracture, proximal (plateau); No MEDICAID Arthroscopically aided treatment of tibial 29856 fracture, proximal (plateau); No MEDICAID Arthroscopy, hip, diagnostic with or 29860 without synovial biopsy (separate No MEDICAID Arthroscopy, hip, surgical; with removal of 29861 loose body or foreign body No MEDICAID Arthroscopy, hip, surgical; with 29862 debridement/shaving of articular No MEDICAID Arthroscopy, hip, surgical; with 29863 synovectomy No MEDICAID ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, MOSAICPLASTY) (INCLUDES 29866 HARVESTING OF THE AUTOGRAFT) No MEDICAID ARTHROSCOPY, KNEE; SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, 29867 MOSAICPLASTY) No MEDICAID ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR 29868 LATERAL No MEDICAID Arthroscopy, knee, diagnostic, with or 29870 without synovial biopsy (separate No MEDICAID ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND 29871 DRAINAGE No MEDICAID Arthroscopy, knee, surgical; with lateral 29873 release No MEDICAID ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAG 29874 No MEDICAID Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf 29875 No MEDICAID Arthroscopy, knee, surgical; synovectomy, 29876 major, two or more No MEDICAID ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE 29877 (CHONDROPLASTY) No MEDICAID ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE 29879 No MEDICAID Arthroscopy, knee, surgical; with 29880 meniscectomy (medial AND lateral, No MEDICAID Arthroscopy, knee, surgical; with 29881 meniscectomy (medial OR lateral, No MEDICAID Arthroscopy, knee, surgical; with 29882 meniscus repair (medial OR lateral) No MEDICAID Arthroscopy, knee, surgical; with 29883 meniscus repair (medial AND lateral) No MEDICAID Arthroscopy, knee, surgical; with lysis of 29884 adhesions, with or without No MEDICAID

82 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arthroscopy, knee, surgical; drilling for 29885 osteochondritis dissecans with No MEDICAID Arthroscopy, knee, surgical; drilling for 29886 intact osteochondritis No MEDICAID Arthroscopy, knee, surgical; drilling for 29887 intact osteochondritis No MEDICAID Arthroscopically aided anterior cruciate ligament repair/augmentation or 29888 No MEDICAID Arthroscopically aided posterior cruciate ligament repair/augmentation 29889 No MEDICAID Arthroscopy, ankle, surgical, excision of 29891 osteochondral defect of talus No MEDICAID Arthroscopically aided repair of large 29892 osteochondritis dissecans lesion, No MEDICAID 29893 Endoscopic plantar fasciotomy No MEDICAID Arthroscopy, ankle (tibiotalar and 29894 fibulotalar joints), surgical; with No MEDICAID Arthroscopy, ankle (tibiotalar and 29895 fibulotalar joints), surgical; No MEDICAID Arthroscopy, ankle (tibiotalar and 29897 fibulotalar joints), surgical; No MEDICAID Arthroscopy, ankle (tibiotalar and 29898 fibulotalar joints), surgical; No MEDICAID Arthroscopy, ankle (tibiotalar and 29899 fibulotalar joints), surgical; with No MEDICAID Arthroscopy, metacarpophalangeal joint, 29900 diagnostic, includes synovial No MEDICAID Arthroscopy, metacarpophalangeal joint, 29901 surgical; with debridement No MEDICAID Arthroscopy, metacarpophalangeal joint, 29902 surgical; with reduction of No MEDICAID ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH REMOVAL OF 29904 LOOSE BODY OR FOREIGN BODY No MEDICAID ARTHROSCOPY, SUBTALAR JOINT, 29905 SURGICAL; WITH SYNOVECTOMY No MEDICAID ARTHROSCOPY, SUBTALAR JOINT, 29906 SURGICAL; WITH DEBRIDEMENT No MEDICAID ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SUBTALAR 29907 ARTHRODESIS No MEDICAID 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) No MEDICAID 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) No MEDICAID 29916 Arthroscopy, hip, surgical; with labral repair No MEDICAID UNLISTED ARTHROSCOPY 29999 PROCEDURE Yes MEDICAID Drainage abscess or hematoma, nasal, 30000 internal approach No MEDICAID Drainage abscess or hematoma, nasal 30020 septum No MEDICAID 30100 Biopsy, intranasal No MEDICAID 30110 Excision, nasal polyp(s), simple No MEDICAID 30115 Excision, nasal polyp(s), extensive No MEDICAID Excision or destruction (eg, laser), 30117 intranasal lesion; internal No MEDICAID Excision or destruction (eg, laser), 30118 intranasal lesion; external No MEDICAID Excision or surgical planing of skin of 30120 Yes nose for rhinophyma MEDICAID Excision dermoid cyst, nose; simple, skin, 30124 subcutaneous No MEDICAID Excision dermoid cyst, nose; complex, 30125 under bone or cartilage No MEDICAID

83 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision turbinate, partial or complete, 30130 any method No MEDICAID Submucous resection turbinate, partial or 30140 complete, any method No MEDICAID 30150 Rhinectomy; partial No MEDICAID 30160 Rhinectomy; total No MEDICAID 30200 Injection into turbinate(s), therapeutic No MEDICAID 30210 Displacement therapy (Proetz type) No MEDICAID Insertion, nasal septal prosthesis (button) 30220 No MEDICAID Removal foreign body, intranasal; office 30300 type procedure No MEDICAID REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERAL 30310 ANESTHESIA No MEDICAID REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL 30320 RHINOTOMY No MEDICAID RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR 30400 ELEVATION OF NASAL TIP Yes MEDICAID RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF 30410 NASAL TIP Yes MEDICAID RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR 30420 Yes MEDICAID RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL 30430 TIP WORK) Yes MEDICAID RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY 30435 WORK WITH OSTEOTOMIES) Yes MEDICAID RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND 30450 OSTEOTOMIES) Yes MEDICAID RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR 30460 LENGTHENING; TIP ONLY Yes MEDICAID RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO 30462 CONGENITAL CLEFT LIP AND/OR Yes PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OS MEDICAID REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER 30465 Yes GRAFTING, LATERAL NASAL WALL RECONSTRUCTION) MEDICAID SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT 30520 CARTILAGE SCORING, CONTOURING Yes OR REPLACEMENT WITH GRAFT MEDICAID 30540 Repair choanal atresia; intranasal No MEDICAID 30545 Repair choanal atresia; transpalatine No MEDICAID 30560 Lysis intranasal synechia No MEDICAID Repair fistula; oromaxillary (combine with 30580 31030 if antrotomy is No MEDICAID 30600 Repair fistula; oronasal No MEDICAID SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT 30620 INCLUDE OBTAINING GRAFT) No MEDICAID 30630 Repair nasal septal perforations No MEDICAID Cautery and/or ablation, mucosa of 30801 turbinates, unilateral or bilateral, No MEDICAID Cautery and/or ablation, mucosa of 30802 turbinates, unilateral or bilateral, No MEDICAID

84 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Control nasal hemorrhage, anterior, 30901 simple (limited cautery and/or No MEDICAID Control nasal hemorrhage, anterior, 30903 complex (extensive cautery and/or No MEDICAID Control nasal hemorrhage, posterior, with 30905 posterior nasal packs and/or No MEDICAID Control nasal hemorrhage, posterior, with 30906 posterior nasal packs and/or No MEDICAID 30915 Ligation arteries; ethmoidal No MEDICAID Ligation arteries; internal maxillary artery, 30920 transantral No MEDICAID Fracture nasal turbinate(s), therapeutic 30930 No MEDICAID 30999 UNLISTED PROCEDURE, NOSE Yes MEDICAID Lavage by cannulation; maxillary sinus 31000 (antrum puncture or natural No MEDICAID Lavage by cannulation; sphenoid sinus 31002 No MEDICAID Sinusotomy, maxillary (antrotomy); 31020 intranasal No MEDICAID Sinusotomy, maxillary (antrotomy); radical 31030 (Caldwell-Luc) without No MEDICAID Sinusotomy, maxillary (antrotomy); radical 31032 (Caldwell-Luc) with removal No MEDICAID Pterygomaxillary fossa surgery, any 31040 approach No MEDICAID Sinusotomy, sphenoid, with or without 31050 biopsy; No MEDICAID Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or 31051 No MEDICAID Sinusotomy frontal; external, simple 31070 (trephine operation) No MEDICAID Sinusotomy frontal; transorbital, unilateral 31075 (for mucocele or osteoma, No MEDICAID Sinusotomy frontal; obliterative without 31080 osteoplastic flap, brow No MEDICAID Sinusotomy frontal; obliterative, without 31081 osteoplastic flap, coronal No MEDICAID Sinusotomy frontal; obliterative, with 31084 osteoplastic flap, brow incision No MEDICAID Sinusotomy frontal; obliterative, with 31085 osteoplastic flap, coronal No MEDICAID Sinusotomy frontal; nonobliterative, with 31086 osteoplastic flap, brow No MEDICAID Sinusotomy frontal; nonobliterative, with 31087 osteoplastic flap, coronal No MEDICAID Sinusotomy, unilateral, three or more 31090 paranasal sinuses (frontal, No MEDICAID 31200 Ethmoidectomy; intranasal, anterior No MEDICAID 31201 Ethmoidectomy; intranasal, total No MEDICAID 31205 Ethmoidectomy; extranasal, total No MEDICAID Maxillectomy; without orbital exenteration 31225 No MEDICAID Maxillectomy; with orbital exenteration (en 31230 bloc) No MEDICAID Nasal endoscopy, diagnostic, unilateral or 31231 bilateral (separate No MEDICAID Nasal/sinus endoscopy, diagnostic with 31233 maxillary sinusoscopy (via No MEDICAID Nasal/sinus endoscopy, diagnostic with 31235 sphenoid sinusoscopy (via No MEDICAID Nasal/sinus endoscopy, surgical; with 31237 biopsy, polypectomy or No MEDICAID Nasal/sinus endoscopy, surgical; with 31238 control of nasal hemorrhage No MEDICAID Nasal/sinus endoscopy, surgical; with 31239 dacryocystorhinostomy No MEDICAID Nasal/sinus endoscopy, surgical; with 31240 concha bullosa resection No MEDICAID

85 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Nasal/sinus endoscopy, surgical; with 31241 ligation of sphenopalatine artery No MEDICAID Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from 31253 frontal sinus, when performed No MEDICAID Nasal/sinus endoscopy, surgical; with 31254 ethmoidectomy, partial (anterior) No MEDICAID Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and 31255 No MEDICAID Nasal/sinus endoscopy, surgical, with 31256 maxillary antrostomy; No MEDICAID Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy 31257 No MEDICAID Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus 31259 No MEDICAID Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal 31267 No MEDICAID Nasal/sinus endoscopy, surgical with 31276 frontal sinus exploration, with or No MEDICAID Nasal/sinus endoscopy, surgical, with 31287 sphenoidotomy; No MEDICAID Nasal/sinus endoscopy, surgical, with 31288 sphenoidotomy; with removal of No MEDICAID Nasal/sinus endoscopy, surgical, with 31290 repair of cerebrospinal fluid No MEDICAID Nasal/sinus endoscopy, surgical, with 31291 repair of cerebrospinal fluid No MEDICAID Nasal/sinus endoscopy, surgical; with 31292 medial or inferior orbital wall No MEDICAID Nasal/sinus endoscopy, surgical; with 31293 medial orbital wall and inferior No MEDICAID Nasal/sinus endoscopy, surgical; with 31294 optic nerve decompression No MEDICAID 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa No MEDICAID 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) No MEDICAID 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) No MEDICAID Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia 31298 (eg, balloon dilation) No MEDICAID UNLISTED PROCEDURE, ACCESSORY 31299 SINUSES Yes MEDICAID Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or 31300 No MEDICAID Laryngectomy; total, without radical neck 31360 dissection No MEDICAID Laryngectomy; total, with radical neck 31365 dissection No MEDICAID Laryngectomy; subtotal supraglottic, 31367 without radical neck dissection No MEDICAID Laryngectomy; subtotal supraglottic, with 31368 radical neck dissection No MEDICAID Partial laryngectomy (hemilaryngectomy); 31370 horizontal No MEDICAID

86 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Partial laryngectomy (hemilaryngectomy); 31375 laterovertical No MEDICAID Partial laryngectomy (hemilaryngectomy); 31380 anterovertical No MEDICAID Partial laryngectomy (hemilaryngectomy); antero-latero-vertical 31382 No MEDICAID Pharyngolaryngectomy, with radical neck 31390 dissection; without No MEDICAID Pharyngolaryngectomy, with radical neck 31395 dissection; with reconstruction No MEDICAID Arytenoidectomy or arytenoidopexy, 31400 external approach No MEDICAID 31420 Epiglottidectomy No MEDICAID Intubation, endotracheal, emergency 31500 procedure No MEDICAID Tracheotomy tube change prior to 31502 establishment of fistula tract No MEDICAID Laryngoscopy, indirect; diagnostic 31505 (separate procedure) No MEDICAID 31510 Laryngoscopy, indirect; with biopsy No MEDICAID Laryngoscopy, indirect; with removal of 31511 foreign body No MEDICAID Laryngoscopy, indirect; with removal of 31512 lesion No MEDICAID Laryngoscopy, indirect; with vocal cord 31513 injection No MEDICAID Laryngoscopy direct, with or without 31515 tracheoscopy; for aspiration No MEDICAID Laryngoscopy direct, with or without 31520 tracheoscopy; diagnostic, newborn No MEDICAID Laryngoscopy direct, with or without 31525 tracheoscopy; diagnostic, except No MEDICAID Laryngoscopy direct, with or without 31526 tracheoscopy; diagnostic, with No MEDICAID Laryngoscopy direct, with or without 31527 tracheoscopy; with insertion of No MEDICAID Laryngoscopy direct, with or without 31528 tracheoscopy; with dilation, No MEDICAID Laryngoscopy direct, with or without 31529 tracheoscopy; with dilation, No MEDICAID Laryngoscopy, direct, operative, with 31530 foreign body removal; No MEDICAID Laryngoscopy, direct, operative, with 31531 foreign body removal; with No MEDICAID Laryngoscopy, direct, operative, with 31535 biopsy; No MEDICAID Laryngoscopy, direct, operative, with 31536 biopsy; with operating microscope No MEDICAID Laryngoscopy, direct, operative, with 31540 excision of tumor and/or stripping No MEDICAID Laryngoscopy, direct, operative, with 31541 excision of tumor and/or stripping No MEDICAID Laryngoscopy, direct, operative, with 31545 operating microscope or No MEDICAID Laryngoscopy, direct, operative, with 31546 operating microscope or No MEDICAID Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age 31551 No MEDICAID Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, 31552 age 12 years or older No MEDICAID Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, younger than 12 years of age 31553 No MEDICAID Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, age 31554 12 years or older No MEDICAID

87 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Laryngoscopy, direct, operative, with 31560 arytenoidectomy; No MEDICAID Laryngoscopy, direct, operative, with 31561 arytenoidectomy; with operating No MEDICAID Laryngoscopy, direct, with injection into 31570 vocal cord(s), therapeutic; No MEDICAID Laryngoscopy, direct, with injection into 31571 vocal cord(s), therapeutic; No MEDICAID Laryngoscopy, flexible; with ablation or destruction of lesion(s) with laser, 31572 unilateral No MEDICAID Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral 31573 No MEDICAID Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, 31574 transoral), unilateral No MEDICAID Laryngoscopy, flexible fiberoptic; 31575 diagnostic No MEDICAID Laryngoscopy, flexible fiberoptic; with 31576 biopsy No MEDICAID Laryngoscopy, flexible fiberoptic; with 31577 removal of foreign body No MEDICAID Laryngoscopy, flexible fiberoptic; with 31578 removal of lesion No MEDICAID Laryngoscopy, flexible or rigid fiberoptic, 31579 with stroboscopy No MEDICAID Laryngoplasty; for laryngeal web, two 31580 stage, with keel insertion and No MEDICAID Laryngoplasty; with open reduction of 31584 fracture No MEDICAID 31587 Laryngoplasty, cricoid split No MEDICAID Laryngeal reinnervation by neuromuscular 31590 pedicle No MEDICAID Laryngoplasty, medialization, unilateral 31591 No MEDICAID 31592 Cricotracheal resection No MEDICAID Section recurrent laryngeal nerve, 31595 therapeutic (separate procedure), No MEDICAID 31599 UNLISTED PROCEDURE, LARYNX Yes MEDICAID Tracheostomy, planned (separate 31600 procedure); No MEDICAID Tracheostomy, planned (separate 31601 procedure); under two years No MEDICAID Tracheostomy, emergency procedure; 31603 transtracheal No MEDICAID Tracheostomy, emergency procedure; 31605 cricothyroid membrane No MEDICAID Tracheostomy, fenestration procedure 31610 with skin flaps No MEDICAID Construction of tracheoesophageal fistula and subsequent insertion of an 31611 No MEDICAID Tracheal puncture, percutaneous with 31612 transtracheal aspiration and/or No MEDICAID Tracheostoma revision; simple, without 31613 flap rotation No MEDICAID Tracheostoma revision; complex, with flap 31614 rotation No MEDICAID Tracheobronchoscopy through 31615 established tracheostomy incision No MEDICAID Bronchoscopy, rigid or flexible, with or 31622 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31623 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31624 without fluoroscopic guidance; No MEDICAID

88 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Bronchoscopy, rigid or flexible, with or 31625 without fluoroscopic guidance; No MEDICAID BRONCHOSCOPY, RIGID OR FLEXIBLE, INCL FLUOROSCOPIC GUIDANCE, WHEN DONE; W/PLACEMENT FIDUCIAL MARKERS, 31626 SINGLE OR MULTIPLE No MEDICAID BRONCHOSCOPY, RIGID OR FLEXIBLE, INCL FLUOROSCOPIC GUIDANCE, WHEN DONE; WITH COMPUTER-ASSISTED, IMAGE- 31627 GUIDED NAVIGATION No MEDICAID Bronchoscopy, rigid or flexible, with or 31628 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31629 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31630 without fluoroscopic No MEDICAID Bronchoscopy, rigid or flexible, with or 31631 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31632 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31633 without fluoroscopic guidance; No MEDICAID 31634 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if performed

No MEDICAID Bronchoscopy, rigid or flexible, with or 31635 without fluoroscopic guidance; No MEDICAID Bronchoscopy, rigid or flexible, with or 31636 without fluoroscopic No MEDICAID Bronchoscopy, rigid or flexible, with or 31637 without fluoroscopic No MEDICAID Bronchoscopy, rigid or flexible, with or 31638 without fluoroscopic No MEDICAID Bronchoscopy, rigid or flexible, with or 31640 without fluoroscopic guidance; No MEDICAID Bronchoscopy, (rigid or flexible); with 31641 destruction of tumor or relief No MEDICAID Bronchoscopy, (rigid or flexible); with 31643 placement of catheter(s) for No MEDICAID Bronchoscopy, (rigid or flexible); with 31645 therapeutic aspiration of No MEDICAID Bronchoscopy, (rigid or flexible); with 31646 therapeutic aspiration of No MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, 31647 assessment of air leak, airway sizing, and No insertion of bronchial valve(s), initial lobe

MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 31648 No with removal of bronchial valve(s), initial lobe MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), each 31649 additional lobe (List separately in addition No to code for primary procedure) MEDICAID

89 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and 31651 insertion of bronchial valve(s), each No additional lobe (List separately in addition to code for primary procedure[s])

MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) with endobronchial ultrasound (EBUS) guided transtracheal and or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures

31652 No MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) with endobronchial ultrasound (EBUS) guided transtracheal and. Or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures

31653 No MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) with endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])

31654 No MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 31660 with bronchial thermoplasty, 1 lobe No MEDICAID Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 31661 with bronchial thermoplasty, 2 or more lobes No MEDICAID Catheterization with bronchial brush 31717 biopsy No MEDICAID Catheter aspiration (separate procedure); 31720 nasotracheal No MEDICAID Catheter aspiration (separate procedure); 31725 tracheobronchial with No MEDICAID Transtracheal (percutaneous) introduction of needle wire dilator/stent 31730 No MEDICAID 31750 Tracheoplasty; cervical No MEDICAID Tracheoplasty; tracheopharyngeal 31755 fistulization, each stage No MEDICAID 31760 Tracheoplasty; intrathoracic No MEDICAID 31766 Carinal reconstruction No MEDICAID 31770 Bronchoplasty; graft repair No MEDICAID Bronchoplasty; excision stenosis and 31775 anastomosis No MEDICAID Excision tracheal stenosis and 31780 anastomosis; cervical No MEDICAID Excision tracheal stenosis and 31781 anastomosis; cervicothoracic No MEDICAID Excision of tracheal tumor or carcinoma; 31785 cervical No MEDICAID Excision of tracheal tumor or carcinoma; 31786 thoracic No MEDICAID Suture of tracheal wound or injury; 31800 cervical No MEDICAID Suture of tracheal wound or injury; 31805 intrathoracic No MEDICAID

90 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Surgical closure tracheostomy or fistula; 31820 without plastic repair No MEDICAID Surgical closure tracheostomy or fistula; 31825 with plastic repair No MEDICAID 31830 Revision of tracheostomy scar No MEDICAID UNLISTED PROCEDURE, TRACHEA, 31899 BRONCHI Yes MEDICAID Thoracostomy; with rib resection for 32035 empyema No MEDICAID Thoracostomy; with open flap drainage for 32036 empyema No MEDICAID Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), 32096 unilateral No MEDICAID Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral 32097 No MEDICAID Thoracotomy, with biopsy(ies) of pleura 32098 No MEDICAID Thoracotomy, major; with exploration and 32100 biopsy No MEDICAID Thoracotomy, major; with control of 32110 traumatic hemorrhage and/or repair No MEDICAID Thoracotomy, major; for postoperative 32120 complications No MEDICAID Thoracotomy, major; with open 32124 intrapleural pneumonolysis No MEDICAID Thoracotomy, major; with cyst(s) removal, 32140 with or without a pleural No MEDICAID Thoracotomy, major; with excision- 32141 plication of bullae, with or without No MEDICAID Thoracotomy, major; with removal of 32150 intrapleural foreign body or fibrin No MEDICAID Thoracotomy, major; with removal of 32151 intrapulmonary foreign body No MEDICAID Thoracotomy, major; with cardiac 32160 massage No MEDICAID PNEUMONOSTOMY; WITH OPEN 32200 DRAINAGE OF ABSCESS OR CYST No MEDICAID Pleural scarification for repeat 32215 pneumothorax No MEDICAID Decortication, pulmonary (separate 32220 procedure); total No MEDICAID Decortication, pulmonary (separate 32225 procedure); partial No MEDICAID Pleurectomy, parietal (separate 32310 procedure) No MEDICAID Decortication and parietal pleurectomy 32320 No MEDICAID 32400 Biopsy, pleura; percutaneous needle No MEDICAID Biopsy, lung or mediastinum, 32405 percutaneous needle No MEDICAID Removal of lung, total pneumonectomy; 32440 No MEDICAID Removal of lung, total pneumonectomy; with resection of segment of 32442 No MEDICAID Removal of lung, total pneumonectomy; 32445 extrapleural No MEDICAID Removal of lung, other than total 32480 pneumonectomy; single lobe No MEDICAID Removal of lung, other than total 32482 pneumonectomy; two lobes No MEDICAID Removal of lung, other than total 32484 pneumonectomy; single segment No MEDICAID Removal of lung, other than total 32486 pneumonectomy; with circumferential No MEDICAID Removal of lung, other than total 32488 pneumonectomy; all remaining lung No MEDICAID

91 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; EXCISION- PLICATION OF EMPHYSEMATOUS LUNG(S) (BULLOUS OR NON- BULLOUS) FOR LUNG VO 32491 No MEDICAID Resection and repair of portion of 32501 bronchus (bronchoplasty) when No MEDICAID RESECTION OF APICAL LUNG TUMOR (EG PANCOAST TUMOR) INCLD CHEST WALL RESECTION, RIB(S) RESECTION(S) NEUROVASCULAR DISSECTION, WHEN 32503 No MEDICAID RESECTION OF APICAL LUNG TUMOR (EG PANCOAST TUMOR) INCLD CHEST WALL RESECTION, RIB(S) RESECTION(S) NEUROVASCULAR DISSECTION, WHEN 32504 No MEDICAID Thoracotomy; with therapeutic wedge 32505 resection (eg, mass, nodule), initial No MEDICAID Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary 32506 procedure) No MEDICAID Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to 32507 code for primary procedure) No MEDICAID Extrapleural enucleation of empyema 32540 (empyemectomy) No MEDICAID INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER 32550 WITH CUFF No MEDICAID TUBE THORACOSTOMY, INCLUDES WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, EMPYEMA), WHEN PERFORMED (SEPARATE 32551 PROCEDURE) No MEDICAID REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER 32552 WITH CUFF No MEDICAID PLACE INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA-THORACIC; 1 OR> 32553 No MEDICAID Thoracentesis, needle or catheter, 32554 aspiration of the pleural space; without imaging guidance No MEDICAID Thoracentesis, needle or catheter, 32555 aspiration of the pleural space; with imaging guidance No MEDICAID Pleural drainage, percutaneous, with 32556 insertion of indwelling catheter; without imaging guidance No MEDICAID Pleural drainage, percutaneous, with 32557 insertion of indwelling catheter; with imaging guidance No MEDICAID CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT 32560 PNEUMOTHORAX) No MEDICAID INSTILLATION, VIA CHEST TUBE/CATHETER, AGENT FOR FIBRINOLYSIS (EG, FIBRINOLYTIC AGENTFOR BREAKUP OF 32561 MULTILOCULATE...); INITIAL No MEDICAID

92 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INSTILLATION, VIA CHEST TUBE/CATHETER, AGENT FOR FIBRINOLYSIS (EG, FIBRINOLYTIC AGENTFOR BREAKUP OF MULTILOCULA..); SUBSEQUENT DAY 32562 No MEDICAID Thoracoscopy, diagnostic (separate 32601 procedure); lungs and pleural space, No MEDICAID Thoracoscopy, diagnostic (separate 32604 procedure); pericardial sac, with No MEDICAID Thoracoscopy, diagnostic (separate 32606 procedure); mediastinal space, with No MEDICAID Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), 32607 unilateral No MEDICAID Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral 32608 No MEDICAID Thoracoscopy; with biopsy(ies) of pleura 32609 No MEDICAID Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) 32650 No MEDICAID Thoracoscopy, surgical; with partial 32651 pulmonary decortication No MEDICAID Thoracoscopy, surgical; with total 32652 pulmonary decortication, including No MEDICAID Thoracoscopy, surgical; with removal of 32653 intrapleural foreign body or No MEDICAID Thoracoscopy, surgical; with control of 32654 traumatic hemorrhage No MEDICAID Thoracoscopy, surgical; with excision- 32655 plication of bullae, including any No MEDICAID Thoracoscopy, surgical; with parietal 32656 pleurectomy No MEDICAID Thoracoscopy, surgical; with removal of 32658 clot or foreign body from No MEDICAID Thoracoscopy, surgical; with creation of 32659 pericardial window or partial No MEDICAID Thoracoscopy, surgical; with excision of 32661 pericardial cyst, tumor, or No MEDICAID Thoracoscopy, surgical; with excision of 32662 mediastinal cyst, tumor, or No MEDICAID Thoracoscopy, surgical; with lobectomy, 32663 total or segmental No MEDICAID THORACOSCOPY, SURGICAL; WITH 32664 THORACIC SYMPATHECTOMY No MEDICAID Thoracoscopy, surgical; with 32665 esophagomyotomy (Heller type) No MEDICAID Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial 32666 unilateral No MEDICAID Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) 32667 No MEDICAID Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) 32668 No MEDICAID Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) 32669 No MEDICAID Thoracoscopy, surgical; with removal of 2 32670 lobes (bilobectomy) No MEDICAID Thoracoscopy, surgical; with removal of 32671 lung (pneumonectomy) No MEDICAID

93 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Thoracoscopy, surgical; with resection- plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed

32672 No MEDICAID Thoracoscopy, surgical; with resection of thymus, unilateral or bilateral 32673 No MEDICAID Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) 32674 No MEDICAID Thoracic target(s) delineation for stereotactic body radiation therapy 32701 (SRS/SBRT), (photon or particle beam), entire course of treatment No MEDICAID Repair lung hernia through chest wall 32800 No MEDICAID Closure of chest wall following open flap 32810 drainage for empyema (Clagett No MEDICAID Open closure of major bronchial fistula 32815 No MEDICAID Major reconstruction, chest wall 32820 (posttraumatic) No MEDICAID DONOR PNEUMONECTOMY(IES) (INCLUDING COLD PRESERVATION) 32850 Yes FROM CADAVER DONOR MEDICAID LUNG TRANSPLANT, SINGLE; 32851 WITHOUT CARDIOPULMONARY Yes BYPASS MEDICAID LUNG TRANSPLANT, SINGLE; WITH 32852 Yes CARDIOPULMONARY BYPASS MEDICAID LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN 32853 Yes BLOC); WITHOUT CARDIOPULMONARY BYPASS MEDICAID LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN 32854 Yes BLOC); WITH CARDIOPULMONARY BYPASS MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR LUNG ALLOGRAFT PRIOR TO TRANSPLANT; INCL 32855 DISSECTION FROM SURROUNDING Yes SOFT TISS...UNILAT MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR LUNG ALLOGRAFT PRIOR TO TRANSPLANT; INCL 32856 DISSECTION FROM SURROUNDING Yes SOFT TISS...BILATERA MEDICAID Resection of ribs, extrapleural, all stages 32900 No MEDICAID Thoracoplasty, Schede type or 32905 extrapleural (all stages); No MEDICAID Thoracoplasty, Schede type or extrapleural (all stages); with closure of 32906 No MEDICAID Pneumonolysis, extraperiosteal, including filling or packing procedures 32940 No MEDICAID Pneumothorax, therapeutic, intrapleural 32960 injection of air No MEDICAID

94 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation termed code 0340T 32994 No MEDICAID 32997 Total lung lavage (unilateral) No MEDICAID ALBATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE PULMONARY TURMOR(S) INCL PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EX 32998 No MEDICAID UNLISTED PROCEDURE, LUNGS AND 32999 PLEURA Yes MEDICAID 33010 Pericardiocentesis; initial No MEDICAID 33011 Pericardiocentesis; subsequent No MEDICAID 33015 Tube pericardiostomy No MEDICAID Pericardiotomy for removal of clot or 33020 foreign body (primary procedure) No MEDICAID Creation of pericardial window or partial 33025 resection for drainage No MEDICAID Pericardiectomy, subtotal or complete; without cardiopulmonary bypass 33030 No MEDICAID Pericardiectomy, subtotal or complete; with cardiopulmonary bypass 33031 No MEDICAID 33050 Excision of pericardial cyst or tumor No MEDICAID Excision of intracardiac tumor, resection with cardiopulmonary bypass 33120 No MEDICAID 33130 Resection of external cardiac tumor No MEDICAID TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY (SEPARATE 33140 PROCEDURE) No MEDICAID PERFORMED ST THE TIME OF OTHER OPEN CARDIAC PROCEDURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 33141 No MEDICAID INSERTION OF EPICARDIAL 33202 ELECTRODE(S); OPEN INCISION No MEDICAID INSERTION OF EPICARDIAL ELECTRODE(S); ENDOSCOPIC 33203 APPROACH No MEDICAID Insertion or replacement of permanent pacemaker with transvenous 33206 No MEDICAID Insertion or replacement of permanent pacemaker with transvenous 33207 No MEDICAID Insertion or replacement of permanent pacemaker with transvenous 33208 No MEDICAID Insertion or replacement of temporary transvenous single chamber 33210 No MEDICAID Insertion or replacement of temporary transvenous dual chamber pacing 33211 No MEDICAID Insertion or replacement of pacemaker pulse generator only; single 33212 No MEDICAID Insertion or replacement of pacemaker pulse generator only; dual 33213 No MEDICAID

95 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Upgrade of implanted pacemaker system, conversion of single chamber 33214 No MEDICAID Repositioning of previously implanted transvenous pacemaker or pacing 33215 No MEDICAID Insertion of a transvenous electrode; 33216 Yes single chamber (one electrode) MEDICAID Insertion of a transvenous electrode; dual 33217 Yes chamber (two electrodes) MEDICAID Repair of single transvenous electrode for a single chamber, permanent 33218 No MEDICAID Repair of two transvenous electrodes for 33220 a dual chamber permanent No MEDICAID Insertion of pacemaker pulse generator only; with existing multiple leads 33221 No MEDICAID Revision or relocation of skin pocket for 33222 pacemaker No MEDICAID REVISION OF SKIN POCKET FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR 33223 No MEDICAID Insertion of pacing electrode, cardiac 33224 venous system, for left Yes MEDICAID Insertion of pacing electrode, cardiac 33225 venous system, for left Yes MEDICAID Repositioning of previously implanted cardiac venous system (left 33226 No MEDICAID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system 33227 No MEDICAID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system 33228 No MEDICAID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system 33229 No MEDICAID Insertion of pacing cardioverter- defibrillator pulse generator only; with 33230 existing dual leads Yes MEDICAID Insertion of pacing cardioverter- defibrillator pulse generator only; with 33231 existing multiple leads Yes MEDICAID Removal of permanent pacemaker pulse 33233 generator No MEDICAID Removal of transvenous pacemaker 33234 electrode(s); single lead system, No MEDICAID Removal of transvenous pacemaker 33235 electrode(s); dual lead system No MEDICAID Removal of permanent epicardial 33236 pacemaker and electrodes by No MEDICAID Removal of permanent epicardial 33237 pacemaker and electrodes by No MEDICAID Removal of permanent transvenous 33238 electrode(s) by thoracotomy No MEDICAID INSERTION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR 33240 Yes MEDICAID SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR 33241 No MEDICAID

96 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY 33243 THORACOTOMY No MEDICAID REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY 33244 TRANSVENOUS EXTRACTION No MEDICAID INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR 33249 DUAL CHAMBER PACING No CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULS MEDICAID INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR 33249 DUAL CHAMBER PACING No CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULS MEDICAID INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR AND 33249 INSERTION OF PULS No MEDICAID Operative ablation of supraventricular 33250 arrhythmogenic focus or pathway No MEDICAID Operative ablation of supraventricular 33251 arrhythmogenic focus or pathway No MEDICAID OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, 33254 LIMITED No MEDICAID OPERATIVE TISSUE ABLATION OF 33255 ATRIA, EXTENSIVE; W/O BYPASS No MEDICAID OPERATIVE TISSUE ALBATION OF 33256 ATRIA, EXTENSIVE W/ BYPASS No MEDICAID OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), LIMITED (EG, MODIFIED MAZE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 33257 No MEDICAID OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), EXTENSIVE (EG, MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 33258 No MEDICAID OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), EXTENSIVE (EG, MAZE PROCEDURE), WITH CARDIOPULMONARY BYPASS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 33259 No MEDICAID Operative ablation of ventricular 33261 arrhythmogenic focus with No MEDICAID Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead 33262 system No MEDICAID Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead 33263 system No MEDICAID

97 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead 33264 system No MEDICAID ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION OF ATRIA, LIMITED 33265 No MEDICAID ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION OF ATRIA, 33266 EXTENSIVE No MEDICAID Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, 33270 evaluation of sensing for arrhythmia Yes termination, and programming or reprogramming of sensing or therapeutic parameters, when performed MEDICAID Insertion of subcutaneous implantable 33271 Yes defibrillator electrode MEDICAID Removal of subcutaneous implantable 33272 defibrillator electrode No MEDICAID Repositioning of previously implanted subcutaneous implantable defibrillator 33273 electrode No MEDICAID IMPLANTATION PF PATIENT- 33282 ACTIVATED CARDIAC EVENT Yes RECORDER MEDICAID REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT 33284 RECORDER No MEDICAID Repair of cardiac wound; without bypass 33300 No MEDICAID Repair of cardiac wound; with 33305 cardiopulmonary bypass No MEDICAID Cardiotomy, exploratory (includes removal 33310 of foreign body, atrial or No MEDICAID Cardiotomy, exploratory (includes removal 33315 of foreign body, atrial or No MEDICAID Suture repair of aorta or great vessels; 33320 without shunt or No MEDICAID Suture repair of aorta or great vessels; 33321 with shunt bypass No MEDICAID Insertion of graft, aorta or great vessels; 33330 without shunt, or No MEDICAID Insertion of graft, aorta or great vessels; 33332 with shunt bypass No MEDICAID Insertion of graft, aorta or great vessels; with cardiopulmonary bypass 33335 No MEDICAID Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

33340 No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 33361 percutaneous femoral artery approach No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open 33362 femoral artery approach No MEDICAID

98 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open 33363 axillary artery approach No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open 33364 iliac artery approach No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 33365 transaortic approach (eg, median sternotomy, mediastinotomy) No MEDICAID 33366 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and 33367 venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous 33368 cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) No MEDICAID Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation 33369 (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) No MEDICAID Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, debridement, debulking, and/or simple commissural resuspension) 33390 No MEDICAID Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (eg, leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty) 33391 No MEDICAID 33404 Construction of apical-aortic conduit No MEDICAID Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic 33405 No MEDICAID Replacement, aortic valve, with cardiopulmonary bypass; with allograft 33406 No MEDICAID Replacement, aortic valve, with cardiopulmonary bypass; with stentless 33410 No MEDICAID Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus 33411 No MEDICAID Replacement, aortic valve; with 33412 transventricular aortic annulus No MEDICAID Replacement, aortic valve; by translocation of autologous pulmonary 33413 No MEDICAID Repair of left ventricular outflow tract 33414 obstruction by patch No MEDICAID

99 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Resection or incision of subvalvular tissue 33415 for discrete subvalvular No MEDICAID Ventriculomyotomy (-myectomy) for 33416 idiopathic hypertrophic subaortic No MEDICAID Aortoplasty (gusset) for supravalvular 33417 stenosis No MEDICAID Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; 33418 initial prosthesis No MEDICAID Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) 33419 No MEDICAID 33420 Valvotomy, mitral valve; closed heart No MEDICAID Valvotomy, mitral valve; open heart, with 33422 cardiopulmonary bypass No MEDICAID Valvuloplasty, mitral valve, with 33425 cardiopulmonary bypass; No MEDICAID Valvuloplasty, mitral valve, with 33426 cardiopulmonary bypass; with No MEDICAID Valvuloplasty, mitral valve, with 33427 cardiopulmonary bypass; radical No MEDICAID Replacement, mitral valve, with 33430 cardiopulmonary bypass No MEDICAID Valvectomy, tricuspid valve, with 33460 cardiopulmonary bypass No MEDICAID Valvuloplasty, tricuspid valve; without ring 33463 insertion No MEDICAID Valvuloplasty, tricuspid valve; with ring 33464 insertion No MEDICAID Replacement, tricuspid valve, with 33465 cardiopulmonary bypass No MEDICAID Tricuspid valve repositioning and plication 33468 for Ebstein anomaly No MEDICAID Valvotomy, pulmonary valve, closed 33470 heart; transventricular No MEDICAID Valvotomy, pulmonary valve, closed 33471 heart; via pulmonary artery No MEDICAID Valvotomy, pulmonary valve, open heart; 33474 with cardiopulmonary bypass No MEDICAID 33475 Replacement, pulmonary valve No MEDICAID Right ventricular resection for infundibular 33476 stenosis, with or without No MEDICAID Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed. 33477 No MEDICAID Outflow tract augmentation (gusset), with 33478 or without commissurotomy or No MEDICAID Repair of non-structural prosthetic valve 33496 dysfunction with No MEDICAID Repair of coronary arteriovenous or 33500 arteriocardiac chamber fistula; with No MEDICAID Repair of coronary arteriovenous or 33501 arteriocardiac chamber fistula; No MEDICAID Repair of anomalous coronary artery; by 33502 ligation No MEDICAID Repair of anomalous coronary artery; by 33503 graft, without cardiopulmonary No MEDICAID Repair of anomalous coronary artery; by 33504 graft, with cardiopulmonary No MEDICAID Repair of anomalous coronary artery; with 33505 construction of intrapulmonary No MEDICAID Repair of anomalous coronary artery; by 33506 translocation from pulmonary No MEDICAID

100 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REPAIR OF ANOMALOUS (EG, INTRAMURAL) AORTIC ORIGIN OF CORONARY ARTERYBY UNROOFING 33507 OR TRANSLOCATION No MEDICAID Endoscopy, surgical, including video- 33508 assisted harvest of vein(s) for No MEDICAID Coronary artery bypass, vein only; single 33510 coronary venous graft No MEDICAID Coronary artery bypass, vein only; two 33511 coronary venous grafts No MEDICAID Coronary artery bypass, vein only; three 33512 coronary venous grafts No MEDICAID Coronary artery bypass, vein only; four 33513 coronary venous grafts No MEDICAID Coronary artery bypass, vein only; five 33514 coronary venous grafts No MEDICAID Coronary artery bypass, vein only; six or 33516 more coronary venous grafts No MEDICAID Coronary artery bypass, using venous 33517 graft(s) and arterial graft(s); No MEDICAID Coronary artery bypass, using venous graft(s) and arterial graft(s); two 33518 No MEDICAID Coronary artery bypass, using venous 33519 graft(s) and arterial graft(s); No MEDICAID Coronary artery bypass, using venous 33521 graft(s) and arterial graft(s); No MEDICAID Coronary artery bypass, using venous 33522 graft(s) and arterial graft(s); No MEDICAID Coronary artery bypass, using venous graft(s) and arterial graft(s); six 33523 No MEDICAID Reoperation, coronary artery bypass 33530 procedure or valve procedure, more No MEDICAID Coronary artery bypass, using arterial 33533 graft(s); single arterial graft No MEDICAID Coronary artery bypass, using arterial 33534 graft(s); two coronary arterial No MEDICAID Coronary artery bypass, using arterial 33535 graft(s); three coronary arterial No MEDICAID Coronary artery bypass, using arterial 33536 graft(s); four or more coronary No MEDICAID Myocardial resection (eg, ventricular 33542 aneurysmectomy) No MEDICAID Repair of postinfarction ventricular septal 33545 defect, with or without No MEDICAID SURCIAL VENTRICULAR RESTORATION PROC, INCLDS PROSTHETIC PATCH, WHEN 33548 PERFORMED (EG VENTRICULAR No REMODELING, SVR, SAVER, DOR PROC'S) MEDICAID Coronary endarterectomy, open, any 33572 method, of left anterior descending, No MEDICAID Closure of atrioventricular valve (mitral or 33600 tricuspid) by suture or No MEDICAID Closure of semilunar valve (aortic or 33602 pulmonary) by suture or patch No MEDICAID Anastomosis of pulmonary artery to aorta 33606 (Damus-Kaye-Stansel No MEDICAID Repair of complex cardiac anomaly other 33608 than pulmonary atresia with No MEDICAID Repair of complex cardiac anomalies (eg, 33610 single ventricle with subaortic No MEDICAID Repair of double outlet right ventricle with 33611 intraventricular tunnel No MEDICAID Repair of double outlet right ventricle with 33612 intraventricular tunnel No MEDICAID Repair of complex cardiac anomalies (eg, 33615 tricuspid atresia) by closure No MEDICAID

101 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair of complex cardiac anomalies (eg, 33617 single ventricle) by modified No MEDICAID Repair of single ventricle with aortic 33619 outflow obstruction and aortic No MEDICAID 33620 Application of right and left pulmonary artery bands (eg, hybrid approach stage 1) No MEDICAID 33621 Transthoracic insertion of catheter for stent placement with catheter removal and closure (eg, hybrid approach stage 1) No MEDICAID 33622 Reconstruction of complex cardiac anomaly (eg, single ventricle or hypoplastic left heart) with palliation of single ventricle with aortic outflow obstruction and aortic arch hypoplasia, creation of cavopulmonary anastomosis, and removal of right and left pulmonary bands (eg, hybrid approach stage 2, Norwood, bidirectional Glenn, pulmonary artery debanding) No MEDICAID Repair atrial septal defect, secundum, with cardiopulmonary bypass, with 33641 No MEDICAID Direct or patch closure, sinus venosus, 33645 with or without anomalous No MEDICAID Repair of atrial septal defect and 33647 ventricular septal defect, with No MEDICAID Repair of incomplete or partial 33660 atrioventricular canal (ostium primum No MEDICAID Repair of intermediate or transitional 33665 atrioventricular canal, with or No MEDICAID Repair of complete atrioventricular canal, 33670 with or without prosthetic No MEDICAID CLOSURE OF MULTIPLE 33675 VENTRICULAR SEPTAL DEFECTS; No MEDICAID CLOSURE OF VENTRICULAR SEPTAL DEFECTS; WITH PULMONARY 33676 VALVOTOMY No MEDICAID CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; 33677 WITH REMOVAL No MEDICAID Closure of ventricular septal defect, with 33681 or without patch; No MEDICAID Closure of ventricular septal defect, with 33684 or without patch; with No MEDICAID Closure of ventricular septal defect, with 33688 or without patch; with No MEDICAID 33690 Banding of pulmonary artery No MEDICAID Complete repair tetralogy of Fallot without 33692 pulmonary atresia; No MEDICAID Complete repair tetralogy of Fallot without 33694 pulmonary atresia; with No MEDICAID Complete repair tetralogy of Fallot with 33697 pulmonary atresia including No MEDICAID Repair sinus of Valsalva fistula, with 33702 cardiopulmonary bypass; No MEDICAID Repair sinus of Valsalva fistula, with 33710 cardiopulmonary bypass; with No MEDICAID Repair sinus of Valsalva aneurysm, with 33720 cardiopulmonary bypass No MEDICAID Closure of aortico-left ventricular tunnel 33722 No MEDICAID REPAIR OF ISOLATED PARTIAL ANOMALOUS PULMONARY VENOUS 33724 RETURN No MEDICAID REPAIR OF PULMONARY VENOUS 33726 STENOSIS No MEDICAID

102 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Complete repair of anomalous venous return (supracardiac, intracardiac, 33730 No MEDICAID Repair of cor triatriatum or supravalvular mitral ring by resection of 33732 No MEDICAID Atrial septectomy or septostomy; closed 33735 heart (Blalock-Hanlon type No MEDICAID Atrial septectomy or septostomy; open 33736 heart with cardiopulmonary No MEDICAID Atrial septectomy or septostomy; open 33737 heart, with inflow occlusion No MEDICAID Shunt; subclavian to pulmonary artery 33750 (Blalock-Taussig type operation) No MEDICAID Shunt; ascending aorta to pulmonary 33755 artery (Waterston type operation) No MEDICAID Shunt; descending aorta to pulmonary artery (Potts-Smith type operation) 33762 No MEDICAID 33764 Shunt; central, with prosthetic graft No MEDICAID Shunt; superior vena cava to pulmonary 33766 artery for flow to one lung No MEDICAID Shunt; superior vena cava to pulmonary artery for flow to both lungs 33767 No MEDICAID ANASTOMOSIS, CAVOPULMONARY, 2ND SUPERIOR VENA CACA (LST SEP 33768 IN ADD TO PRIMARY PROC) No MEDICAID Repair of transposition of the great 33770 arteries with ventricular septal No MEDICAID Repair of transposition of the great 33771 arteries with ventricular septal No MEDICAID Repair of transposition of the great 33774 arteries, atrial baffle procedure No MEDICAID Repair of transposition of the great 33775 arteries, atrial baffle procedure No MEDICAID Repair of transposition of the great 33776 arteries, atrial baffle procedure No MEDICAID Repair of transposition of the great 33777 arteries, atrial baffle procedure No MEDICAID Repair of transposition of the great 33778 arteries, aortic pulmonary artery No MEDICAID Repair of transposition of the great 33779 arteries, aortic pulmonary artery No MEDICAID Repair of transposition of the great 33780 arteries, aortic pulmonary artery No MEDICAID Repair of transposition of the great 33781 arteries, aortic pulmonary artery No MEDICAID AORTIC ROOT TRANSLOCATION W/VENTRICULAR SEPTAL DEFECT & PULMONARY STENOSIS REPAIR (IE, NIKAIDOH PROC); WO CORONARY 33782 OSTIUM REIMPLAN No MEDICAID AORTIC ROOT TRANSLOCATE W/VENTRICULAR SEPTAL DEFECT&PULMONARY STENOSIS REPAIR W/REIMPLANTATION OF 1 OR 33783 2 CORONANARY OSTIA No MEDICAID Total repair, truncus arteriosus (Rastelli 33786 type operation) No MEDICAID Reimplantation of an anomalous 33788 pulmonary artery No MEDICAID Aortic suspension (aortopexy) for tracheal 33800 decompression (eg, for No MEDICAID Division of aberrant vessel (vascular ring); 33802 No MEDICAID Division of aberrant vessel (vascular ring); 33803 with reanastomosis No MEDICAID Obliteration of aortopulmonary septal 33813 defect; without cardiopulmonary No MEDICAID

103 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Obliteration of aortopulmonary septal 33814 defect; with cardiopulmonary No MEDICAID Repair of patent ductus arteriosus; by 33820 ligation No MEDICAID Repair of patent ductus arteriosus; by 33822 division, under 18 years No MEDICAID Repair of patent ductus arteriosus; by 33824 division, 18 years and older No MEDICAID Excision of coarctation of aorta, with or 33840 without associated patent No MEDICAID Excision of coarctation of aorta, with or 33845 without associated patent No MEDICAID Excision of coarctation of aorta, with or 33851 without associated patent No MEDICAID Repair of hypoplastic or interrupted aortic 33852 arch using autogenous or No MEDICAID Repair of hypoplastic or interrupted aortic 33853 arch using autogenous or No MEDICAID Ascending aorta graft, with cardiopulmonary bypass, includes valve 33860 suspension, when performed No MEDICAID Ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved conduit and coronary reconstruction (eg, Bentall) 33863 No MEDICAID Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic root remodeling (eg, David Procedure, Yacoub Procedure) 33864 No MEDICAID Transverse arch graft, with 33870 cardiopulmonary bypass No MEDICAID Descending thoracic aorta graft, with or 33875 without bypass No MEDICAID Repair of thoracoabdominal aortic 33877 aneurysm with graft, with or without No MEDICAID ENDOVASCULAR REPAIR OF DESCENDIGN THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION PENETRATING ULCER, INTRAMURAL HEMATOMA 33880 No MEDICAID ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION PENETRATING ULCER, INTRAMURAL HEMATOMA 33881 No MEDICAID PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF DESCENDIGN THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, 33883 No MEDICAID PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF DESCENDIGN THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, 33884 No MEDICAID PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) DELAYED ENDOVASCULAR REPAIR OF DESCENDIGN THORACIC AORTA 33886 No MEDICAID

104 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSPOSITION PRFMD IN CONJUNCTION W/ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, BY NECK I 33889 No MEDICAID BYPASS GRAFT, W/ OTHER THAN VEIN, TRANSCERVICAL RETROPHARYNGEAL CAROTID- CAROTID, PERFORMED IN CONJUNCTION WENDOVASCULAR 33891 REPAIR OF No MEDICAID Pulmonary artery embolectomy; with 33910 cardiopulmonary bypass No MEDICAID Pulmonary artery embolectomy; without 33915 cardiopulmonary bypass No MEDICAID Pulmonary endarterectomy, with or 33916 without embolectomy, with No MEDICAID Repair of pulmonary artery stenosis by 33917 reconstruction with patch or No MEDICAID Repair of pulmonary atresia with 33920 ventricular septal defect, by No MEDICAID Transection of pulmonary artery with 33922 cardiopulmonary bypass No MEDICAID Ligation and takedown of a systemic-to- 33924 pulmonary artery shunt, No MEDICAID REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY UNIFOCALIZATION; W/O 33925 CARDIOPULMONARY BYPASS No MEDICAID REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY UNIFOCALIZATION; W/ 33926 CARDIOPULMONARY BYPASS No MEDICAID Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy termed code 0051T‐0053T 33927 No MEDICAID Removal and replacement of total 33928 replacement heart system (artificial heart) Yes termed code 0051T‐0053T MEDICAID Removal of a total replacement heart system (artificial heart) for heart 33929 transplantation (List separately in addition Yes to code for primary procedure) termed code 0051T‐0053T MEDICAID DONOR CARDIECTOMY- PNEUMONECTOMY, WITH COLD 33930 PRESERVATION No ExGEN MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR HEART/LUNG ALLOGRAFT PRIOR TO TRANSPLANT; 33933 INCL DISSECTION FROM Yes SURROUNDING TISS TO PREP MEDICAID HEART-LUNG TRANSPLANT WITH 33935 RECIPIENT CARDIECTOMY- Yes PNEUMONECTOMY MEDICAID DONOR CARDIECTOMY, WITH COLD 33940 PRESERVATION No ExGEN MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR HEART ALLOGRAFT PRIOR TO TRANSPLANT; 33944 INCL DISSECTION FROM Yes SURROUNDING TISS TO PREP AORTA, MEDICAID HEART TRANSPLANT, WITH OR 33945 WITHOUT RECIPIENT CARDIECTOMY Yes MEDICAID

105 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, 33946 veno-venous No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, 33947 veno-arterial No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-venous 33948 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-arterial 33949 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) 33951 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) 33952 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of 33953 age No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older 33954 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

33955 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, 6 years and older 33956 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) 33957 No MEDICAID

106 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) 33958 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed) 33959 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed) 33962 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed) 33963 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed)

33964 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age 33965 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and 33966 older No MEDICAID Insertion of intra-aortic balloon assist 33967 Yes device, percutaneous MEDICAID Removal of intra-aortic balloon assist 33968 device, percutaneous No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of 33969 age No MEDICAID Insertion of intra-aortic balloon assist 33970 device through the femoral No MEDICAID Removal of intra-aortic balloon assist 33971 device including repair of No MEDICAID Insertion of intra-aortic balloon assist 33973 device through the ascending No MEDICAID Removal of intra-aortic balloon assist 33974 device from the ascending aorta, No MEDICAID

107 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IMPLANTATION OF VENTRICULAR 33975 ASSIST DEVICE; SINGLE VENTRICLE Yes SUPPORT MEDICAID IMPLANTATION OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR 33976 SUPPORT No MEDICAID REMOVAL OF VENTRICULAR ASSIST DEVICE; SINGLE VENTRICLE 33977 SUPPORT No MEDICAID REMOVAL OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR SUPPORT 33978 No MEDICAID INSERTION OF INTRACORPORAL 33979 VENTRICULAR ASSIST DEVICE No MEDICAID REMOVAL OF INTRACORPORAL 33980 VENTRICULAR ASSIST DEVICE No MEDICAID REPLACEMENT OF EXTRACORPOREAL VENTRICULAR ASSIST DEVICE, SINGLE OR BIVENTRICULAR, PUMP(S), SINGLE 33981 OR EACH PUMP No MEDICAID REPLACE EXTRACORPOREAL VENTRICULAR ASSIST DEVICE PUMP(S); IMPLANTABLE INTRACORPOREAL, SINGLE VENTRICLE, WO CARDIOPULMARY 33982 BYPASS No MEDICAID REPLACE EXTRACORPOREAL VENTRICULAR ASSIST DEVICE PUMP(S); IMPLANTABLE INTRACORPOREAL, SINGLE VENTRICLE, WITH CARDIOPULMARY 33983 BYPASS No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older 33984 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

33985 No MEDICAID Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older 33986 No MEDICAID Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) 33987 No MEDICAID Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for 33988 ECMO/ECLS No MEDICAID Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for 33989 ECMO/ECLS No MEDICAID Insertion of ventricular assist device, percutaneous including radiological 33990 Yes supervision and interpretation; arterial access only MEDICAID

108 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Insertion of ventricular assist device, percutaneous including radiological 33991 supervision and interpretation; both Yes arterial and venous access, with transseptal puncture MEDICAID Removal of percutaneous ventricular 33992 assist device at separate and distinct session from insertion No MEDICAID Repositioning of percutaneous ventricular assist device with imaging guidance at 33993 separate and distinct session from insertion No MEDICAID UNLISTED PROCEDURE, CARDIAC 33999 SURGERY Yes MEDICAID Embolectomy or thrombectomy, with or 34001 without catheter; carotid, No MEDICAID Embolectomy or thrombectomy, with or 34051 without catheter; innominate, No MEDICAID Embolectomy or thrombectomy, with or 34101 without catheter; axillary, No MEDICAID Embolectomy or thrombectomy, with or 34111 without catheter; radial or ulnar No MEDICAID Embolectomy or thrombectomy, with or 34151 without catheter; renal, celiac, No MEDICAID Embolectomy or thrombectomy, with or 34201 without catheter; femoropopliteal, No MEDICAID Embolectomy or thrombectomy, with or 34203 without catheter; No MEDICAID Thrombectomy, direct or with catheter; 34401 vena cava, iliac vein, by No MEDICAID Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal 34421 No MEDICAID Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal 34451 No MEDICAID Thrombectomy, direct or with catheter; subclavian vein, by neck incision 34471 No MEDICAID Thrombectomy, direct or with catheter; axillary and subclavian vein, by 34490 No MEDICAID 34501 Valvuloplasty, femoral vein No MEDICAID Reconstruction of vena cava, any method 34502 No MEDICAID Venous valve transposition, any vein 34510 donor No MEDICAID Cross-over vein graft to venous system 34520 No MEDICAID 34530 Saphenopopliteal vein anastomosis No MEDICAID Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) termed code 34800‐ 34806

34701 No MEDICAID

109 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endovascular repair of infrarenal aorta by deployment of an aorto‐aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) termed code 34800‐34806

34702 No MEDICAID Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐uni‐iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) termed code 34800‐ 34806

34703 No MEDICAID Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐uni‐iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) termed code 34800‐34806

34704 No MEDICAID

110 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) termed code 34800‐ 34806

34705 No MEDICAID Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐bi‐iliac endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) termed code 34800‐34806

34706 No MEDICAID Endovascular repair of iliac artery by deployment of an ilio‐iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation) termed codes 34900, 75953

34707 No MEDICAID Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption) termed code 34900, 75954

34708 No MEDICAID

111 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure) termed codes 34825‐34826, 75953

34709 No MEDICAID Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated termed codes 34825‐34826

34710 No MEDICAID Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; each additional vessel treated (List separately in addition to code for primary procedure) termed codes 34825‐ 34826

34711 No MEDICAID Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation 34712 No MEDICAID Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary 34713 procedure) No MEDICAID Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary 34714 procedure) No MEDICAID

112 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure) 34715 No MEDICAID Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)

34716 No MEDICAID Endovascular placement of iliac artery occlusion device (List separately 34808 No MEDICAID Open femoral artery exposure for delivery of endovascular prosthesis, by 34812 No MEDICAID Placement of femoral-femoral prosthetic graft during endovascular aortic 34813 No MEDICAID Open iliac artery exposure for delivery of 34820 endovascular prosthesis or No MEDICAID Open repair of infrarenal aortic aneurysm or dissection, plus repair of 34830 No MEDICAID Open repair of infrarenal aortic aneurysm or dissection, plus repair of 34831 No MEDICAID Open repair of infrarenal aortic aneurysm or dissection, plus repair of 34832 No MEDICAID OPEN ILIAC ARTERY EXPOSURE W/CREATION OF CONDUIT FOR DELIVERY OF AORTIC OR ILIAC ENDOVASCULAR PROTHESIS, BY 34833 ABDOMINIAL No MEDICAID Open brachial artery exposure to assist in 34834 the deployment of infrarenal No MEDICAID Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of 34839 physician time Not Covered MEDICAID Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and 34841 interpretation, including target zone Yes angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

MEDICAID

113 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and 34842 interpretation, including target zone Yes angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and 34843 interpretation, including target zone Yes angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and 34844 interpretation, including target zone Yes angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and 34845 all associated radiological supervision and Yes interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

MEDICAID Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and 34846 interpretation, including target zone Yes angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID

114 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and 34847 interpretation, including target zone Yes angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and 34848 interpretation, including target zone Yes angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35001 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35002 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35005 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35011 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35013 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35021 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35022 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35045 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35081 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35082 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35091 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35092 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35102 No MEDICAID

115 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35103 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35111 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35112 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35121 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35122 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35131 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35132 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35141 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35142 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35151 No MEDICAID Direct repair of aneurysm, pseudoaneurysm, or excision (partial or 35152 No MEDICAID Repair, congenital arteriovenous fistula; 35180 head and neck No MEDICAID Repair, congenital arteriovenous fistula; 35182 thorax and abdomen No MEDICAID Repair, congenital arteriovenous fistula; 35184 extremities No MEDICAID Repair, acquired or traumatic 35188 arteriovenous fistula; head and neck No MEDICAID Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen 35189 No MEDICAID Repair, acquired or traumatic 35190 arteriovenous fistula; extremities No MEDICAID 35201 Repair blood vessel, direct; neck No MEDICAID Repair blood vessel, direct; upper 35206 extremity No MEDICAID Repair blood vessel, direct; hand, finger 35207 No MEDICAID Repair blood vessel, direct; intrathoracic, 35211 with bypass No MEDICAID Repair blood vessel, direct; intrathoracic, 35216 without bypass No MEDICAID Repair blood vessel, direct; intra- 35221 abdominal No MEDICAID Repair blood vessel, direct; lower 35226 extremity No MEDICAID Repair blood vessel with vein graft; neck 35231 No MEDICAID Repair blood vessel with vein graft; upper 35236 extremity No MEDICAID Repair blood vessel with vein graft; 35241 intrathoracic, with bypass No MEDICAID Repair blood vessel with vein graft; 35246 intrathoracic, without bypass No MEDICAID Repair blood vessel with vein graft; intra- 35251 abdominal No MEDICAID Repair blood vessel with vein graft; lower 35256 extremity No MEDICAID

116 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair blood vessel with graft other than 35261 vein; neck No MEDICAID Repair blood vessel with graft other than 35266 vein; upper extremity No MEDICAID Repair blood vessel with graft other than 35271 vein; intrathoracic, with No MEDICAID Repair blood vessel with graft other than 35276 vein; intrathoracic, without No MEDICAID Repair blood vessel with graft other than 35281 vein; intra-abdominal No MEDICAID Repair blood vessel with graft other than 35286 vein; lower extremity No MEDICAID Thromboendarterectomy, with or without 35301 patch graft; carotid, vertebral, No MEDICAID THROMBOENDARTERECTOMY; 35302 SUPERFICIAL FEMORAL ARTERY No MEDICAID THROMBOENDARTERECTOMY; 35303 POPLITEAL ARTERY No MEDICAID THROMBOENDARTERECTOMY; 35304 TIBIOPERONEAL TRUNK ARTERY No MEDICAID THROMBOENDARTERECTOMY; TIBIAL OR PERONEAL ARTERY, INITIAL 35305 VESSEL No MEDICAID THROMBOENDARTERECTOMY; TIBIAL OR PERONEAL ARTERY, EACH ADD 35306 No MEDICAID Thromboendarterectomy, with or without 35311 patch graft; subclavian, No MEDICAID Thromboendarterectomy, with or without 35321 patch graft; axillary-brachial No MEDICAID Thromboendarterectomy, with or without 35331 patch graft; abdominal aorta No MEDICAID Thromboendarterectomy, with or without patch graft; mesenteric, celiac, 35341 No MEDICAID Thromboendarterectomy, with or without 35351 patch graft; iliac No MEDICAID Thromboendarterectomy, with or without 35355 patch graft; iliofemoral No MEDICAID Thromboendarterectomy, with or without patch graft; combined aortoiliac 35361 No MEDICAID Thromboendarterectomy, with or without 35363 patch graft; combined No MEDICAID Thromboendarterectomy, with or without 35371 patch graft; common femoral No MEDICAID Thromboendarterectomy, with or without 35372 patch graft; deep (profunda) No MEDICAID Reoperation, carotid, thromboendarterectomy, more than one 35390 month after No MEDICAID Angioscopy (non-coronary vessels or 35400 grafts) during therapeutic No MEDICAID Harvest of upper extremity vein, one 35500 segment, for lower extremity or No MEDICAID 35501 Bypass graft, with vein; carotid No MEDICAID Bypass graft, with vein; carotid-subclavian 35506 No MEDICAID Bypass graft, with vein; carotid-vertebral 35508 No MEDICAID Bypass graft, with vein; carotid-carotid 35509 No MEDICAID Bypass graft, with vein; carotid-brachial 35510 No MEDICAID Bypass graft, with vein; subclavian- 35511 subclavian No MEDICAID Bypass graft, with vein; subclavian- 35512 brachial No MEDICAID Bypass graft, with vein; subclavian- 35515 vertebral No MEDICAID

117 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Bypass graft, with vein; subclavian-axillary 35516 No MEDICAID Bypass graft, with vein; axillary-axillary 35518 No MEDICAID Bypass graft, with vein; axillary-femoral 35521 No MEDICAID Bypass graft, with vein; axillary-brachial 35522 No MEDICAID BYPASS GRAFT, WITH VEIN; 35523 BRACHIAL-ULNAR OR -RADIAL No MEDICAID Bypass graft, with vein; brachial-brachial 35525 No MEDICAID Bypass graft, with vein; aortosubclavian, aortoinnominate, or aortocarotid 35526 No MEDICAID Bypass graft, with vein; aortoceliac or 35531 aortomesenteric No MEDICAID Bypass graft, with vein; axillary-femoral- 35533 femoral No MEDICAID 35535 Bypass graft, with vein; hepatorenal No MEDICAID 35536 Bypass graft, with vein; splenorenal No MEDICAID BYPASS GRAFT, WITH VEIN; 35537 AORTOILIAC No MEDICAID BYPASS GRAFT, WITH VEIN; AORTOBI- 35538 ILIAC No MEDICAID BYPASS GRAFT, WITH VEIN; 35539 AORTOFEMORAL No MEDICAID BYPASS GRAFT, WITH VEIN; 35540 AORTOBIFEMORAL No MEDICAID Bypass graft, with vein; femoral-popliteal 35556 No MEDICAID Bypass graft, with vein; femoral-femoral 35558 No MEDICAID 35560 Bypass graft, with vein; aortorenal No MEDICAID 35563 Bypass graft, with vein; ilioiliac No MEDICAID 35565 Bypass graft, with vein; iliofemoral No MEDICAID Bypass graft, with vein; femoral-anterior 35566 tibial, posterior tibial, No MEDICAID Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk- 35570 tibial No MEDICAID Bypass graft, with vein; popliteal-tibial, - 35571 peroneal artery or other No MEDICAID Harvest of femoropopliteal vein, one 35572 segment, for vascular No MEDICAID 35583 In-situ vein bypass; femoral-popliteal No MEDICAID In-situ vein bypass; femoral-anterior tibial, 35585 posterior tibial, or No MEDICAID In-situ vein bypass; popliteal-tibial, 35587 peroneal No MEDICAID Harvest of upper extremity artery, one 35600 segment, for coronary artery No MEDICAID Bypass graft, with other than vein; carotid 35601 No MEDICAID Bypass graft, with other than vein; carotid- 35606 subclavian No MEDICAID Bypass graft, with other than vein; 35612 subclavian-subclavian No MEDICAID Bypass graft, with other than vein; 35616 subclavian-axillary No MEDICAID Bypass graft, with other than vein; axillary- 35621 femoral No MEDICAID Bypass graft, with other than vein; axillary- 35623 popliteal or -tibial No MEDICAID Bypass graft, with other than vein; aortosubclavian, aortoinnominate, or 35626 aortocarotid No MEDICAID Bypass graft, with other than vein; 35631 aortoceliac, aortomesenteric, No MEDICAID Bypass graft, with other than vein; ilio- 35632 celiac No MEDICAID

118 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Bypass graft, with other than vein; ilio- 35633 mesenteric No MEDICAID Bypass graft, with other than vein; 35634 iliorenal No MEDICAID Bypass graft, with other than vein; 35636 splenorenal (splenic to renal No MEDICAID BYPASS GRAFT, WITH OTHER THAN 35637 VEIN; AORTOILIAC No MEDICAID BYPASS GRAFT, WITH OTHER THAN 35638 VEIN; AORTOBI-ILIAC No MEDICAID Bypass graft, with other than vein; carotid- 35642 vertebral No MEDICAID Bypass graft, with other than vein; 35645 subclavian-vertebral No MEDICAID Bypass graft, with other than vein; 35646 aortobifemoral No MEDICAID Bypass graft, with other than vein; 35647 aortofemoral No MEDICAID Bypass graft, with other than vein; axillary- 35650 axillary No MEDICAID Bypass graft, with other than vein; axillary- 35654 femoral-femoral No MEDICAID Bypass graft, with other than vein; femoral- 35656 popliteal No MEDICAID Bypass graft, with other than vein; femoral- 35661 femoral No MEDICAID Bypass graft, with other than vein; ilioiliac 35663 No MEDICAID Bypass graft, with other than vein; 35665 iliofemoral No MEDICAID Bypass graft, with other than vein; femoral- 35666 anterior tibial, posterior No MEDICAID Bypass graft, with other than vein; 35671 popliteal-tibial or -peroneal artery No MEDICAID Bypass graft; composite, prosthetic and 35681 vein (List separately in No MEDICAID Bypass graft; autogenous composite, two 35682 segments of veins from two No MEDICAID Bypass graft; autogenous composite, 35683 three or more segments of vein No MEDICAID Placement of vein patch or cuff at distal 35685 anastomosis of bypass graft, No MEDICAID Creation of distal arteriovenous fistula 35686 during lower extremity bypass No MEDICAID Transposition and/or reimplantation; 35691 vertebral to carotid artery No MEDICAID Transposition and/or reimplantation; 35693 vertebral to subclavian artery No MEDICAID Transposition and/or reimplantation; 35694 subclavian to carotid artery No MEDICAID Transposition and/or reimplantation; 35695 carotid to subclavian artery No MEDICAID Reimplantation, visceral artery to 35697 infrarenal aortic prosthesis, each No MEDICAID Reoperation, femoral-popliteal or femoral 35700 (popliteal)-anterior tibial, No MEDICAID Exploration (not followed by surgical 35701 repair), with or without lysis of No MEDICAID Exploration (not followed by surgical 35721 repair), with or without lysis of No MEDICAID Exploration (not followed by surgical 35741 repair), with or without lysis of No MEDICAID Exploration (not followed by surgical 35761 repair), with or without lysis of No MEDICAID Exploration for postoperative hemorrhage, thrombosis or infection; neck 35800 No MEDICAID Exploration for postoperative hemorrhage, thrombosis or infection; chest 35820 No MEDICAID

119 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Exploration for postoperative hemorrhage, 35840 thrombosis or infection; No MEDICAID Exploration for postoperative hemorrhage, 35860 thrombosis or infection; No MEDICAID 35870 Repair of graft-enteric fistula No MEDICAID Thrombectomy of arterial or venous graft 35875 (other than hemodialysis graft No MEDICAID Thrombectomy of arterial or venous graft 35876 (other than hemodialysis graft No MEDICAID Revision, lower extremity arterial bypass, 35879 without thrombectomy, open; No MEDICAID Revision, lower extremity arterial bypass, 35881 without thrombectomy, open; No MEDICAID REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS 35883 GRAFT No MEDICAID REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS 35884 GRAFT No MEDICAID 35901 Excision of infected graft; neck No MEDICAID 35903 Excision of infected graft; extremity No MEDICAID 35905 Excision of infected graft; thorax No MEDICAID 35907 Excision of infected graft; abdomen No MEDICAID Introduction of needle or intracatheter, 36000 vein No MEDICAID Injection procedures (eg, thrombin) for 36002 percutaneous treatment of No MEDICAID Injection procedure for extremity 36005 venography (including introduction of No MEDICAID Introduction of catheter, superior or 36010 inferior vena cava No MEDICAID SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER 36011 BRANCH No MEDICAID Selective catheter placement, venous 36012 system; second order, or more No MEDICAID Introduction of catheter, right heart or 36013 main pulmonary artery No MEDICAID Selective catheter placement, left or right 36014 pulmonary artery No MEDICAID Selective catheter placement, segmental or subsegmental pulmonary 36015 No MEDICAID Introduction of needle or intracatheter, carotid or vertebral artery 36100 No MEDICAID Introduction of needle or intracatheter; 36140 extremity artery No MEDICAID Introduction of needle or intracatheter, 36160 aortic, translumbar No MEDICAID 36200 Introduction of catheter, aorta No MEDICAID Selective catheter placement, arterial 36215 system; each first order thoracic No MEDICAID Selective catheter placement, arterial 36216 system; initial second order No MEDICAID Selective catheter placement, arterial 36217 system; initial third order or No MEDICAID Selective catheter placement, arterial 36218 system; additional second order, No MEDICAID Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, 36221 and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed No MEDICAID

120 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation 36222 and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed No MEDICAID Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision 36223 and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed

No MEDICAID Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological 36224 supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed

No MEDICAID Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological 36225 supervision and interpretation, includes angiography of the cervicocerebral arch, when performed No MEDICAID Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and 36226 interpretation, includes angiography of the cervicocerebral arch, when performed

No MEDICAID Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological 36227 supervision and interpretation (List separately in addition to code for primary procedure) No MEDICAID Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological 36228 supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure)

No MEDICAID Selective catheter placement, arterial 36245 system; each first order No MEDICAID Selective catheter placement, arterial 36246 system; initial second order No MEDICAID Selective catheter placement, arterial 36247 system; initial third order or No MEDICAID Selective catheter placement, arterial 36248 system; additional second order, No MEDICAID

121 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36251 No MEDICAID Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

36252 No MEDICAID Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36253 No MEDICAID Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

36254 No MEDICAID INSERTION OF IMPLANTABLE INTRA- 36260 ARTERIAL INFUSION PUMP No MEDICAID REVISION OF IMPLANTED INTRA- 36261 ARTERIAL INFUSION PUMP No MEDICAID Removal of implanted intra-arterial 36262 infusion pump No MEDICAID UNLISTED PROCEDURE, VASCULAR 36299 INJECTION Yes MEDICAID Venipuncture, under age 3 years, 36400 necessitating physician’s skill, not to No MEDICAID Venipuncture, under age 3 years, 36405 necessitating physician’s skill, not to No MEDICAID Venipuncture, under age 3 years, 36406 necessitating physician’s skill, not to No MEDICAID Venipuncture, age 3 years or older, 36410 necessitating physician's skill No MEDICAID

122 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Collection of venous blood by 36415 venipuncture No MEDICAID Collection of capillary blood specimen (eg, 36416 finger, heel, ear stick) No MEDICAID Venipuncture, cutdown; under age 1 year 36420 No MEDICAID 36425 Venipuncture, cutdown; age 1 or over No MEDICAID Transfusion, blood or blood components 36430 No MEDICAID Push transfusion, blood, 2 years or under 36440 No MEDICAID Exchange transfusion, blood; newborn 36450 No MEDICAID Exchange transfusion, blood; other than 36455 newborn No MEDICAID 36456 Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn No MEDICAID 36460 Transfusion, intrauterine, fetal No MEDICAID Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) 36465 No MEDICAID Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg

36466 No MEDICAID SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER 36468 Yes VEINS (TELANGIECTASIA); LIMB OR TRUNK MEDICAID INJECTION OF SCLEROSING 36470 SOLUTION; SINGLE VEIN Yes MEDICAID INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME 36471 LEG Yes MEDICAID Endovenous ablation therapy of incompetent vein, extremity, inclusive of 36473 all imaging guidance and monitoring, Yes percutaneous, mechanochemical; first vein treated MEDICAID Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; 36474 subsequent vein(s) treated in a single Yes extremity, each through separate access sites (List separately in addition to code for primary procedure) MEDICAID ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCL IMAGING 36475 GUIDANCE/MONITORING, Yes PERCUTANEOUS, RADIOFREQUENCY; 1ST VE MEDICAID

123 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCL IMAGING 36476 GUIDANCE/MONITORING, Yes PERCUTANEOUS, RADIOFREQUENCY; 2ND VE MEDICAID ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCL IMAGING 36478 GUIDANCE/MONITORING, Yes PERCUTANEOUS, LASER; 1ST VEIN TREATE MEDICAID ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCL IMAGING 36479 GUIDANCE/MONITORING, Yes PERCUTANEOUS, LASER; 2ND & MORE VEIN MEDICAID Percutaneous portal vein catheterization 36481 by any method No MEDICAID Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; 36482 first vein treated No MEDICAID Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36483 No MEDICAID Venous catheterization for selective organ 36500 blood sampling No MEDICAID Catheterization of umbilical vein for 36510 diagnosis or therapy, newborn No MEDICAID THERAPEUTIC APHERESIS; FOR 36511 WHITE BLOOD CELLS No MEDICAID Therapeutic apheresis; for red blood cells 36512 No MEDICAID THERAPEUTIC APHERESIS; FOR 36513 PLATELETS No MEDICAID Therapeutic apheresis; for plasma 36514 pheresis No MEDICAID THERAPEUTIC APHERESIS;WITH EXTRACORPOREAL SELECTIVE ADSORPTION OR SELECTIVE FILTRATION AND PLASMA 36516 REINFUSION No MEDICAID 36522 Photopheresis, extracorporeal No MEDICAID Insertion of non-tunneled centrally 36555 inserted central venous catheter; No MEDICAID Insertion of non-tunneled centrally 36556 inserted central venous catheter; No MEDICAID Insertion of tunneled centrally inserted 36557 central venous catheter, No MEDICAID Insertion of tunneled centrally inserted 36558 central venous catheter, No MEDICAID Insertion of tunneled centrally inserted central venous access device, 36560 No MEDICAID Insertion of tunneled centrally inserted central venous access device, 36561 No MEDICAID

124 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Insertion of tunneled centrally inserted central venous access device 36563 No MEDICAID Insertion of tunneled centrally inserted central venous access device, 36565 No MEDICAID Insertion of tunneled centrally inserted central venous access device, 36566 No MEDICAID Insertion of peripherally inserted central 36568 venous catheter (PICC), No MEDICAID Insertion of peripherally inserted central 36569 venous catheter (PICC), No MEDICAID Insertion of peripherally inserted central 36570 venous access device, with No MEDICAID Insertion of peripherally inserted central 36571 venous access device, with No MEDICAID Repair of tunneled or non-tunneled central 36575 venous access catheter, No MEDICAID Repair of central venous access device, with subcutaneous port or pump, 36576 No MEDICAID Replacement, catheter only, of central 36578 venous access device, with No MEDICAID Replacement, complete, of a non- 36580 tunneled centrally inserted central No MEDICAID Replacement, complete, of a tunneled centrally inserted central venous 36581 No MEDICAID Replacement, complete, of a tunneled centrally inserted central venous 36582 No MEDICAID Replacement, complete, of a tunneled centrally inserted central venous 36583 No MEDICAID Replacement, complete, of a peripherally 36584 inserted central venous No MEDICAID Replacement, complete, of a peripherally inserted central venous access 36585 No MEDICAID Removal of tunneled central venous 36589 catheter, without subcutaneous port No MEDICAID Removal of tunneled central venous 36590 access device, with subcutaneous No MEDICAID COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE VENOUS ACCESS DEVICE 36591 No MEDICAID COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PERIPHERAL CATHETER, VENOUS, NOT OTHERWISE SPECIFIED 36592 No MEDICAID DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR 36593 ACCESS DEVICE OR CATHETER No MEDICAID Mechanical removal of pericatheter 36595 obstructive material (eg, fibrin No MEDICAID Mechanical removal of intraluminal 36596 (intracatheter) obstructive material No MEDICAID Repositioning of previously placed central 36597 venous catheter under No MEDICAID CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXTG CENTRAL VENOUS ACCESS DEVICE, INCLD FLUROSCOPY, IMAGE 36598 DOCUMNTN & REPT No MEDICAID Arterial puncture, withdrawal of blood for 36600 diagnosis No MEDICAID Arterial catheterization or cannulation for 36620 sampling, monitoring or No MEDICAID

125 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Arterial catheterization or cannulation for 36625 sampling, monitoring or No MEDICAID Arterial catheterization for prolonged 36640 infusion therapy (chemotherapy), No MEDICAID Catheterization, umbilical artery, newborn, 36660 for diagnosis or therapy No MEDICAID Placement of needle for intraosseous 36680 infusion No MEDICAID Insertion of cannula for hemodialysis, other purpose (separate 36800 No MEDICAID Insertion of cannula for hemodialysis, other purpose (separate 36810 No MEDICAID Insertion of cannula for hemodialysis, other purpose (separate 36815 No MEDICAID ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC 36818 VEIN TRANSPOSITION No MEDICAID Arteriovenous anastomosis, open; by 36819 upper arm basilic vein No MEDICAID Arteriovenous anastomosis, open; by 36820 forearm vein transposition No MEDICAID Arteriovenous anastomosis, open; direct, 36821 any site (eg, Cimino type) No MEDICAID Insertion of arterial and venous cannula(s) 36823 for isolated extracorporeal No MEDICAID Creation of arteriovenous fistula by other 36825 than direct arteriovenous No MEDICAID Creation of arteriovenous fistula by other 36830 than direct arteriovenous No MEDICAID Thrombectomy, open, arteriovenous 36831 fistula without revision, autogenous No MEDICAID Revision, open, arteriovenous fistula; 36832 without thrombectomy, autogenous No MEDICAID Revision, open, arteriovenous fistula; with 36833 thrombectomy, autogenous or No MEDICAID Insertion of Thomas shunt (separate 36835 procedure) No MEDICAID DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS 36838 (STEAL SYNDROME) No MEDICAID External cannula declotting (separate 36860 procedure); without balloon No MEDICAID External cannula declotting (separate 36861 procedure); with balloon catheter No MEDICAID 36901 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report;

No MEDICAID

126 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 36902 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty

No MEDICAID 36903 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

No MEDICAID 36904 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); No MEDICAID 36905 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty

No MEDICAID

127 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 36906 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit

No MEDICAID 36907 Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty (List separately in addition to code for primary procedure) No MEDICAID 36908 Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure) No MEDICAID 36909 Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiological supervision and interpretation necessary to complete the intervention (List separately in addition to code for primary procedure) No MEDICAID Venous anastomosis, open; portocaval 37140 No MEDICAID Venous anastomosis, open; renoportal 37145 No MEDICAID Venous anastomosis, open; caval- 37160 mesenteric No MEDICAID Venous anastomosis, open; splenorenal, 37180 proximal No MEDICAID Venous anastomosis, open; splenorenal, distal (selective decompression 37181 No MEDICAID INSERTION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S)(TIPS)(INCLUDES VENOUS ACCESS, HEPATIC & PORTAL VEIN 37182 CATHETERIZATION, No MEDICAID REVISION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S)(TIPS)(INCLUDES VENOUS ACCESS, HEPATIC & PORTAL VEIN 37183 CATHETERIZATION, No MEDICAID

128 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PRIMARY PERCUTANEOUS TRANSUMINAL MECH THROMBECTOMY, NONCORONARY, ARTERIAL/ARTERIAL BYPASS GRAFT, INCLD FLUOROSCOPIC GUIDANCE & 37184 INT No MEDICAID PRIMARY PERCUTANEOUS TRANSLUMINAL MECH THROMBECTOMY, NONCORONARY, ARTERIAL/ARTERIAL BYPASS GRAFT INCLDG FLUOROSCOPIC GUIDANCE & 37185 IN No MEDICAID SECONDARY PERCUTANEOUS TRANSLUMINAL MECH THROMBECTOMY, (EG, NONPRIMARY MECH, SNARE BASKET, SUCTION TENQ), NON CORONARY, ARTERIAL/A 37186 No MEDICAID PERCUTANEOUS TRANSLUMINAL MECH THROMBECTOMY, VEIN(S) INCLDG INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS & FLROUOSCOPIC 37187 No MEDICAID PERCUTANEOUS TRANSLUMINAL MECH THROMBECTOMY, VEIN(S) INCLDG INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS & FLROUOSCOPIC 37188 No MEDICAID Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed 37191 No MEDICAID Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed 37192 No MEDICAID Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when 37193 performed No MEDICAID Thrombolysis, cerebral, by intravenous 37195 infusion No MEDICAID Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, 37197 and imaging guidance (ultrasound or fluoroscopy), when performed

No MEDICAID 37200 Transcatheter biopsy No MEDICAID Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any 37211 method, including radiological supervision and interpretation, initial treatment day No MEDICAID

129 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Transcatheter therapy, venous infusion for thrombolysis, any method, including 37212 radiological supervision and interpretation, initial treatment day No MEDICAID Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day 37213 during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; No MEDICAID Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, 37214 including follow-up catheter contrast injection, position change, or exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method

No MEDICAID TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), 37215 CERVICAL CAROTID No MEDICAID TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, PERCUTANEOUS; WITHOUT DISTAL 37216 EMBOLIC PROTECTION No MEDICAID 37217 Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation No MEDICAID Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation 37218 No MEDICAID 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty No MEDICAID 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed No MEDICAID 37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) No MEDICAID

130 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) No MEDICAID 37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty No MEDICAID 37225 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed No MEDICAID 37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed No MEDICAID 37227 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed No MEDICAID 37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty No MEDICAID 37229 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed No MEDICAID 37230 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

No MEDICAID 37231 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed No MEDICAID 37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

No MEDICAID 37233 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) No MEDICAID

131 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

No MEDICAID 37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) No MEDICAID 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery No MEDICAID 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) No MEDICAID 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein No MEDICAID 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) No MEDICAID 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) No MEDICAID

132 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)

No MEDICAID 37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction No MEDICAID 37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation No MEDICAID Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery

37246 No MEDICAID Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure)

37247 No MEDICAID Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein 37248 No MEDICAID Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) 37249 No MEDICAID

133 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/ or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)

37252 No MEDICAID Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/ or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure); Each additional noncoronary vessel

37253 No MEDICAID Vascular endoscopy, surgical, with 37500 ligation of perforator veins, No MEDICAID UNLISTED VASCULAR ENDOSCOPY 37501 PROCEDURES Yes MEDICAID 37565 Ligation, internal jugular vein No MEDICAID 37600 Ligation; external carotid artery No MEDICAID Ligation; internal or common carotid artery 37605 No MEDICAID Ligation; internal or common carotid 37606 artery, with gradual occlusion, as No MEDICAID Ligation or banding of angioaccess 37607 arteriovenous fistula No MEDICAID LIGATION OR BIOPSY, TEMPORAL 37609 ARTERY No MEDICAID Ligation, major artery (eg, post-traumatic, 37615 rupture); neck No MEDICAID Ligation, major artery (eg, post-traumatic, 37616 rupture); chest No MEDICAID Ligation, major artery (eg, post-traumatic, 37617 rupture); abdomen No MEDICAID Ligation, major artery (eg, post-traumatic, 37618 rupture); extremity No MEDICAID 37619 Ligation of inferior vena cava No MEDICAID 37650 Ligation of femoral vein No MEDICAID 37660 Ligation of common iliac vein No MEDICAID Ligation and division of long saphenous 37700 vein at saphenofemoral junction, Yes MEDICAID LIGATION, DIVISION & STRIPPING, 37718 Yes SHORT SAPHENOUS VEIN MEDICAID LIGATION, DIVISION & STRIPPING, LONG (GREATER) SAPHENOUS VEINS 37722 Yes FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW MEDICAID Ligation and division and complete 37735 Yes stripping of long or short saphenous MEDICAID Ligation of perforator veins, subfascial, 37760 radical (Linton type), with or Yes MEDICAID LIGATION OF PERFORATOR VEINS(S), SUBFASCIAL, OPEN INCLUDING 37761 ULTRASOUND GUIDANCE, WHEN Yes PERFORMED, 1 LEG MEDICAID STAB PHLEBECTOMY OF VARICOSE 37765 VEINS, ONE EXTREMITY; 10-20 STAB Yes INCISIONS MEDICAID STAB PHLEBECTOMY OF VARICOSE 37766 VEINS, ONE EXTREMITY; MORE THAN Yes 20 INCISIONS MEDICAID LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT 37780 Yes SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE) MEDICAID

134 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LIGATION, DIVISION, AND/OR 37785 EXCISION OF VARICOSE VEIN Yes (CLUSTERS), ONE LEG MEDICAID Penile revascularization, artery, with or 37788 Yes without vein graft MEDICAID 37790 Penile venous occlusive procedure Yes MEDICAID UNLISTED PROCEDURE, VASCULAR 37799 SURGERY Yes MEDICAID Splenectomy; total (separate procedure) 38100 No MEDICAID Splenectomy; partial (separate procedure) 38101 No MEDICAID Splenectomy; total, en bloc for extensive disease, in conjunction with 38102 No MEDICAID Repair of ruptured spleen (splenorrhaphy) with or without partial 38115 No MEDICAID 38120 Laparoscopy, surgical, splenectomy No MEDICAID UNLISTED LAPAROSCOPY 38129 PROCEDURE, SPLEEN Yes MEDICAID Injection procedure for splenoportography 38200 No MEDICAID MANAGEMENT OF RECIPIENT HEMATOPOIETIC PROGENITOR CELL DONOR SEARCH AND CELL 38204 ACQUISITION No MEDICAID BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING 38205 Yes FOR TRANPLANTATION, PER COLLECTION; ALLOGENIC MEDICAID BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING 38206 Yes FOR TRANPLANTATION, PER COLLECTION; AUTOLOGOUS MEDICAID TRANSPLANT PREPARATION OF OF HEMATOPOIETIC PROGENITOR 38207 Yes CELLS; CRYOPRESERVATION AND STORAGE MEDICAID THAWING OF PREVIOULSY FROZEN 38208 Yes HARVEST, WITHOUT WASHING MEDICAID THAWING OF PREVIOUSLY FROZEN 38209 Yes HARVEST, WITH WASHING MEDICAID SPECIFIC CELL DEPLETION WITH 38210 Yes HARVEST, T-CELL DEPLETION MEDICAID 38211 TUMOR CELL DEPLETION Yes MEDICAID 38212 RED BLOOD CELL REMOVAL Yes MEDICAID 38213 PLATELET DEPLETION Yes MEDICAID 38214 PLASMA (VOLUME) DEPLETION Yes MEDICAID CELL CONCENTRATION IN PLASMA, 38215 MONONUCLEAR, OR BUFFY COAT Yes LAYER MEDICAID 38220 Bone marrow; aspiration only No MEDICAID Bone marrow; biopsy, needle or trocar 38221 No MEDICAID Diagnostic bone marrow; biopsy(ies) and 38222 aspiration(s) No MEDICAID BONE MARROW HARVESTING FOR 38230 Yes TRANSPLANTATION MEDICAID Bone marrow harvesting for 38232 Yes transplantation; autologous MEDICAID BONE MARROW OR BLOOD-DERIVED 38240 PERIPHERAL STEM CELL Yes TRANSPLANTATION; ALLOGENIC MEDICAID BONE MARROW OR BLOOD-DERIVED 38241 PERIPHERAL STEM CELL Yes TRANSPLANTATION; AUTOLOGOUS MEDICAID ALLOGENEIC DONOR LYMPHOCYTE 38242 Yes INFUSIONS MEDICAID Hematopoietic progenitor cell (HPC); HPC 38243 Yes boost MEDICAID

135 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Drainage of lymph node abscess or 38300 lymphadenitis; simple No MEDICAID Drainage of lymph node abscess or 38305 lymphadenitis; extensive No MEDICAID Lymphangiotomy or other operations on 38308 lymphatic channels No MEDICAID Suture and/or ligation of thoracic duct; 38380 cervical approach No MEDICAID Suture and/or ligation of thoracic duct; 38381 thoracic approach No MEDICAID Suture and/or ligation of thoracic duct; 38382 abdominal approach No MEDICAID Biopsy or excision of lymph node(s); 38500 open, superficial No MEDICAID Biopsy or excision of lymph node(s); by 38505 needle, superficial (eg, No MEDICAID Biopsy or excision of lymph node(s); 38510 open, deep cervical node(s) No MEDICAID Biopsy or excision of lymph node(s); 38520 open, deep cervical node(s) with No MEDICAID Biopsy or excision of lymph node(s); 38525 open, deep axillary node(s) No MEDICAID Biopsy or excision of lymph node(s); 38530 open, internal mammary node(s) No MEDICAID 38542 Dissection, deep jugular node(s) No MEDICAID Excision of cystic hygroma, axillary or 38550 cervical; without deep No MEDICAID Excision of cystic hygroma, axillary or 38555 cervical; with deep No MEDICAID Limited lymphadenectomy for staging (separate procedure); pelvic and 38562 No MEDICAID Limited lymphadenectomy for staging 38564 (separate procedure); No MEDICAID Laparoscopy, surgical; with 38570 retroperitoneal lymph node sampling No MEDICAID Laparoscopy, surgical; with bilateral total 38571 pelvic lymphadenectomy No MEDICAID Laparoscopy, surgical; with bilateral total 38572 pelvic lymphadenectomy and No MEDICAID Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed 38573 No MEDICAID UNLISTED LAPAROSCOPY 38589 PROCEDURE, LYMPHATIC SYSTEM Yes MEDICAID 38700 Suprahyoid lymphadenectomy No MEDICAID Cervical lymphadenectomy (complete) 38720 No MEDICAID Cervical lymphadenectomy (modified 38724 radical neck dissection) No MEDICAID 38740 Axillary lymphadenectomy; superficial No MEDICAID 38745 Axillary lymphadenectomy; complete No MEDICAID Thoracic lymphadenectomy, regional, 38746 including mediastinal and No MEDICAID Abdominal lymphadenectomy, regional, including celiac, gastric, portal, 38747 No MEDICAID Inguinofemoral lymphadenectomy, 38760 superficial, including Cloquets node No MEDICAID Inguinofemoral lymphadenectomy, 38765 superficial, in continuity with pelvic No MEDICAID Pelvic lymphadenectomy, including 38770 external iliac, hypogastric, and No MEDICAID Retroperitoneal transabdominal lymphadenectomy, extensive, including 38780 No MEDICAID

136 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection procedure; lymphangiography 38790 No MEDICAID Injection procedure; for identification of 38792 sentinel node No MEDICAID 38794 Cannulation, thoracic duct No MEDICAID 38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) No MEDICAID UNLISTED PROCEDURE, HEMIC OR 38999 LYMPHATIC SYSTEM Yes MEDICAID Mediastinotomy with exploration, 39000 drainage, removal of foreign body, or No MEDICAID Mediastinotomy with exploration, 39010 drainage, removal of foreign body, or No MEDICAID 39200 Excision of mediastinal cyst No MEDICAID 39220 Excision of mediastinal tumor No MEDICAID Mediastinscopy; includes biopsy(ies) of mediastinal mass (e.g., lymphoma), when 39401 performed No MEDICAID Mediastinscopy; includes biopsy(ies) of mediastinal mass (e.g., lymphoma), when performed with lymph node biopsy(ies) (e.g., 39402 lung cancer staging) No MEDICAID UNLISTED PROCEDURE, 39499 MEDIASTINUM Yes MEDICAID Repair, laceration of diaphragm, any 39501 approach No MEDICAID Repair, neonatal diaphragmatic hernia, 39503 with or without chest tube No MEDICAID Repair, diaphragmatic hernia (other than 39540 neonatal), traumatic; acute No MEDICAID Repair, diaphragmatic hernia (other than 39541 neonatal), traumatic; chronic No MEDICAID Imbrication of diaphragm for eventration, 39545 transthoracic or No MEDICAID Resection, diaphragm; with simple repair 39560 (eg, primary suture) No MEDICAID Resection, diaphragm; with complex 39561 repair (eg, prosthetic material, No MEDICAID UNLISTED PROCEDURE, DIAPHRAGM 39599 Yes MEDICAID 40490 Biopsy of lip No MEDICAID VERMILIONECTOMY (LIP SHAVE), 40500 WITH MUCOSAL ADVANCEMENT No MEDICAID EXCISION OF LIP; TRANSVERSE WEDGE EXCISION WITH PRIMARY 40510 CLOSURE No MEDICAID EXCISION OF LIP; V-EXCISION WITH PRIMARY DIRECT LINEAR CLOSURE 40520 No MEDICAID EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH LOCAL FLAP (EG, ESTLANDER OR FAN) 40525 No MEDICAID EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH CROSS LIP FLAP (ABBE-ESTLANDER) 40527 No MEDICAID RESECTION OF LIP, MORE THAN ONE- FOURTH, WITHOUT 40530 RECONSTRUCTION No MEDICAID REPAIR LIP, FULL THICKNESS; 40650 VERMILION ONLY No MEDICAID REPAIR LIP, FULL THICKNESS; UP TO 40652 HALF VERTICAL HEIGHT No MEDICAID REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR 40654 COMPLEX No MEDICAID

137 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR COMPLETE, UNILATERAL 40700 No MEDICAID PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, ONE STAGE PROCEDURE 40701 No MEDICAID PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 40702 ONE OF TWO STAGES No MEDICAID PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY RECREATION OF DEFECT AND 40720 RECLOSURE No MEDICAID PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; WITH CROSS LIP PEDICLE FLAP (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND 40761 INSERTING No MEDICAID 40799 UNLISTED PROCEDURE, LIPS Yes MEDICAID DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; 40800 SIMPLE No MEDICAID Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated 40801 No MEDICAID REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; 40804 SIMPLE No MEDICAID Removal of embedded foreign body, 40805 vestibule of mouth; complicated No MEDICAID INCISION OF LABIAL FRENUM 40806 (FRENOTOMY) No MEDICAID 40808 Biopsy, vestibule of mouth No MEDICAID EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 40810 MOUTH No MEDICAID Excision of lesion of mucosa and 40812 submucosa, vestibule of mouth; with No MEDICAID Excision of lesion of mucosa and 40814 submucosa, vestibule of mouth; with No MEDICAID Excision of lesion of mucosa and 40816 submucosa, vestibule of mouth; No MEDICAID Excision of mucosa of vestibule of mouth 40818 as donor graft No MEDICAID Excision of frenum, labial or buccal 40819 Yes (frenumectomy, frenulectomy, MEDICAID Destruction of lesion or scar of vestibule of mouth by physical methods 40820 No MEDICAID Closure of laceration, vestibule of mouth; 40830 2.5 cm or less No MEDICAID Closure of laceration, vestibule of mouth; 40831 over 2.5 cm or complex No MEDICAID 40840 Vestibuloplasty; anterior No MEDICAID 40842 Vestibuloplasty; posterior, unilateral No MEDICAID 40843 Vestibuloplasty; posterior, bilateral No MEDICAID 40844 Vestibuloplasty; entire arch No MEDICAID Vestibuloplasty; complex (including ridge 40845 No extension, muscle MEDICAID UNLISTED PROCEDURE, VESTIBULE 40899 OF MOUTH Yes MEDICAID Intraoral incision and drainage of abscess, cyst, or hematoma of tongue 41000 No MEDICAID Intraoral incision and drainage of abscess, cyst, or hematoma of tongue 41005 No MEDICAID

138 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Intraoral incision and drainage of abscess, cyst, or hematoma of tongue 41006 No MEDICAID Intraoral incision and drainage of abscess, cyst, or hematoma of tongue 41007 No MEDICAID 41008 Drainage of mouth lesion No MEDICAID Intraoral incision and drainage of abscess, cyst, or hematoma of tongue 41009 No MEDICAID INCISION OF LINGUAL FRENUM 41010 Yes (FRENOTOMY) MEDICAID Extraoral incision and drainage of 41015 abscess, cyst, or hematoma of floor No MEDICAID Extraoral incision and drainage of 41016 abscess, cyst, or hematoma of floor No MEDICAID Extraoral incision and drainage of 41017 abscess, cyst, or hematoma of floor No MEDICAID Extraoral incision and drainage of 41018 abscess, cyst, or hematoma of floor No MEDICAID PLACEMENT OF NEEDLES, CATHETERS, OR OTHER DEVICE(S) INTO HEAD AND/OR NECK REGION (PERCUTANEOUS, TRANSORAL, OR TRANSNASAL) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT 41019 APPLICATION No MEDICAID 41100 Biopsy of tongue; anterior two-thirds No MEDICAID 41105 Biopsy of tongue; posterior one-third No MEDICAID 41108 Biopsy of floor of mouth No MEDICAID Excision of lesion of tongue without 41110 closure No MEDICAID Excision of lesion of tongue with closure; 41112 anterior two-thirds No MEDICAID Excision of lesion of tongue with closure; 41113 posterior one-third No MEDICAID Excision of lesion of tongue with closure; 41114 with local tongue flap No MEDICAID EXCISION OF LINGUAL FRENUM 41115 Yes (FRENECTOMY) MEDICAID 41116 Excision, lesion of floor of mouth No MEDICAID Glossectomy; less than one-half tongue 41120 No MEDICAID 41130 Glossectomy; hemiglossectomy No MEDICAID Glossectomy; partial, with unilateral 41135 radical neck dissection No MEDICAID Glossectomy; complete or total, with or 41140 without tracheostomy, without No MEDICAID Glossectomy; complete or total, with or 41145 without tracheostomy, with No MEDICAID Glossectomy; composite procedure with 41150 resection floor of mouth and No MEDICAID Glossectomy; composite procedure with 41153 resection floor of mouth, with No MEDICAID Glossectomy; composite procedure with 41155 resection floor of mouth, No MEDICAID Repair of laceration 2.5 cm or less; floor 41250 of mouth and/or anterior No MEDICAID Repair of laceration 2.5 cm or less; 41251 posterior one-third of tongue No MEDICAID Repair of laceration of tongue, floor of 41252 mouth, over 2.6 cm or complex No MEDICAID Fixation of tongue, mechanical, other than 41500 suture (eg, K-wire) No MEDICAID Suture of tongue to lip for micrognathia (Douglas type procedure) 41510 No MEDICAID Tongue base suspension, permanent 41512 suture technique No MEDICAID Frenoplasty (surgical revision of frenum, 41520 eg, with Z-plasty) No MEDICAID

139 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Submucosal ablation of the tongue base, 41530 radiofrequency, one or more sites; per No session MEDICAID UNLISTED PROCEDURE, TONGUE, 41599 FLOOR OF MOUTH Yes MEDICAID Drainage of abscess, cyst, hematoma from dentoalveolar structures 41800 No MEDICAID Removal of embedded foreign body from 41805 dentoalveolar structures; soft No MEDICAID Removal of embedded foreign body from 41806 dentoalveolar structures; bone No MEDICAID Gingivectomy, excision gingiva, each 41820 Yes quadrant MEDICAID Operculectomy, excision pericoronal 41821 Yes tissues MEDICAID Excision of fibrous tuberosities, 41822 Yes dentoalveolar structures MEDICAID Excision of osseous tuberosities, 41823 Yes dentoalveolar structures MEDICAID Excision of lesion or tumor (except listed 41825 Yes above), dentoalveolar MEDICAID Excision of lesion or tumor (except listed 41826 Yes above), dentoalveolar MEDICAID Excision of lesion or tumor (except listed 41827 Yes above), dentoalveolar MEDICAID Excision of hyperplastic alveolar mucosa, 41828 Yes each quadrant (specify) MEDICAID Alveolectomy, including curettage of 41830 Yes osteitis or sequestrectomy MEDICAID Destruction of lesion (except excision), 41850 Yes dentoalveolar structures MEDICAID 41870 Periodontal mucosal grafting Yes MEDICAID Gingivoplasty, each quadrant (specify) 41872 Yes MEDICAID ALVEOLOPLASTY, EACH QUADRANT 41874 Yes (SPECIFY) MEDICAID UNLISTED PROCEDURE, 41899 DENTOALVEOLAR STRUCTURES Yes MEDICAID 42000 Drainage of abscess of palate, uvula No MEDICAID 42100 Biopsy of palate, uvula No MEDICAID Excision, lesion of palate, uvula; without 42104 closure No MEDICAID Excision, lesion of palate, uvula; with 42106 simple primary closure No MEDICAID Excision, lesion of palate, uvula; with local 42107 flap closure No MEDICAID RESECTION OF PALATE OR 42120 EXTENSIVE RESECTION OF LESION No MEDICAID 42140 UVULECTOMY, EXCISION OF UVULA No MEDICAID PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, 42145 UVULOPHARYNGOPLASTY) No MEDICAID DESTRUCTION OF LESION, PALATE 42160 OR UVULA (THERMAL, CRYO OR No CHEMICAL) MEDICAID Repair, laceration of palate; up to 2 cm 42180 No MEDICAID Repair, laceration of palate; over 2 cm or 42182 complex No MEDICAID PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY 42200 No MEDICAID PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; SOFT TISSUE ONLY 42205 No MEDICAID

140 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; WITH BONE GRAFT TO ALVEOLAR RIDGE (INCLUDES 42210 OBTAINING GRAFT) No MEDICAID PALATOPLASTY FOR CLEFT PALATE; 42215 MAJOR REVISION No MEDICAID PALATOPLASTY FOR CLEFT PALATE; SECONDARY LENGTHENING 42220 PROCEDURE No MEDICAID PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP 42225 No MEDICAID LENGTHENING OF PALATE, AND 42226 PHARYNGEAL FLAP No MEDICAID LENGTHENING OF PALATE, WITH 42227 ISLAND FLAP No MEDICAID REPAIR OF ANTERIOR PALATE, 42235 INCLUDING VOMER FLAP No MEDICAID 42260 REPAIR OF NASOLABIAL FISTULA No MEDICAID MAXILLARY IMPRESSION FOR 42280 PALATAL PROSTHESIS No MEDICAID INSERTION OF PIN-RETAINED 42281 PALATAL PROSTHESIS No MEDICAID UNLISTED PROCEDURE, PALATE, 42299 UVULA Yes MEDICAID 42300 Drainage of abscess; parotid, simple No MEDICAID Drainage of abscess; parotid, complicated 42305 No MEDICAID Drainage of abscess; submaxillary or 42310 sublingual, intraoral No MEDICAID Drainage of abscess; submaxillary, 42320 external No MEDICAID Sialolithotomy; submandibular 42330 (submaxillary), sublingual or parotid, No MEDICAID Sialolithotomy; submandibular 42335 (submaxillary), complicated, intraoral No MEDICAID Sialolithotomy; parotid, extraoral or 42340 complicated intraoral No MEDICAID 42400 Biopsy of salivary gland; needle No MEDICAID 42405 Biopsy of salivary gland; incisional No MEDICAID Excision of sublingual salivary cyst 42408 (ranula) No MEDICAID Marsupialization of sublingual salivary 42409 cyst (ranula) No MEDICAID Excision of parotid tumor or parotid gland; 42410 lateral lobe, without nerve No MEDICAID Excision of parotid tumor or parotid gland; 42415 lateral lobe, with No MEDICAID Excision of parotid tumor or parotid gland; 42420 total, with dissection and No MEDICAID Excision of parotid tumor or parotid gland; 42425 total, en bloc removal with No MEDICAID Excision of parotid tumor or parotid gland; 42426 total, with unilateral No MEDICAID Excision of submandibular (submaxillary) 42440 gland No MEDICAID 42450 Excision of sublingual gland No MEDICAID Plastic repair of salivary duct, 42500 sialodochoplasty; primary or simple No MEDICAID Plastic repair of salivary duct, 42505 sialodochoplasty; secondary or No MEDICAID Parotid duct diversion, bilateral (Wilke 42507 type procedure); No MEDICAID Parotid duct diversion, bilateral (Wilke 42509 type procedure); with excision No MEDICAID Parotid duct diversion, bilateral (Wilke 42510 type procedure); with ligation No MEDICAID 42550 Injection procedure for sialography No MEDICAID 42600 Closure salivary fistula No MEDICAID 42650 Dilation salivary duct No MEDICAID

141 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Dilation and catheterization of salivary 42660 duct, with or without injection No MEDICAID 42665 Ligation salivary duct, intraoral No MEDICAID UNLISTED PROCEDURE, SALIVARY 42699 GLANDS OR DUCTS Yes MEDICAID Incision and drainage abscess; 42700 peritonsillar No MEDICAID Incision and drainage abscess; 42720 retropharyngeal or parapharyngeal, No MEDICAID Incision and drainage abscess; 42725 retropharyngeal or parapharyngeal, No MEDICAID 42800 Biopsy; oropharynx No MEDICAID Biopsy; nasopharynx, visible lesion, 42804 simple No MEDICAID Biopsy; nasopharynx, survey for unknown 42806 primary lesion No MEDICAID Excision or destruction of lesion of 42808 pharynx, any method No MEDICAID Removal of foreign body from pharynx 42809 No MEDICAID Excision branchial cleft cyst or vestige, 42810 confined to skin and No MEDICAID Excision branchial cleft cyst, vestige, or 42815 fistula, extending beneath No MEDICAID Tonsillectomy and adenoidectomy; under 42820 age 12 No MEDICAID Tonsillectomy and adenoidectomy; age 12 42821 or over No MEDICAID Tonsillectomy, primary or secondary; 42825 under age 12 No MEDICAID Tonsillectomy, primary or secondary; age 42826 12 or over No MEDICAID Adenoidectomy, primary; under age 12 42830 No MEDICAID Adenoidectomy, primary; age 12 or over 42831 No MEDICAID Adenoidectomy, secondary; under age 12 42835 No MEDICAID Adenoidectomy, secondary; age 12 or 42836 over No MEDICAID Radical resection of tonsil, tonsillar pillars, 42842 and/or retromolar No MEDICAID Radical resection of tonsil, tonsillar pillars, 42844 and/or retromolar No MEDICAID Radical resection of tonsil, tonsillar pillars, 42845 and/or retromolar No MEDICAID 42860 Excision of tonsil tags No MEDICAID Excision or destruction lingual tonsil, any 42870 method (separate procedure) No MEDICAID 42890 Limited pharyngectomy No MEDICAID Resection of lateral pharyngeal wall or 42892 pyriform sinus, direct closure No MEDICAID Resection of pharyngeal wall requiring closure with myocutaneous flap 42894 No MEDICAID 42900 Suture pharynx for wound or injury No MEDICAID Pharyngoplasty (plastic or reconstructive 42950 operation on pharynx) No MEDICAID 42953 Pharyngoesophageal repair No MEDICAID Pharyngostomy (fistulization of pharynx, 42955 external for feeding) No MEDICAID Control oropharyngeal hemorrhage, 42960 primary or secondary (eg, No MEDICAID Control oropharyngeal hemorrhage, 42961 primary or secondary (eg, No MEDICAID Control oropharyngeal hemorrhage, 42962 primary or secondary (eg, No MEDICAID Control of nasopharyngeal hemorrhage, primary or secondary (eg, 42970 No MEDICAID

142 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Control of nasopharyngeal hemorrhage, primary or secondary (eg, 42971 No MEDICAID Control of nasopharyngeal hemorrhage, primary or secondary (eg, 42972 No MEDICAID UNLISTED PROCEDURE, PHARYNX, 42999 ADENOIDS, OR TONSILS Yes MEDICAID Esophagotomy, cervical approach, with 43020 removal of foreign body No MEDICAID 43030 Cricopharyngeal myotomy No MEDICAID Esophagotomy, thoracic approach, with 43045 removal of foreign body No MEDICAID Excision of lesion, esophagus, with 43100 primary repair; cervical approach No MEDICAID Excision of lesion, esophagus, with 43101 primary repair; thoracic or No MEDICAID Total or near total esophagectomy, 43107 without thoracotomy; with No MEDICAID Total or near total esophagectomy, 43108 without thoracotomy; with colon No MEDICAID Total or near total esophagectomy, with 43112 thoracotomy; with No MEDICAID Total or near total esophagectomy, with 43113 thoracotomy; with colon No MEDICAID Partial esophagectomy, cervical, with free 43116 intestinal graft, including No MEDICAID Partial esophagectomy, distal two-thirds, with thoracotomy and separate 43117 No MEDICAID Partial esophagectomy, distal two-thirds, with thoracotomy and separate 43118 No MEDICAID Partial esophagectomy, distal two-thirds, 43121 with thoracotomy only, with or No MEDICAID Partial esophagectomy, thoracoabdominal or abdominal approach, with or 43122 No MEDICAID Partial esophagectomy, thoracoabdominal or abdominal approach, with or 43123 No MEDICAID Total or partial esophagectomy, without reconstruction (any approach), 43124 No MEDICAID Diverticulectomy of hypopharynx or 43130 esophagus, with or without myotomy; No MEDICAID Diverticulectomy of hypopharynx or 43135 esophagus, with or without myotomy; No MEDICAID Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when 43180 performed No MEDICAID 43191 Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure) No MEDICAID 43192 Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance No MEDICAID 43193 Esophagoscopy, rigid, transoral; with biopsy, single or multiple No MEDICAID 43194 Esophagoscopy, rigid, transoral; with removal of foreign body No MEDICAID 43195 Esophagoscopy, rigid, transoral; with balloon dilation (less than 30 mm diameter) No MEDICAID

143 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43196 Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire No MEDICAID 43197 Esophagoscopy, flexible, transnasal; diagnostic, includes collection of specimen(s) by brushing or washing when performed (separate procedure) No MEDICAID 43198 Esophagoscopy, flexible, transnasal; with biopsy, single or multiple No MEDICAID Esophagoscopy, rigid or flexible; 43200 diagnostic, with or without collection No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTIONS(S), ANY 43201 SUBSTANCE No MEDICAID Esophagoscopy, rigid or flexible; with 43202 biopsy, single or multiple No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL 43204 VARICES No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION OF 43205 ESOPHAGEAL VARICES No MEDICAID Esophagoscopy, rigid or flexible; with 43206 optical endomicroscopy No MEDICAID Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed 43210 No MEDICAID 43211 Esophagoscopy, flexible, transoral; with endoscopic mucosal resection No MEDICAID 43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) No MEDICAID 43213 Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed) No MEDICAID 43214 Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF 43215 FOREIGN BODY No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS 43216 OR BIPOLAR CAUTERY No MEDICAID Esophagoscopy, rigid or flexible; with 43217 removal of tumor(s), polyp(s), or No MEDICAID ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION (LESS THAN 30 MM DIAMETER) 43220 No MEDICAID Esophagoscopy, rigid or flexible; with 43226 insertion of guide wire followed No MEDICAID Esophagoscopy, rigid or flexible; with 43227 control of bleeding (eg, No MEDICAID

144 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) No MEDICAID Esophagoscopy, rigid or flexible; with 43231 endoscopic ultrasound examination No MEDICAID Esophagoscopy, rigid or flexible; with 43232 transendoscopic ultrasound-guided No MEDICAID 43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) No MEDICAID Upper gastrointestinal endoscopy 43235 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43236 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43237 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43238 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43239 including esophagus, stomach, and No MEDICAID UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSMURAL DRAINAGE OF 43240 PSEUDOCYST No MEDICAID Upper gastrointestinal endoscopy 43241 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43242 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43243 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43244 including esophagus, stomach, and No MEDICAID UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DILATIO 43245 No MEDICAID Upper gastrointestinal endoscopy 43246 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43247 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43248 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43249 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43250 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy 43251 including esophagus, stomach, and No MEDICAID Upper gastrointestinal endoscopy including esophagus, stomach, and either 43252 the duodenum and/or jejunum as appropriate; with optical endomicroscopy No MEDICAID

145 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43253 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound- guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)

No MEDICAID 43254 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection No MEDICAID UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL 43255 No MEDICAID UPPER GI ENDOSCOPY INCL ESOPHAGUS, STOMACH & DUODENUM &/OR JEJUNUM; 43257 W/DELIVERY OF THERMAL ENERGY No TO SPHICNTER MUSCLE FOR GERD TX. MEDICAID Upper gastrointestinal endoscopy 43259 including esophagus, stomach, and No MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP); 43260 diagnostic, No MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP); with 43261 biopsy, No MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP); with 43262 No MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP); with 43263 pressure No MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP); with 43264 No MEDICAID ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE DESTRUCTION, LITHOTRIPSY OF STONE(S), ANY 43265 METHOD No MEDICAID 43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) No MEDICAID 43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) No MEDICAID Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s) (List separately in addition to code(s) for primary 43273 procedure) No MEDICAID

146 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post- dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent No MEDICAID 43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) No MEDICAID 43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post- dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged

No MEDICAID 43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct No MEDICAID 43278 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed No MEDICAID Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when 43279 performed No MEDICAID Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet 43280 No MEDICAID LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCL FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH 43281 No MEDICAID LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCL FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH 43282 No MEDICAID 43283 Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure) No MEDICAID Laparoscopy, surgical, esophageal sphincter augmentation procedure, 43284 placement of sphincter augmentation No device (ie, magnetic band), including cruroplasty when performed MEDICAID Removal of esophageal sphincter 43285 augmentation device No MEDICAID

147 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, laparoscopic transhiatal esophagectomy)

43286 No MEDICAID Esophagectomy, distal two-thirds, with laparoscopic mobilization of the abdominal and lower mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with separate thoracoscopic mobilization of the middle and upper mediastinal esophagus and thoracic esophagogastrostomy (ie, laparoscopic thoracoscopic esophagectomy, Ivor Lewis esophagectomy)

43287 No MEDICAID Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, thoracoscopic, laparoscopic and cervical incision esophagectomy, McKeown esophagectomy, tri-incisional esophagectomy) 43288 No MEDICAID UNLISTED LAPAROSCOPY 43289 PROCEDURE, ESOPHAGUS Yes MEDICAID Esophagoplasty (plastic repair or 43300 reconstruction), cervical approach; No MEDICAID Esophagoplasty (plastic repair or 43305 reconstruction), cervical approach; No MEDICAID Esophagoplasty (plastic repair or 43310 reconstruction), thoracic approach; No MEDICAID Esophagoplasty (plastic repair or 43312 reconstruction), thoracic approach; No MEDICAID Esophagoplasty for congenital defect 43313 (plastic repair or reconstruction), No MEDICAID Esophagoplasty for congenital defect 43314 (plastic repair or reconstruction), No MEDICAID Esophagogastrostomy (cardioplasty), with or without vagotomy and 43320 No MEDICAID Esophagogastric fundoplasty; with fundic 43325 patch (Thal-Nissen procedure) No MEDICAID 43327 Esophagogastric fundoplasty partial or complete; laparotomy No MEDICAID 43328 Esophagogastric fundoplasty partial or complete; thoracotomy No MEDICAID Esophagomyotomy (Heller type); 43330 abdominal approach No MEDICAID Esophagomyotomy (Heller type); thoracic 43331 approach No MEDICAID 43332 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis No MEDICAID

148 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43333 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis No MEDICAID 43334 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis No MEDICAID 43335 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis No MEDICAID 43336 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis No MEDICAID 43337 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis No MEDICAID 43338 Esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure) No MEDICAID Esophagojejunostomy (without total 43340 gastrectomy); abdominal approach No MEDICAID Esophagojejunostomy (without total 43341 gastrectomy); thoracic approach No MEDICAID Esophagostomy, fistulization of esophagus, external; thoracic approach 43351 No MEDICAID Esophagostomy, fistulization of esophagus, external; cervical approach 43352 No MEDICAID Gastrointestinal reconstruction for 43360 previous esophagectomy, for No MEDICAID Gastrointestinal reconstruction for 43361 previous esophagectomy, for No MEDICAID 43400 Ligation, direct, esophageal varices No MEDICAID Transection of esophagus with repair, for 43401 esophageal varices No MEDICAID Ligation or stapling at gastroesophageal junction for pre-existing 43405 No MEDICAID Suture of esophageal wound or injury; 43410 cervical approach No MEDICAID Suture of esophageal wound or injury; transthoracic or transabdominal 43415 No MEDICAID Closure of esophagostomy or fistula; 43420 cervical approach No MEDICAID Closure of esophagostomy or fistula; 43425 transthoracic or transabdominal No MEDICAID Dilation of esophagus, by unguided sound 43450 or bougie, single or multiple No MEDICAID Dilation of esophagus, over guide wire 43453 No MEDICAID Esophagogastric tamponade, with balloon 43460 (Sengstaaken type) No MEDICAID Free jejunum transfer with microvascular 43496 anastomosis No MEDICAID UNLISTED PROCEDURE, ESOPHAGUS 43499 Yes MEDICAID Gastrotomy; with exploration or foreign 43500 body removal No MEDICAID

149 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Gastrotomy; with suture repair of bleeding 43501 ulcer No MEDICAID Gastrotomy; with suture repair of pre- 43502 existing esophagogastric No MEDICAID Gastrotomy; with esophageal dilation and 43510 insertion of permanent No MEDICAID Pyloromyotomy, cutting of pyloric muscle 43520 (Fredet-Ramstedt type No MEDICAID 43605 Biopsy of stomach, by laparotomy No MEDICAID EXCISION, LOCAL; ULCER OR BENIGN 43610 TUMOR OF STOMACH No MEDICAID EXCISION, LOCAL; MALIGNANT 43611 TUMOR OF STOMACH No MEDICAID GASTRECTOMY, TOTAL; WITH 43620 ESOPHAGOENTEROSTOMY No MEDICAID GASTRECTOMY, TOTAL; WITH ROUX- 43621 EN-Y RECONSTRUCTION No MEDICAID GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, 43622 ANY TYPE No MEDICAID GASTRECTOMY, PARTIAL, DISTAL; 43631 WITH GASTRODUODENOSTOMY No MEDICAID GASTRECTOMY, PARTIAL, DISTAL; 43632 WITH GASTROJEJUNOSTOMY No MEDICAID GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION 43633 No MEDICAID GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL 43634 POUCH No MEDICAID VAGOTOMY WHEN PERFORMED WITH PARTIAL DISTAL GASTRECTOMY (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY 43635 PROCEDURE) No MEDICAID VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT GASTROSTOMY; TRUNCAL OR 43640 SELECTIVE No MEDICAID VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT GASTROSTOMY; PARIETAL CELL (HIGHLY SELECTIVE) 43641 No MEDICAID LAPAROSCOPY, SURGICAL; IMPLANTATION OR REPLACEMENT OF 43647 Yes GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM MEDICAID LAPAROSCOPY, SURGICAL; REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, 43648 ANTRUM Yes MEDICAID LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, 43651 TRUNCAL No MEDICAID TRANSECTION OF VAGUS NERVES, 43652 SELECTIVE OR HIGHLY SELECTIVE No MEDICAID GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) 43653 (SEPARATE PROCEDURE) No MEDICAID UNLISTED LAPAROSCOPY 43659 PROCEDURE, STOMACH Yes MEDICAID Naso- or oro-gastric tube placement, 43752 requiring physician's skill and No MEDICAID 43753 Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed No MEDICAID

150 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 43754 Gastric intubation and aspiration, diagnostic; single specimen (eg, acid analysis) No MEDICAID 43755 Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with gastric stimulation, single or double lumen tube (gastric secretory study) (eg, histamine, insulin, pentagastrin, calcium, secretin), includes drug administration No MEDICAID 43756 Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (eg, bile study for crystals or afferent loop culture) No MEDICAID 43757 Duodenal intubation and aspiration, diagnostic, includes image guidance; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube, includes drug administration No MEDICAID 43760 Change of gastrostomy tube No MEDICAID Repositioning of the gastric feeding tube, 43761 any method, through the No MEDICAID 43800 Pyloroplasty No MEDICAID 43810 Gastroduodenostomy No MEDICAID 43820 Gastrojejunostomy; without vagotomy No MEDICAID Gastrojejunostomy; with vagotomy, any 43825 type No MEDICAID Gastrostomy, open; without construction of gastric tube (eg, Stamm 43830 No MEDICAID Gastrostomy, open; neonatal, for feeding 43831 No MEDICAID Gastrostomy, open; with construction of 43832 gastric tube (eg, Janeway No MEDICAID Gastrorrhaphy, suture of perforated 43840 duodenal or gastric ulcer, wound, or No MEDICAID GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR 43842 MORBID OBESITY; VERTICAL-BANDED Yes GASTROPLASTY MEDICAID REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT 43850 VAGOTOMY No MEDICAID REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITH 43855 VAGOTOMY No MEDICAID REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY 43860 OR BOWEL RESECT No MEDICAID REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY 43865 OR BOWEL RESECT No MEDICAID 43870 Closure of gastrostomy, surgical No MEDICAID 43880 Closure of gastrocolic fistula No MEDICAID

151 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IMPLANTATION OF GASTRIC NEUROSTIMULATOR ELECTRODES, 43881 ANTRUM, OPEN Yes MEDICAID REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, 43882 ANTRUM, OPEN Yes MEDICAID UNLISTED PROCEDURE, STOMACH 43999 Yes MEDICAID Enterolysis (freeing of intestinal adhesion) 44005 (separate procedure) No MEDICAID Duodenotomy, for exploration, biopsy(s), 44010 or foreign body removal No MEDICAID Tube or needle catheter jejunostomy for 44015 enteral alimentation, No MEDICAID Enterotomy, small intestine, other than 44020 duodenum; for exploration, No MEDICAID Enterotomy, small intestine, other than 44021 duodenum; for decompression No MEDICAID Colotomy, for exploration, biopsy(s), or 44025 foreign body removal No MEDICAID Reduction of volvulus, intussusception, internal hernia, by laparotomy 44050 No MEDICAID Correction of malrotation by lysis of 44055 duodenal bands and/or reduction of No MEDICAID Biopsy of intestine by capsule, tube, 44100 peroral (one or more specimens) No MEDICAID Excision of one or more lesions of small 44110 or large intestine not No MEDICAID Excision of one or more lesions of small 44111 or large intestine not No MEDICAID Enterectomy, resection of small intestine; 44120 single resection and No MEDICAID Enterectomy, resection of small intestine; each additional resection and 44121 No MEDICAID Enterectomy, resection of small intestine; 44125 with enterostomy No MEDICAID Enterectomy, resection of small intestine for congenital atresia, single 44126 No MEDICAID Enterectomy, resection of small intestine for congenital atresia, single 44127 No MEDICAID Enterectomy, resection of small intestine for congenital atresia, single 44128 No MEDICAID Enteroenterostomy, anastomosis of 44130 intestine, with or without cutaneous No MEDICAID DONOR ENTERECTOMY, INCLUDING 44132 COLD PRESERVATION OPEN FROM Yes CADAVER DONOR MEDICAID DONOR ENTERECTOMY, INCLUDING COLD PRESERVATION OPEN PARTIAL 44133 Yes FROM LIVING DONOR (REV 2005) MEDICAID INTESTINAL ALLOTRANSPLANTATION; 44135 FROM CADAVER DONOR. Yes MEDICAID INTESTINAL ALLOTRANSPLANTATION; 44136 FROM LIVING DONOR. Yes MEDICAID REMOVAL OF TRANSPLANTED 44137 INTESTINAL ALLOGRAFT, COMPLETE Yes MEDICAID Mobilization (take-down) of splenic flexure 44139 performed in conjunction No MEDICAID 44140 Colectomy, partial; with anastomosis No ExGEN MEDICAID Colectomy, partial; with skin level 44141 cecostomy or colostomy No MEDICAID 44143 (Hartmann type procedure) No MEDICAID

152 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Colectomy, partial; with resection, with 44144 colostomy or ileostomy and No MEDICAID Colectomy, partial; with coloproctostomy (low pelvic anastomosis) 44145 No MEDICAID Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with 44146 No MEDICAID Colectomy, partial; abdominal and 44147 transanal approach No MEDICAID Colectomy, total, abdominal, without 44150 proctectomy; with ileostomy or No MEDICAID Colectomy, total, abdominal, without 44151 proctectomy; with continent No MEDICAID Colectomy, total, abdominal, with 44155 proctectomy; with ileostomy No MEDICAID Colectomy, total, abdominal, with 44156 proctectomy; with continent ileostomy No MEDICAID COLECTOMY, TOTAL, ABDOMINAL, W/PROCTECTOMY; W/ILEOANAL 44157 ANASTOMOSIS, No MEDICAID COLECTOMY, TOTAL, ABDOMINAL, W/PROTECTOMY; W/ILEOANAL 44158 ANASTOMOSIS, CREATE No MEDICAID Colectomy, partial, with removal of 44160 terminal ileum with ileocolostomy No MEDICAID 44180 Lap, enterolysis No MEDICAID 44186 Lap, jejunostomy No MEDICAID 44187 Lap, ileo/jejuno-stomy No MEDICAID 44188 Lap, colostomy No MEDICAID Laparoscopy, surgical; enterectomy, 44202 resection of small intestine, single No MEDICAID LAPAROSCOPIC RESECTION OF 44203 SMALL INTESTINE No MEDICAID Laparoscopy, surgical; colectomy, partial, 44204 with anastomosis No MEDICAID Laparoscopy, surgical; colectomy, partial, 44205 with removal of terminal No MEDICAID COLETOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE 44206 PROCEDURE) No MEDICAID COLETOMY, PARTIAL WITH ANASTOMOSIS, WITH 44207 COLOPROCTOSTOMY No MEDICAID COLECTOMY,PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC 44208 ANASTOMOSIS) WITH COLOSTOMY No MEDICAID COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY, WITH 44210 ILEOSTOMY No MEDICAID LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, W/PROCTECTOMY, W/ILEOANAL ANASTOMOSIS, CREATE ILEAL 44211 RESERVOIR No MEDICAID Laparoscopy, surgical; colectomy, total, 44212 abdominal, with proctectomy, No MEDICAID 44213 Lap, mobil splenic fl add-on No MEDICAID 44227 Lap, close enterostomy No MEDICAID UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE ( EXCEPT 44238 RECTUM) Yes MEDICAID Enterostomy or cecostomy, tube (eg, for 44300 decompression or feeding) No MEDICAID Ileostomy or jejunostomy, non-tube 44310 (separate procedure) No MEDICAID Revision of ileostomy; simple (release of superficial scar) (separate 44312 No MEDICAID

153 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Revision of ileostomy; complicated 44314 (reconstruction in-depth) (separate No MEDICAID Continent ileostomy (Kock procedure) 44316 (separate procedure) No MEDICAID Colostomy or skin level cecostomy; 44320 (separate procedure) No MEDICAID Colostomy or skin level cecostomy; with 44322 multiple biopsies (eg, for No MEDICAID Revision of colostomy; simple (release of superficial scar) (separate 44340 No MEDICAID Revision of colostomy; complicated 44345 (reconstruction in-depth) (separate No MEDICAID Revision of colostomy; with repair of 44346 paracolostomy hernia (separate No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44360 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44361 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44363 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44364 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44365 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44366 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44369 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44370 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44372 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44373 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44376 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44377 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44378 No MEDICAID Small intestinal endoscopy, enteroscopy beyond second portion of 44379 No MEDICAID Ileoscopy, through stoma; diagnostic, with 44380 or without collection of No MEDICAID Ileoscopy, through stoma; with 44381 transendoscopic balloon dilation No MEDICAID Ileoscopy, through stoma; with biopsy, 44382 single or multiple No MEDICAID Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) 44384 No MEDICAID Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; 44385 No MEDICAID

154 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; 44386 No MEDICAID Colonoscopy through stoma; diagnostic, with or without collection of 44388 No MEDICAID Colonoscopy through stoma; with biopsy, 44389 single or multiple No MEDICAID Colonoscopy through stoma; with removal 44390 of foreign body No MEDICAID Colonoscopy through stoma; with control 44391 of bleeding (eg, injection, No MEDICAID Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other 44392 No MEDICAID Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other 44394 No MEDICAID Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 44401 No MEDICAID Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed) 44402 No MEDICAID Colonoscopy through stoma; with 44403 endoscopic mucosal resection No MEDICAID Colonoscopy through stoma; with directed submucosal injection(s), any substance 44404 No MEDICAID Colonoscopy through stoma; with 44405 transendoscopic balloon dilation No MEDICAID Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and 44406 cecum and adjacent structures No MEDICAID Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent 44407 structures No MEDICAID Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 44408 No MEDICAID Introduction of long gastrointestinal tube 44500 (eg, Miller-Abbott) (separate No MEDICAID Suture of small intestine (enterorrhaphy) 44602 for perforated ulcer, No MEDICAID Suture of small intestine (enterorrhaphy) 44603 for perforated ulcer, No MEDICAID Suture of large intestine (colorrhaphy) for 44604 perforated ulcer, No MEDICAID Suture of large intestine (colorrhaphy) for 44605 perforated ulcer, No MEDICAID Intestinal stricturoplasty (enterotomy and 44615 enterorrhaphy) with or No MEDICAID Closure of enterostomy, large or small 44620 intestine; No MEDICAID Closure of enterostomy, large or small 44625 intestine; with resection and No MEDICAID

155 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Closure of enterostomy, large or small 44626 intestine; with resection and No MEDICAID Closure of intestinal cutaneous fistula 44640 No MEDICAID Closure of enteroenteric or enterocolic 44650 fistula No MEDICAID Closure of enterovesical fistula; without 44660 intestinal or bladder No MEDICAID Closure of enterovesical fistula; with 44661 intestine and/or bladder No MEDICAID Intestinal plication (separate procedure) 44680 No MEDICAID Exclusion of small intestine from pelvis by mesh or other prosthesis, or 44700 No MEDICAID Intraoperative colonic lavage (List 44701 separately in addition to code for No MEDICAID Preparation of fecal microbiota for 44705 instillation, including assessment of donor specimen No MEDICAID BACKBENCH STANDARD PREP OF CADAVER OR LIVING DONOR INTESTINE ALLOGRAFT BEFORE 44715 TRANSPLANT; INCL Yes MOBILIZATION/FASHIONING OF SUPERIOR MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 44720 INTESTINE ALLOGRAFT PRIOR TO Yes TRANSPLANT; VENOUS ANASTOMOSIS, EACH MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 44721 INTESTINE ALLOGRAFT PRIOR TO Yes TRANSPLANT; ARTERIAL ANASTOMOSIS, EACH MEDICAID UNLISTED PROCEDURE, INTESTINE 44799 Yes MEDICAID Excision of Meckel's diverticulum 44800 (diverticulectomy) or No MEDICAID Excision of lesion of mesentery (separate 44820 procedure) No MEDICAID Suture of mesentery (separate procedure) 44850 No MEDICAID UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY 44899 Yes MEDICAID Incision and drainage of appendiceal 44900 abscess; open No MEDICAID 44950 Appendectomy; No MEDICAID Appendectomy; when done for indicated purpose at time of other major 44955 No MEDICAID Appendectomy; for ruptured appendix 44960 with abscess or generalized No MEDICAID Laparoscopy, surgical, appendectomy 44970 No MEDICAID UNLISTED LAPAROSCOPY 44979 PROCEDURE, APPENDIX Yes MEDICAID Transrectal drainage of pelvic abscess 45000 No MEDICAID Incision and drainage of submucosal 45005 abscess, rectum No MEDICAID Incision and drainage of deep 45020 supralevator, pelvirectal, or retrorectal No MEDICAID Biopsy of anorectal wall, anal approach (eg, congenital megacolon) 45100 No MEDICAID 45108 Anorectal myomectomy No MEDICAID Proctectomy; complete, combined 45110 abdominoperineal, with colostomy No MEDICAID

156 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Proctectomy; partial resection of rectum, 45111 transabdominal approach No MEDICAID Proctectomy, combined abdominoperineal, pull-through procedure 45112 (eg, No MEDICAID Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, 45113 No MEDICAID Proctectomy, partial, with anastomosis; abdominal and transsacral 45114 No MEDICAID Proctectomy, partial, with anastomosis; transsacral approach only 45116 No MEDICAID Proctectomy, combined abdominoperineal pull-through procedure (eg, 45119 No MEDICAID Proctectomy, complete (for congenital megacolon), abdominal and 45120 No MEDICAID Proctectomy, complete (for congenital megacolon), abdominal and 45121 No MEDICAID Proctectomy, partial, without anastomosis, 45123 perineal approach No MEDICAID Pelvic exenteration for colorectal 45126 malignancy, with proctectomy (with or No MEDICAID Excision of rectal procidentia, with 45130 anastomosis; perineal approach No MEDICAID Excision of rectal procidentia, with anastomosis; abdominal and perineal 45135 No MEDICAID Excision of ileoanal reservoir with 45136 ileostomy No MEDICAID 45150 Division of stricture of rectum No MEDICAID Excision of rectal tumor by proctotomy, transsacral or transcoccygeal 45160 No MEDICAID EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPIA (IE, 45171 PARTIAL THICKNESS) No MEDICAID EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPIA (IE, PARTIAL 45172 THICKNESS) No MEDICAID Destruction of rectal tumor (eg, 45190 electrodessication, electrosurgery, No MEDICAID Proctosigmoidoscopy, rigid; diagnostic, with or without collection of 45300 No MEDICAID Proctosigmoidoscopy, rigid; with dilation 45303 (eg, balloon, guide wire, No MEDICAID Proctosigmoidoscopy, rigid; with biopsy, 45305 single or multiple No MEDICAID Proctosigmoidoscopy, rigid; with removal 45307 of foreign body No MEDICAID Proctosigmoidoscopy, rigid; with removal 45308 of single tumor, polyp, or No MEDICAID Proctosigmoidoscopy, rigid; with removal 45309 of single tumor, polyp, or No MEDICAID Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or 45315 No MEDICAID Proctosigmoidoscopy, rigid; with control of 45317 bleeding (eg, injection, No MEDICAID Proctosigmoidoscopy, rigid; with ablation 45320 of tumor(s), polyp(s), or No MEDICAID Proctosigmoidoscopy, rigid; with 45321 decompression of volvulus No MEDICAID

157 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Proctosigmoidoscopy, rigid; with 45327 transendoscopic stent placement No MEDICAID Sigmoidoscopy, flexible; diagnostic, with 45330 or without collection of No MEDICAID Sigmoidoscopy, flexible; with biopsy, 45331 single or multiple No MEDICAID Sigmoidoscopy, flexible; with removal of 45332 foreign body No MEDICAID Sigmoidoscopy, flexible; with removal of 45333 tumor(s), polyp(s), or other No MEDICAID Sigmoidoscopy, flexible; with control of 45334 bleeding (eg, injection, No MEDICAID Sigmoidoscopy, flexible; with directed 45335 submucosal injection(s), any No MEDICAID Sigmoidoscopy, flexible; with decompression of volvulus, any method 45337 No MEDICAID Sigmoidoscopy, flexible; with removal of 45338 tumor(s), polyp(s), or other No MEDICAID Sigmoidoscopy, flexible; with dilation by 45340 balloon, 1 or more strictures No MEDICAID Sigmoidoscopy, flexible; with endoscopic 45341 ultrasound examination No MEDICAID Sigmoidoscopy, flexible; with 45342 transendoscopic ultrasound guided No MEDICAID Sigmoidoscopy, flexible; with transendoscopic stent placement 45345 (includes No MEDICAID Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) 45346 No MEDICAID Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post- dilation and guide wire passage, when performed) 45347 No MEDICAID Sigmoidoscopy, flexible; with endoscopic 45349 mucosal resection No MEDICAID Sigmoidoscopy, flexible; with band 45350 ligation(s) (eg, hemorrhoids) No MEDICAID Colonoscopy, flexible, proximal to splenic 45378 flexure; diagnostic, with or No MEDICAID Colonoscopy, flexible, proximal to splenic 45379 flexure; with removal of No MEDICAID Colonoscopy, flexible, proximal to splenic 45380 flexure; with biopsy, single No MEDICAID Colonoscopy, flexible, proximal to splenic 45381 flexure; with directed No MEDICAID Colonoscopy, flexible, proximal to splenic 45382 flexure; with control of No MEDICAID Colonoscopy, flexible, proximal to splenic 45384 flexure; with removal of No MEDICAID Colonoscopy, flexible, proximal to splenic 45385 flexure; with removal of No MEDICAID Colonoscopy, flexible, proximal to splenic 45386 flexure; with dilation by No MEDICAID Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) 45388 No MEDICAID Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post- dilation and guide wire passage, when performed) 45389 No MEDICAID Colonoscopy, flexible; with endoscopic 45390 mucosal resection No MEDICAID

158 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Colonoscopy, flexible, proximal to splenic 45391 flexure; with No MEDICAID Colonoscopy, flexible, proximal to splenic 45392 flexure; with No MEDICAID Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45393 No MEDICAID 45395 Lap, removal of rectum No MEDICAID 45397 Lap, remove rectum w/pouch No MEDICAID Colonoscopy, flexible; with band 45398 ligation(s) (eg, hemorrhoids) No MEDICAID 45399 Unlisted procedure, colon Yes MEDICAID 45400 Laparoscopic proctopexy No MEDICAID 45402 Lap proctopexy w/sig resect No MEDICAID UNLISTED LAPAROSCOPY 45499 PROCEDURE, RECTUM Yes MEDICAID 45500 Proctoplasty; for stenosis No MEDICAID Proctoplasty; for prolapse of mucous 45505 membrane No MEDICAID Perirectal injection of sclerosing solution 45520 for prolapse No MEDICAID Proctopexy for prolapse; abdominal 45540 approach No MEDICAID Proctopexy for prolapse; perineal 45541 approach No MEDICAID Proctopexy combined with sigmoid 45550 resection, abdominal approach No MEDICAID Repair of rectocele (separate procedure) 45560 No MEDICAID Exploration, repair, and presacral 45562 drainage for rectal injury; No MEDICAID Exploration, repair, and presacral 45563 drainage for rectal injury; with No MEDICAID 45800 Closure of rectovesical fistula; No MEDICAID Closure of rectovesical fistula; with 45805 colostomy No MEDICAID 45820 Closure of rectourethral fistula; No MEDICAID Closure of rectourethral fistula; with 45825 colostomy No MEDICAID Reduction of procidentia (separate 45900 procedure) under anesthesia No MEDICAID Dilation of anal sphincter (separate 45905 procedure) under anesthesia other No MEDICAID Dilation of rectal stricture (separate 45910 procedure) under anesthesia other No MEDICAID Removal of fecal impaction or foreign 45915 body (separate procedure) under No MEDICAID 45990 Surg dx exam, anorectal No MEDICAID 45999 UNLISTED PROCEDURE, RECTUM Yes MEDICAID 46020 Placement of seton No MEDICAID 46030 Removal of anal seton, other marker No MEDICAID Incision and drainage of ischiorectal 46040 and/or perirectal abscess No MEDICAID Incision and drainage of intramural, 46045 intramuscular, or submucosal No MEDICAID Incision and drainage, perianal abscess, 46050 superficial No MEDICAID Incision and drainage of ischiorectal or 46060 intramural abscess, with No MEDICAID 46070 Incision, anal septum (infant) No MEDICAID Sphincterotomy, anal, division of sphincter 46080 (separate procedure) No MEDICAID Incision of thrombosed hemorrhoid, 46083 external No MEDICAID Fissurectomy, with or without 46200 sphincterotomy No MEDICAID 46210 Cryptectomy; single No MEDICAID

159 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cryptectomy; multiple (separate 46211 procedure) No MEDICAID Papillectomy or excision of single tag, 46220 anus (separate procedure) No MEDICAID Hemorrhoidectomy, by simple ligature (eg, 46221 rubber band) No MEDICAID Excision of external hemorrhoid tags 46230 and/or multiple papillae No MEDICAID Hemorrhoidectomy, external, complete 46250 No MEDICAID Hemorrhoidectomy, internal and external, 46255 simple; No MEDICAID Hemorrhoidectomy, internal and external, 46257 simple; with fissurectomy No MEDICAID Hemorrhoidectomy, internal and external, simple; with fistulectomy, with 46258 No MEDICAID Hemorrhoidectomy, internal and external, 46260 complex or extensive; No MEDICAID Hemorrhoidectomy, internal and external, 46261 complex or extensive; with No MEDICAID Hemorrhoidectomy, internal and external, 46262 complex or extensive; with No MEDICAID Surgical treatment of anal fistula 46270 (fistulectomy/fistulotomy); No MEDICAID Surgical treatment of anal fistula 46275 (fistulectomy/fistulotomy); No MEDICAID Surgical treatment of anal fistula 46280 (fistulectomy/fistulotomy); complex No MEDICAID Surgical treatment of anal fistula 46285 (fistulectomy/fistulotomy); second No MEDICAID Closure of anal fistula with rectal 46288 advancement flap No MEDICAID Enucleation or excision of external 46320 thrombotic hemorrhoid No MEDICAID Injection of sclerosing solution, 46500 hemorrhoids No MEDICAID Chemodenervation of internal anal 46505 sphincter No MEDICAID Anoscopy; diagnostic, with or without 46600 collection of specimen(s) by No MEDICAID Anoscopy; diagnostic, with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed 46601 No MEDICAID Anoscopy; with dilation (eg, balloon, guide 46604 wire, bougie) No MEDICAID Anoscopy; with biopsy, single or multiple 46606 No MEDICAID Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or 46607 multiple No MEDICAID Anoscopy; with removal of foreign body 46608 No MEDICAID Anoscopy; with removal of single tumor, 46610 polyp, or other lesion by hot No MEDICAID Anoscopy; with removal of single tumor, 46611 polyp, or other lesion by snare No MEDICAID Anoscopy; with removal of multiple 46612 tumors, polyps, or other lesions by No MEDICAID Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar 46614 No MEDICAID Anoscopy; with ablation of tumor(s), 46615 polyp(s), or other lesion(s) not No MEDICAID

160 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anoplasty, plastic operation for stricture; 46700 adult No MEDICAID Anoplasty, plastic operation for stricture; 46705 infant No MEDICAID REPAIR OF ANAL FISTULA WITH 46706 FIBRIN GLUE No MEDICAID REPAIR OF ANORECTAL FISTULA 46707 WITH PLUG (EG, PORICINE SMALL No INSTESTINE SUBMUCOSA (SIS)) MEDICAID 46710 Repr per/vag pouch sngl proc No MEDICAID 46712 Repr per/vag pouch dbl proc No MEDICAID Repair of low imperforate anus; with 46715 anoperineal fistula (cut-back No MEDICAID Repair of low imperforate anus; with 46716 transposition of anoperineal or No MEDICAID Repair of high imperforate anus without 46730 fistula; perineal or No MEDICAID Repair of high imperforate anus without fistula; combined transabdominal 46735 No MEDICAID Repair of high imperforate anus with 46740 rectourethral or rectovaginal No MEDICAID Repair of high imperforate anus with 46742 rectourethral or rectovaginal No MEDICAID Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, 46744 No MEDICAID Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, 46746 No MEDICAID Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, 46748 No MEDICAID Sphincteroplasty, anal, for incontinence or 46750 prolapse; adult No MEDICAID Sphincteroplasty, anal, for incontinence or 46751 prolapse; child No MEDICAID Graft (Thiersch operation) for rectal 46753 incontinence and/or prolapse No MEDICAID Removal of Thiersch wire or suture, anal 46754 canal No MEDICAID Sphincteroplasty, anal, for incontinence, adult; muscle transplant 46760 No MEDICAID Sphincteroplasty, anal, for incontinence, 46761 adult; levator muscle No MEDICAID Sphincteroplasty, anal, for incontinence, adult; implantation artificial 46762 No MEDICAID Destruction of lesion(s), anus (eg, 46900 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), anus (eg, 46910 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), anus (eg, 46916 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), anus (eg, 46917 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), anus (eg, 46922 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), anus (eg, 46924 condyloma, papilloma, molluscum No MEDICAID Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, 46930 cautery, radiofrequency) No MEDICAID Curettage or cautery of anal fissure, 46940 including dilation of anal No MEDICAID Curettage or cautery of anal fissure, 46942 including dilation of anal No MEDICAID Ligation of internal hemorrhoids; single 46945 procedure No MEDICAID

161 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ligation of internal hemorrhoids; multiple 46946 procedures No MEDICAID Hemorrhoidopexy (eg, for prolapsing 46947 internal hemorrhoids) by No MEDICAID 46999 UNLISTED PROCEDURE, ANUS Yes MEDICAID 47000 Biopsy of liver, needle; percutaneous No MEDICAID Biopsy of liver, needle; when done for 47001 indicated purpose at time of No MEDICAID Hepatotomy; for open drainage of 47010 abscess or cyst, one or two stages No MEDICAID Laparotomy, with aspiration and/or 47015 injection of hepatic parasitic (eg, No MEDICAID 47100 Biopsy of liver, wedge No MEDICAID Hepatectomy, resection of liver; partial 47120 lobectomy No MEDICAID Hepatectomy, resection of liver; 47122 trisegmentectomy No MEDICAID Hepatectomy, resection of liver; total left 47125 lobectomy No MEDICAID Hepatectomy, resection of liver; total right 47130 lobectomy No MEDICAID DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM 47133 Yes CADAVER DONOR MEDICAID LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, PARTIAL OR WHOLE, 47135 Yes FROM CADAVER OR LIVING DONOR, ANY AGE MEDICAID DONOR HEPATECTOMY, INCLUDING COLD PRESERVATION FROM LIVING 47140 DONOR; LEFT LATERAL SEGMENT Yes ONLY (SEGMENTS II AND III MEDICAID DONOR HEPATECTOMY, INCLUDING COLD PRESERVATION FROM LIVING 47141 Yes DONOR; TOTAL LEFT LOBECTOMY SEGMENTS I, II, III MEDICAID DONOR HEPATECTOMY, INCLUDING COLD PRESERVATION FROM LIVING 47142 DONOR; TOTAL RIGHT LOBECTOMY Yes SEGMENTS V, VI, VII AND VIII MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR WHOLE LIVER GRAFT PRIOR TO 47143 ALLOTRANSPORATION, INCL Yes CHOLECYSTECTOMY, DISSECTION/REMOVAL OF MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR WHOLE LIVER GRAFT PRIOR TO 47145 ALLOTRANSPORATION, INCL Yes CHOLECYSTECTOMY, DISSECTION/REMOVAL OF MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 47146 GRAFT PRIOR TO Yes ALLOTRANSPLANTATION; VENOUS ANASTOMOSIS, EACH MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 47147 GRAFT PRIOR TO Yes ALLOTRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH MEDICAID Marsupialization of cyst or abscess of liver 47300 No MEDICAID Management of liver hemorrhage; simple 47350 suture of liver wound or injury No MEDICAID

162 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Management of liver hemorrhage; complex suture of liver wound or injury, 47360 No MEDICAID Management of liver hemorrhage; exploration of hepatic wound, extensive 47361 No MEDICAID Management of liver hemorrhage; re- 47362 exploration of hepatic wound for No MEDICAID Laparoscopy, surgical, ablation of one or 47370 more liver tumor(s); No MEDICAID Laparoscopy, surgical, ablation of one or 47371 more liver tumor(s); No MEDICAID UNLISTED LAPAROSCOPIC 47379 PROCEDURE, LIVER. Yes MEDICAID OPEN RADIOFREQUENCY ABLATION 47380 OF LIVER TUMOR No MEDICAID Ablation, open, of one or more liver 47381 tumor(s); cryosurgical No MEDICAID PERCUTANEOUS RADIOFREQUENCY ABLATION OF LIVER TUMOR 47382 No MEDICAID Ablation, 1 or more liver tumor(s), 47383 percutaneous, cryoablation No MEDICAID 47399 UNLISTED PROCEDURE, LIVER Yes MEDICAID Hepaticotomy or hepaticostomy with 47400 exploration, drainage, or removal of No MEDICAID Choledochotomy or choledochostomy with exploration, drainage, or 47420 No MEDICAID Choledochotomy or choledochostomy with exploration, drainage, or 47425 No MEDICAID Transduodenal sphincterotomy or 47460 sphincteroplasty, with or without No MEDICAID Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure) 47480 No MEDICAID Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation 47490 No MEDICAID Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; existing access 47531 No MEDICAID Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; new access (e.g., percutaneous transheptic cholangiogram 47532 No MEDICAID Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; external 47533 No MEDICAID Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; internal- external 47534 No MEDICAID

163 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation 47535 No MEDICAID Exchange of biliary drainage catheter (e.g. external, internal-external, or conversion of internal-external to external only), percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation 47536 No MEDICAID Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (e.g. with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging guidance (e.g., fluoroscopy) and all associated radiological supervision and interpretation 47537 No MEDICAID Placement of stents in bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (e.g., fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation, each stent; existing access

47538 No MEDICAID Placement of stents in bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (e.g., fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation, each stent; new access, with placement of separate biliary drainage catheter

47539 No MEDICAID Placement of stents in bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (e.g., fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation, each stent; new access with placement of separate biliary drainage catheter (e.g., external or internal-external)

47540 No MEDICAID Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (e.g., rendezvous procedure),percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., fluoroscopy and/or ultrasound), and all associated radiological supervision and interpretation; new access

47541 No MEDICAID Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including diagnostic cholangiography when performed, imaging guidance (e.g., fluoroscopy), and all associated radiological supervision and interpretation, each duct (List separately in addition to code for primary procedure) 47542 No MEDICAID

164 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (e.g., brush, forceps, and/ or needle), including imaging guidance (e.g., fluoroscopy), and all associated radiological supervision and interpretation, single or multiple(List separately in addition to code for primary procedure) 47543 No MEDICAID Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction of calculi by any method (e.g., mechanical, electrohydraulic, lithotripsy) when performed, imaging guidance (e.g., fluoroscopy), and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

47544 No MEDICAID Biliary endoscopy, intraoperative 47550 (choledochoscopy) (List separately in No MEDICAID Biliary endoscopy, percutaneous via T- 47552 tube or other tract; diagnostic, No MEDICAID Biliary endoscopy, percutaneous via T- 47553 tube or other tract; with biopsy, No MEDICAID Biliary endoscopy, percutaneous via T- 47554 tube or other tract; with removal No MEDICAID Biliary endoscopy, percutaneous via T- 47555 tube or other tract; with dilation No MEDICAID Biliary endoscopy, percutaneous via T- 47556 tube or other tract; with dilation No MEDICAID Laparoscopy, surgical; cholecystectomy 47562 No MEDICAID Laparoscopy, surgical; cholecystectomy with cholangiography 47563 No MEDICAID Laparoscopy, surgical; cholecystectomy with exploration of common 47564 No MEDICAID Laparoscopy, surgical; 47570 cholecystoenterostomy No MEDICAID UNLISTED LAPAROSCOPY 47579 PROCEDURE, BILIARY TRACT Yes MEDICAID 47600 Cholecystectomy; No MEDICAID Cholecystectomy; with cholangiography 47605 No MEDICAID Cholecystectomy with exploration of 47610 common duct; No MEDICAID Cholecystectomy with exploration of 47612 common duct; with No MEDICAID Cholecystectomy with exploration of 47620 common duct; with transduodenal No MEDICAID Exploration for congenital atresia of bile 47700 ducts, without repair, with No MEDICAID Portoenterostomy (eg, Kasai procedure) 47701 No MEDICAID Excision of bile duct tumor, with or without 47711 primary repair of bile No MEDICAID Excision of bile duct tumor, with or without 47712 primary repair of bile No MEDICAID 47715 Excision of choledochal cyst No MEDICAID 47720 Cholecystoenterostomy; direct No MEDICAID Cholecystoenterostomy; with 47721 gastroenterostomy No MEDICAID 47740 Cholecystoenterostomy; Roux-en-Y No MEDICAID Cholecystoenterostomy; Roux-en-Y with 47741 gastroenterostomy No MEDICAID Anastomosis, of extrahepatic biliary ducts 47760 and gastrointestinal tract No MEDICAID Anastomosis, of intrahepatic ducts and 47765 gastrointestinal tract No MEDICAID Anastomosis, Roux-en-Y, of extrahepatic 47780 biliary ducts and No MEDICAID

165 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anastomosis, Roux-en-Y, of intrahepatic 47785 biliary ducts and No MEDICAID Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end 47800 No MEDICAID 47801 Placement of choledochal stent No MEDICAID 47802 U-tube hepaticoenterostomy No MEDICAID Suture of extrahepatic biliary duct for pre- 47900 existing injury (separate No MEDICAID UNLISTED PROCEDURE, BILIARY 47999 TRACT Yes MEDICAID Placement of drains, peripancreatic, for 48000 acute pancreatitis; No MEDICAID Placement of drains, peripancreatic, for 48001 acute pancreatitis; with No MEDICAID 48020 Removal of pancreatic calculus No MEDICAID Biopsy of pancreas, open (eg, fine needle 48100 aspiration, needle core No MEDICAID Biopsy of pancreas, percutaneous needle 48102 No MEDICAID RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC 48105 TISSUE No MEDICAID Excision of lesion of pancreas (eg, cyst, 48120 adenoma) No MEDICAID Pancreatectomy, distal subtotal, with or 48140 without splenectomy; without No MEDICAID Pancreatectomy, distal subtotal, with or 48145 without splenectomy; with No MEDICAID Pancreatectomy, distal, near-total with 48146 preservation of duodenum No MEDICAID 48148 Excision of ampulla of Vater No MEDICAID Pancreatectomy, proximal subtotal with 48150 total duodenectomy, partial No MEDICAID Pancreatectomy, proximal subtotal with 48152 total duodenectomy, partial No MEDICAID Pancreatectomy, proximal subtotal with 48153 near-total duodenectomy, No MEDICAID Pancreatectomy, proximal subtotal with 48154 near-total duodenectomy, No MEDICAID 48155 Pancreatectomy, total No MEDICAID PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH AUTOLOGOUS 48160 Yes TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLETS MEDICAID Injection procedure for intraoperative 48400 pancreatography (List separately No MEDICAID 48500 Marsupialization of pancreatic cyst No MEDICAID External drainage, pseudocyst of 48510 pancreas; open No MEDICAID Internal anastomosis of pancreatic cyst to 48520 gastrointestinal tract; No MEDICAID Internal anastomosis of pancreatic cyst to 48540 gastrointestinal tract; No MEDICAID 48545 Pancreatorrhaphy for injury No MEDICAID Duodenal exclusion with gastrojejunostomy for pancreatic injury 48547 No MEDICAID PANCREATICOJEJUNOSTOMY, SIDE- 48548 TO-SIDE ANASTOMOSIS No MEDICAID DONOR PANCREATECTOMY, INCLUDING COLD PRESERVA TION 48550 Yes WITH OR WITHOUT DUODENAL SEGMENT FOR TRANSPLANTATION MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR PANCREAS ALLOGRAFT PRIOR TO TRANSPLANT, 48551 INCL SPLENECTOMY, Yes DUODENOTOMY, BILE DUCT LIGATION MEDICAID

166 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BACKBENCH STANDARD PREP OF CADAVER DONOR PANCREAS 48552 ALLOGRAFT PRIOR TO TRANSPLANT, Yes VENOUS ANASTOMOSIS, EACH MEDICAID TRANSPLANTATION OF PANCREATIC 48554 Yes ALLOGRAFT MEDICAID REMOVAL OF TRANSPLANTED 48556 PANCREATIC ALLOGRAFT No ExGEN MEDICAID UNLISTED PROCEDURE, PANCREAS 48999 Yes MEDICAID Exploratory laparotomy, exploratory 49000 celiotomy with or without biopsy(s) No * MEDICAID 49002 Reopening of recent laparotomy No MEDICAID Exploration, retroperitoneal area with or 49010 without biopsy(s) (separate No MEDICAID Drainage of peritoneal abscess or 49020 localized peritonitis, exclusive of No MEDICAID Drainage of subdiaphragmatic or 49040 subphrenic abscess; open No MEDICAID Drainage of retroperitoneal abscess; open 49060 No MEDICAID Drainage of extraperitoneal lymphocele to 49062 peritoneal cavity, open No MEDICAID Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance 49082 No MEDICAID Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance 49083 No MEDICAID Peritoneal lavage, including imaging 49084 guidance, when performed No MEDICAID Biopsy, abdominal or retroperitoneal 49180 mass, percutaneous needle No MEDICAID Sclerotheraphy of a fluid collection (e.g., lymphocele, cyst, or seroma), percutaneous, including contrast injections (s), sclerosant injection(s), diagnostic study, imaging guidance (e.g., ultrasound, fluoroscopy) and radiological supervision and interpretation when performed

49185 No MEDICAID EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR 5 CM DIAMETER OR LESS 49203 No MEDICAID EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR 5.1-10.0 CM DIAMETER 49204 No MEDICAID EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR GREATER THAN 10.0 CM 49205 DIAMETER No MEDICAID Excision of presacral or sacrococcygeal 49215 tumor No MEDICAID Staging laparotomy for Hodgkins disease 49220 or lymphoma (includes No MEDICAID

167 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) 49250 No MEDICAID Omentectomy, epiploectomy, resection of omentum (separate procedure) 49255 No MEDICAID Laparoscopy, abdomen, peritoneum, and 49320 omentum, diagnostic, with or No * MEDICAID Laparoscopy, surgical; with biopsy (single 49321 or multiple) No * MEDICAID Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian 49322 No * MEDICAID Laparoscopy, surgical; with drainage of 49323 lymphocele to peritoneal cavity No MEDICAID Laparoscopy, surgical; with insertion of 49324 tunneled intraperitoneal catheter No MEDICAID LAPAROSCOPY, SURGICAL; W/REVISION OF PREVIOUSLY PLACED 49325 No MEDICAID LAPAROSCOPY, SURGICAL; WITH 49326 OMENTOPEXY No MEDICAID 49327 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) No MEDICAID UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, 49329 PERITONEUM AND OMENTUM Yes MEDICAID Injection of air or contrast into peritoneal cavity (separate procedure) 49400 No MEDICAID REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY 49402 No MEDICAID 49405 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous No MEDICAID 49406 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous No MEDICAID 49407 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal No MEDICAID PLACE INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE, PERCUTAN, INTRA-ABD, INTRA- PELVIC (NOT PROSTATE), &/OR RETROPERI 1OR> 49411 No MEDICAID 49412 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra- abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to code for primary procedure) No MEDICAID

168 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 49418 Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous No MEDICAID Insertion of tunneled intraperitoneal catheter, with subcutaneous port (ie, 49419 totally implantable) No MEDICAID Insertion of tunneled intraperitoneal 49421 catheter for dialysis, open No MEDICAID Removal of tunneled intraperitoneal 49422 catheter No MEDICAID Exchange of previously placed abscess or cyst drainage catheter under 49423 No MEDICAID Contrast injection for assessment of 49424 abscess or cyst via previously No MEDICAID 49425 Insertion of peritoneal-venous shunt No MEDICAID 49426 Revision of peritoneal-venous shunt No MEDICAID Injection procedure (eg, contrast media) 49427 for evaluation of previously No MEDICAID 49428 Ligation of peritoneal-venous shunt No MEDICAID 49429 Removal of peritoneal-venous shunt No MEDICAID INSERTION OF SUBCUTANEOUS EXTENSION TO INTRAPERITONEAL 49435 CANNULA OR No MEDICAID DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS 49436 SEGMEN No MEDICAID INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49440 REPORT No MEDICAID INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49441 REPORT No MEDICAID INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49442 REPORT No MEDICAID CONVERSION OF GASTROSTOMY TUBE TO GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49446 REPORT No MEDICAID REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49450 REPORT No MEDICAID

169 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT 49451 No MEDICAID REPLACEMENT OF GASTRO- JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND 49452 REPORT No MEDICAID MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO- JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, ANY METHOD, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IF PERFORMED, IMAGE DOCUMENTATION AND REPORT 49460 No MEDICAID CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT 49465 No MEDICAID Repair, initial inguinal hernia, preterm 49491 infant (less than 37 weeks No MEDICAID Repair, initial inguinal hernia, preterm 49492 infant (less than 37 weeks No MEDICAID Repair, initial inguinal hernia, full term 49495 infant under age 6 months, or No MEDICAID Repair, initial inguinal hernia, full term 49496 infant under age 6 months, or No MEDICAID Repair initial inguinal hernia, age 6 49500 months to under 5 years, with or No MEDICAID Repair initial inguinal hernia, age 6 49501 months to under 5 years, with or No MEDICAID Repair initial inguinal hernia, age 5 years 49505 or over; reducible No MEDICAID Repair initial inguinal hernia, age 5 years 49507 or over; incarcerated or No MEDICAID Repair recurrent inguinal hernia, any age; 49520 reducible No MEDICAID Repair recurrent inguinal hernia, any age; 49521 incarcerated or strangulated No MEDICAID Repair inguinal hernia, sliding, any age 49525 No MEDICAID 49540 Repair lumbar hernia No MEDICAID Repair initial femoral hernia, any age; 49550 reducible No MEDICAID Repair initial femoral hernia, any age; 49553 incarcerated or strangulated No MEDICAID Repair recurrent femoral hernia; reducible 49555 No MEDICAID Repair recurrent femoral hernia; 49557 incarcerated or strangulated No MEDICAID Repair initial incisional or ventral hernia; 49560 reducible No MEDICAID Repair initial incisional or ventral hernia; 49561 incarcerated or No MEDICAID

170 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Repair recurrent incisional or ventral 49565 hernia; reducible No MEDICAID Repair recurrent incisional or ventral 49566 hernia; incarcerated or No MEDICAID Implantation of mesh or other prosthesis 49568 for incisional or ventral No MEDICAID Repair epigastric hernia (eg, preperitoneal fat); reducible (separate 49570 No MEDICAID Repair epigastric hernia (eg, preperitoneal 49572 fat); incarcerated or No MEDICAID Repair umbilical hernia, under age 5 49580 years; reducible No MEDICAID Repair umbilical hernia, under age 5 49582 years; incarcerated or strangulated No MEDICAID Repair umbilical hernia, age 5 years or 49585 over; reducible No MEDICAID Repair umbilical hernia, age 5 years or 49587 over; incarcerated or No MEDICAID 49590 Repair spigelian hernia No MEDICAID Repair of small omphalocele, with primary 49600 closure No MEDICAID Repair of large omphalocele or gastroschisis; with or without prosthesis 49605 No MEDICAID Repair of large omphalocele or 49606 gastroschisis; with removal of No MEDICAID Repair of omphalocele (Gross type 49610 operation); first stage No MEDICAID Repair of omphalocele (Gross type 49611 operation); second stage No MEDICAID Laparoscopy, surgical; repair initial 49650 inguinal hernia No MEDICAID Laparoscopy, surgical; repair recurrent 49651 inguinal hernia No MEDICAID Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when 49652 performed); reducible No MEDICAID Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated 49653 No MEDICAID Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible 49654 No MEDICAID Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated 49655 No MEDICAID Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible 49656 No MEDICAID Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or 49657 strangulated No MEDICAID UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, 49659 HERNIORRHAPHY, HERNIOTOMY Yes MEDICAID Suture, secondary, of abdominal wall for 49900 evisceration or dehiscence No MEDICAID OMENTAL FLAP, EXTRA-ABDOMINAL (EG FOR RECONSTRUCTION OF STERNAL AND CHEST WALL 49904 DEFECTS No MEDICAID Omental flap, intra-abdominal (List 49905 separately in addition to code for No MEDICAID

171 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Free omental flap with microvascular 49906 anastomosis No MEDICAID UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM 49999 Yes MEDICAID Renal exploration, not necessitating other 50010 specific procedures No MEDICAID Drainage of perirenal or renal abscess; 50020 open No MEDICAID Nephrostomy, nephrotomy with drainage 50040 No MEDICAID 50045 Nephrotomy, with exploration No MEDICAID 50060 Nephrolithotomy; removal of calculus No MEDICAID Nephrolithotomy; secondary surgical 50065 operation for calculus No MEDICAID Nephrolithotomy; complicated by 50070 congenital kidney abnormality No MEDICAID Nephrolithotomy; removal of large 50075 staghorn calculus filling renal pelvis No MEDICAID Percutaneous nephrostolithotomy or 50080 pyelostolithotomy, with or without No MEDICAID Percutaneous nephrostolithotomy or 50081 pyelostolithotomy, with or without No MEDICAID Transection or repositioning of aberrant 50100 renal vessels (separate No MEDICAID 50120 Pyelotomy; with exploration No MEDICAID 50125 Pyelotomy; with drainage, pyelostomy No MEDICAID Pyelotomy; with removal of calculus 50130 (pyelolithotomy, pelviolithotomy, No MEDICAID Pyelotomy; complicated (eg, secondary operation, congenital kidney 50135 No MEDICAID Renal biopsy; percutaneous, by trocar or 50200 needle No MEDICAID Renal biopsy; by surgical exposure of 50205 kidney No MEDICAID Nephrectomy, including partial 50220 ureterectomy, any open approach No MEDICAID Nephrectomy, including partial 50225 ureterectomy, any open approach No MEDICAID Nephrectomy, including partial 50230 ureterectomy, any open approach No MEDICAID Nephrectomy with total ureterectomy and 50234 bladder cuff; through same No MEDICAID Nephrectomy with total ureterectomy and 50236 bladder cuff; through separate No MEDICAID 50240 Nephrectomy, partial No MEDICAID Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and 50250 monitoring, if performed No MEDICAID Excision or unroofing of cyst(s) of kidney 50280 No MEDICAID 50290 Excision of perinephric cyst No MEDICAID DONOR NEPHRECTOMY, INCLUDING COLD PRESERVATION:; FROM 50300 Yes CADAVER DONOR, UTERAL OR BILATERAL MEDICAID DONOR NEPHRECTOMY, INCLUDING COLD PRESERVATION:; OPEN FROM 50320 Yes LIVING DONOR MEDICAID BACKBENCH STANDARD PREP OF CADAVER DONOR RENAL ALLOGRAFT PRIOR TO TRANSPLANT, 50323 INCL DISSECT/REMOVE PERINEPHRIC Yes FAT, DIAPHRAGMATIC/R MEDICAID

172 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BACKBENCH STANDARD PREP OF LIVING DONOR RENAL ALLOGRAFT 50325 (OPEN R LAPAROSCOPIC) PRIOR TO Yes TRANSPLANT, INCL DISSECT/REMOVE PERINEPHRIC MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 50327 ALLOGRAFT PRIOR TO Yes TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 50328 ALLOGRAFT PRIOR TO Yes TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH MEDICAID BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 50329 ALLOGRAFT PRIOR TO Yes TRANSPLANTATION; URETERAL ANASTOMOSIS, EACH MEDICAID RECIPIENT NEPHRECTOMY 50340 Yes (SEPARATE PROCEDURE) MEDICAID RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITHOUT 50360 Yes RECIPIENT NEPHRECTOMY MEDICAID RENAL ALLOTRANSPLANTATION, 50365 IMPLANTATION OF GRAFT; WITH Yes RECIPIENT NEPHRECTOMY MEDICAID REMOVAL OF TRANSPLANTED RENAL 50370 ALLOGRAFT No ExGEN MEDICAID Renal autotransplantation, reimplantation 50380 of kidney Yes MEDICAID 50382 Change ureter stent, percut No MEDICAID 50384 Remove ureter stent, percut No MEDICAID REMOVAL VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION

50385 No MEDICAID REMOVAL VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION 50386 No MEDICAID 50387 Change ext/int ureter stent No MEDICAID 50389 Remove renal tube w/fluoro No MEDICAID Aspiration and/or injection of renal cyst or 50390 pelvis by needle, No MEDICAID Instillation(s) of therapeutic agent into 50391 renal pelvis and/or ureter No MEDICAID Introduction of guide into renal pelvis 50395 and/or ureter with dilation to No MEDICAID Manometric studies through nephrostomy 50396 or pyelostomy tube, or No MEDICAID Pyeloplasty (Foley Y-pyeloplasty), plastic 50400 operation on renal pelvis, No MEDICAID Pyeloplasty (Foley Y-pyeloplasty), plastic 50405 operation on renal pelvis, No MEDICAID

173 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; new access 50430 No MEDICAID Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; existing access 50431 No MEDICAID Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or uretogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation 50432 No MEDICAID Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or uretogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; new access 50433 No MEDICAID Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or uretogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; via pre-existing nephrostomy tract 50434 No MEDICAID Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or uretogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation 50435 No MEDICAID Nephrorrhaphy, suture of kidney wound or 50500 injury No MEDICAID Closure of nephrocutaneous or 50520 pyelocutaneous fistula No MEDICAID Closure of nephrovisceral fistula (eg, 50525 renocolic), including visceral No MEDICAID Closure of nephrovisceral fistula (eg, 50526 renocolic), including visceral No MEDICAID Symphysiotomy for horseshoe kidney with 50540 or without pyeloplasty and/or No MEDICAID Laparoscopy, surgical; ablation of renal 50541 cysts No MEDICAID Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, 50542 when performed No MEDICAID 50543 PARTIAL NEPHRECTOMY No MEDICAID 50544 Laparoscopy, surgical; pyeloplasty No MEDICAID Laparoscopy, surgical; radical nephrectomy (includes removal of 50545 Gerota's No MEDICAID Laparoscopy, surgical; nephrectomy, 50546 including partial ureterectomy No MEDICAID DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION) FROM LIVING DONOR 50547 No ExGEN MEDICAID Laparoscopy, surgical; nephrectomy with 50548 total ureterectomy No MEDICAID UNLISTED LAPAROSCOPY 50549 PROCEDURE, RENAL Yes MEDICAID

174 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Renal endoscopy through established nephrostomy or pyelostomy, with 50551 No MEDICAID Renal endoscopy through established nephrostomy or pyelostomy, with 50553 No MEDICAID Renal endoscopy through established nephrostomy or pyelostomy, with 50555 No MEDICAID Renal endoscopy through established nephrostomy or pyelostomy, with 50557 No MEDICAID Renal endoscopy through established nephrostomy or pyelostomy, with 50561 No MEDICAID RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH RESECTION OF TUMOR 50562 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50570 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50572 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50574 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50575 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50576 No MEDICAID Renal endoscopy through nephrotomy or pyelotomy, with or without 50580 No MEDICAID Lithotripsy, extracorporeal shock wave 50590 No MEDICAID ABLATION, ONE OR MORE RENAL TUMOR(S), PERCUTANEOUS, 50592 UNILATERAL, RADIOFREQUENCY No MEDICAID ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, 50593 CRYOTHERAPY No MEDICAID Ureterotomy with exploration or drainage 50600 (separate procedure) No MEDICAID Ureterotomy for insertion of indwelling 50605 stent, all types No MEDICAID Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) 50606 No MEDICAID Ureterolithotomy; upper one-third of ureter 50610 No MEDICAID Ureterolithotomy; middle one-third of 50620 ureter No MEDICAID Ureterolithotomy; lower one-third of ureter 50630 No MEDICAID Ureterectomy, with bladder cuff (separate 50650 procedure) No MEDICAID Ureterectomy, total, ectopic ureter, 50660 combination abdominal, vaginal No MEDICAID Injection procedure for ureterography or 50684 ureteropyelography through No MEDICAID

175 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Manometric studies through ureterostomy or indwelling ureteral catheter 50686 No MEDICAID 50688 Change of ureterostomy tube No MEDICAID Injection procedure for visualization of 50690 ileal conduit and/or No MEDICAID Placement of the ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; pre-existing nephrostomy tract

50693 No MEDICAID Placement of the ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter 50694 No MEDICAID Placement of the ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation; new access, with separate nephrostomy catheter 50695 No MEDICAID Ureteroplasty, plastic operation on ureter 50700 (eg, stricture) No MEDICAID Urethral embolization or occlusion, including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) 50705 No MEDICAID Balloon dilation, ureteral stricture, including imaging guidance (e.g., ultrasound and /or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) 50706 No MEDICAID Ureterolysis, with or without repositioning 50715 of ureter for No MEDICAID Ureterolysis for ovarian vein syndrome 50722 No MEDICAID Ureterolysis for retrocaval ureter, with 50725 reanastomosis of upper urinary No MEDICAID Revision of urinary-cutaneous 50727 anastomosis (any type urostomy); No MEDICAID Revision of urinary-cutaneous anastomosis (any type urostomy); with 50728 No MEDICAID Ureteropyelostomy, anastomosis of ureter 50740 and renal pelvis No MEDICAID Ureterocalycostomy, anastomosis of 50750 ureter to renal calyx No MEDICAID 50760 Ureteroureterostomy No MEDICAID Transureteroureterostomy, anastomosis of ureter to contralateral ureter 50770 No MEDICAID Ureteroneocystostomy; anastomosis of 50780 single ureter to bladder No MEDICAID Ureteroneocystostomy; anastomosis of 50782 duplicated ureter to bladder No MEDICAID Ureteroneocystostomy; with extensive 50783 ureteral tailoring No MEDICAID Ureteroneocystostomy; with vesico-psoas 50785 hitch or bladder flap No MEDICAID Ureteroenterostomy, direct anastomosis 50800 of ureter to intestine No MEDICAID

176 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ureterosigmoidostomy, with creation of 50810 sigmoid bladder and No MEDICAID Ureterocolon conduit, including intestine 50815 anastomosis No MEDICAID Ureteroileal conduit (ileal bladder), 50820 including intestine anastomosis No MEDICAID Continent diversion, including intestine anastomosis using any segment 50825 No MEDICAID Urinary undiversion (eg, taking down of 50830 ureteroileal conduit, No MEDICAID Replacement of all or part of ureter by 50840 intestine segment, including No MEDICAID 50845 Cutaneous appendico-vesicostomy No MEDICAID Ureterostomy, transplantation of ureter to 50860 skin No MEDICAID Ureterorrhaphy, suture of ureter (separate 50900 procedure) No MEDICAID 50920 Closure of ureterocutaneous fistula No MEDICAID Closure of ureterovisceral fistula 50930 (including visceral repair) No MEDICAID 50940 Deligation of ureter No MEDICAID Laparoscopy, surgical; ureterolithotomy 50945 No MEDICAID Laparoscopy, surgical; ureteroneocystostomy with cystoscopy 50947 and No MEDICAID Laparoscopy, surgical; ureteroneocystostomy without cystoscopy 50948 and No MEDICAID UNLISTED LAPAROSCOPY 50949 PROCEDURE; URETER Yes MEDICAID Ureteral endoscopy through established ureterostomy, with or without 50951 No MEDICAID Ureteral endoscopy through established ureterostomy, with or without 50953 No MEDICAID Ureteral endoscopy through established ureterostomy, with or without 50955 No MEDICAID Ureteral endoscopy through established ureterostomy, with or without 50957 No MEDICAID Ureteral endoscopy through established ureterostomy, with or without 50961 No MEDICAID Ureteral endoscopy through ureterotomy, 50970 with or without irrigation, No MEDICAID Ureteral endoscopy through ureterotomy, 50972 with or without irrigation, No MEDICAID Ureteral endoscopy through ureterotomy, 50974 with or without irrigation, No MEDICAID Ureteral endoscopy through ureterotomy, 50976 with or without irrigation, No MEDICAID Ureteral endoscopy through ureterotomy, 50980 with or without irrigation, No MEDICAID Cystotomy or cystostomy; with fulguration 51020 and/or insertion of No MEDICAID Cystotomy or cystostomy; with cryosurgical destruction of intravesical 51030 No MEDICAID 51040 Cystostomy, cystotomy with drainage No MEDICAID Cystotomy, with insertion of ureteral 51045 catheter or stent (separate No MEDICAID Cystolithotomy, cystotomy with removal of calculus, without vesical neck 51050 No MEDICAID 51060 Transvesical ureterolithotomy No MEDICAID Cystotomy, with calculus basket 51065 extraction and/or ultrasonic or No MEDICAID

177 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Drainage of perivesical or prevesical 51080 space abscess No MEDICAID APIRATION OF BLADDER; BY NEEDLE 51100 No MEDICAID APIRATION OF BLADDER; BY TROCAR 51101 OR INTRACATHETER No MEDICAID APIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC 51102 CATHETER No MEDICAID Excision of urachal cyst or sinus, with or 51500 without umbilical hernia No MEDICAID Cystotomy; for simple excision of vesical 51520 neck (separate procedure) No MEDICAID Cystotomy; for excision of bladder 51525 diverticulum, single or multiple No MEDICAID Cystotomy; for excision of bladder tumor 51530 No MEDICAID Cystotomy for excision, incision, or repair 51535 of ureterocele No MEDICAID 51550 Cystectomy, partial; simple No MEDICAID Cystectomy, partial; complicated (eg, 51555 postradiation, previous surgery, No MEDICAID Cystectomy, partial, with reimplantation of ureter(s) into bladder 51565 No MEDICAID Cystectomy, complete; (separate 51570 procedure) No MEDICAID Cystectomy, complete; with bilateral 51575 pelvic lymphadenectomy, including No MEDICAID Cystectomy, complete, with ureterosigmoidostomy or 51580 ureterocutaneous No MEDICAID Cystectomy, complete, with ureterosigmoidostomy or 51585 ureterocutaneous No MEDICAID Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, 51590 No MEDICAID Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, 51595 No MEDICAID Cystectomy, complete, with continent 51596 diversion, any open technique, No MEDICAID Pelvic exenteration, complete, for vesical, 51597 prostatic or urethral No MEDICAID Injection procedure for cystography or 51600 voiding urethrocystography No MEDICAID Injection procedure and placement of 51605 chain for contrast and/or chain No MEDICAID Injection procedure for retrograde 51610 urethrocystography No MEDICAID Bladder irrigation, simple, lavage and/or 51700 instillation No MEDICAID Insertion of non-indwelling bladder 51701 catheter (eg, straight No MEDICAID Insertion of temporary indwelling bladder 51702 catheter; simple (eg, Foley) No MEDICAID Insertion of temporary indwelling bladder 51703 catheter; complicated (eg, No MEDICAID 51705 Change of cystostomy tube; simple No MEDICAID Change of cystostomy tube; complicated 51710 No MEDICAID ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR 51715 BLADDER NECK No MEDICAID Bladder instillation of anticarcinogenic agent (including detention 51720 No MEDICAID Simple cystometrogram (CMG) (eg, spinal 51725 manometer) No MEDICAID

178 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Complex cystometrogram (eg, calibrated 51726 electronic equipment) No MEDICAID COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT); W/URETHRAL PRESSURE PROFILE STUDIES 51727 (IE,UCPP), ANY TECHNIQUE No MEDICAID COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT); W/VOIDING PRESSURE STUDIES, ANY TECHNIQUE 51728 No MEDICAID COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT); W/VOIDING & URETHRAL PRESSURE PROFILE 51729 STUDIES, ANY TECHNIQUE No MEDICAID Simple uroflowmetry (UFR) (eg, stop- 51736 watch flow rate, mechanical No MEDICAID Complex uroflowmetry (eg, calibrated 51741 electronic equipment) No MEDICAID Urethral pressure profile studies (UPP) 51772 (urethral closure pressure No MEDICAID Electromyography studies (EMG) of anal 51784 or urethral sphincter, other than No MEDICAID Needle electromyography studies (EMG) 51785 of anal or urethral sphincter, No MEDICAID Stimulus evoked response (eg, measurement of bulbocavernosus reflex 51792 No MEDICAID Voiding pressure studies (VP); bladder voiding pressure, any technique 51795 No MEDICAID Voiding pressure studies (VP); intra- 51797 abdominal voiding pressure (AP) No MEDICAID Measurement of post-voiding residual urine and/or bladder capacity by 51798 No MEDICAID Cystoplasty or cystourethroplasty, plastic 51800 operation on bladder and/or No MEDICAID Cystourethroplasty with unilateral or 51820 bilateral ureteroneocystostomy No MEDICAID Anterior vesicourethropexy, or 51840 urethropexy (eg, No MEDICAID Anterior vesicourethropexy, or 51841 urethropexy (eg, No MEDICAID Abdomino-vaginal vesical neck suspension, with or without endoscopic 51845 No MEDICAID Cystorrhaphy, suture of bladder wound, 51860 injury or rupture; simple No MEDICAID Cystorrhaphy, suture of bladder wound, 51865 injury or rupture; complicated No MEDICAID Closure of cystostomy (separate 51880 procedure) No MEDICAID Closure of vesicovaginal fistula, 51900 abdominal approach No MEDICAID 51920 Closure of vesicouterine fistula; No MEDICAID Closure of vesicouterine fistula; with 51925 hysterectomy No MEDICAID 51940 Closure, exstrophy of bladder No MEDICAID Enterocystoplasty, including intestinal 51960 anastomosis No MEDICAID 51980 Cutaneous vesicostomy No MEDICAID Laparoscopy, surgical; urethral 51990 suspension for stress incontinence No MEDICAID Laparoscopy, surgical; sling operation for 51992 stress incontinence (eg, No MEDICAID UNLISTED LAPAROSCOPY 51999 PROCEDURE, BLADDER Yes MEDICAID

179 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cystourethroscopy (separate procedure) 52000 No MEDICAID Cystourethroscopy with irrigation and 52001 evacuation of multiple obstructing No MEDICAID Cystourethroscopy, with ureteral 52005 catheterization, with or without No MEDICAID Cystourethroscopy, with ureteral 52007 catheterization, with or without No MEDICAID Cystourethroscopy, with ejaculatory duct 52010 catheterization, with or No MEDICAID 52204 Cystourethroscopy, with biopsy No MEDICAID 52214 Cystoscopy and treatment No MEDICAID Cystourethroscopy, with fulguration 52224 (including cryosurgery or laser No MEDICAID Cystourethroscopy, with fulguration 52234 (including cryosurgery or laser No MEDICAID Cystourethroscopy, with fulguration 52235 (including cryosurgery or laser No MEDICAID Cystourethroscopy, with fulguration 52240 (including cryosurgery or laser No MEDICAID Cystourethroscopy with insertion of 52250 radioactive substance, with or No MEDICAID Cystourethroscopy, with dilation of 52260 bladder for interstitial cystitis; No MEDICAID Cystourethroscopy, with dilation of 52265 bladder for interstitial cystitis; No MEDICAID Cystourethroscopy, with internal 52270 urethrotomy; female No MEDICAID Cystourethroscopy, with internal 52275 urethrotomy; male No MEDICAID Cystourethroscopy with direct vision 52276 internal urethrotomy No MEDICAID Cystourethroscopy, with resection of 52277 external sphincter (sphincterotomy) No MEDICAID Cystourethroscopy, with calibration and/or 52281 dilation of urethral No MEDICAID Cystourethroscopy, with insertion of 52282 urethral stent No MEDICAID Cystourethroscopy, with steroid injection 52283 into stricture No MEDICAID Cystourethroscopy for treatment of the female urethral syndrome with any 52285 No MEDICAID Cystourethroscopy, with injection(s) for 52287 chemodenervation of the bladder No MEDICAID Cystourethroscopy; with ureteral 52290 meatotomy, unilateral or bilateral No MEDICAID Cystourethroscopy; with resection or 52300 fulguration of orthotopic No MEDICAID Cystourethroscopy; with resection or 52301 fulguration of ectopic No MEDICAID Cystourethroscopy; with incision or 52305 resection of orifice of bladder No MEDICAID Cystourethroscopy, with removal of 52310 foreign body, calculus, or ureteral No MEDICAID Cystourethroscopy, with removal of 52315 foreign body, calculus, or ureteral No MEDICAID Litholapaxy: crushing or fragmentation of calculus by any means in 52317 No MEDICAID Litholapaxy: crushing or fragmentation of calculus by any means in 52318 No MEDICAID Cystourethroscopy (including ureteral 52320 catheterization); with removal of No MEDICAID Cystourethroscopy (including ureteral 52325 catheterization); with No MEDICAID Cystourethroscopy (including ureteral 52327 catheterization); with subureteric No MEDICAID Cystourethroscopy (including ureteral 52330 catheterization); with No MEDICAID

180 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cystourethroscopy, with insertion of 52332 indwelling ureteral stent (eg, No MEDICAID Cystourethroscopy with insertion of 52334 ureteral guide wire through kidney No MEDICAID Cystourethroscopy; with treatment of 52341 ureteral stricture (eg, balloon No MEDICAID Cystourethroscopy; with treatment of 52342 ureteropelvic junction stricture No MEDICAID Cystourethroscopy; with treatment of intra- 52343 renal stricture (eg, balloon No MEDICAID Cystourethroscopy with ureteroscopy; 52344 with treatment of ureteral No MEDICAID Cystourethroscopy with ureteroscopy; 52345 with treatment of ureteropelvic No MEDICAID Cystourethroscopy with ureteroscopy; 52346 with treatment of intra-renal No MEDICAID Cystourethroscopy, with ureteroscopy 52351 and/or pyeloscopy; diagnostic No MEDICAID Cystourethroscopy, with ureteroscopy 52352 and/or pyeloscopy; with removal or No MEDICAID Cystourethroscopy, with ureteroscopy 52353 and/or pyeloscopy; with lithotripsy No MEDICAID Cystourethroscopy, with ureteroscopy 52354 and/or pyeloscopy; with biopsy No MEDICAID Cystourethroscopy, with ureteroscopy 52355 and/or pyeloscopy; with resection No MEDICAID 52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type) No MEDICAID Cystourethroscopy with incision, 52400 fulguration, or resection of congenital No MEDICAID Cystourethroscopy with transurethral 52402 resection or incision of No MEDICAID Cystourethroscopy, with insertion of permanent adjustable transprostatic 52441 implant; single implant No MEDICAID Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary 52442 procedure) No MEDICAID 52450 Transurethral incision of prostate No MEDICAID Transurethral resection of bladder neck 52500 (separate procedure) No MEDICAID Transurethral electrosurgical resection of prostate, including control 52601 No MEDICAID Transurethral resection; of regrowth of 52630 obstructive tissue longer than No MEDICAID Transurethral resection; of postoperative bladder neck contracture 52640 No MEDICAID Non-contact laser coagulation of prostate, 52647 including control of No MEDICAID Contact laser vaporization with or without 52648 transurethral resection of No MEDICAID Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) 52649 No MEDICAID Transurethral drainage of prostatic 52700 abscess No MEDICAID

181 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Urethrotomy or urethrostomy, external (separate procedure); pendulous 53000 No MEDICAID Urethrotomy or urethrostomy, external (separate procedure); perineal 53010 No MEDICAID Meatotomy, cutting of meatus (separate 53020 procedure); except infant No MEDICAID Meatotomy, cutting of meatus (separate 53025 procedure); infant No MEDICAID Drainage of deep periurethral abscess 53040 No MEDICAID Drainage of Skene's gland abscess or 53060 cyst No MEDICAID Drainage of perineal urinary extravasation; uncomplicated (separate 53080 No MEDICAID Drainage of perineal urinary 53085 extravasation; complicated No MEDICAID 53200 Biopsy of urethra No MEDICAID Urethrectomy, total, including cystostomy; 53210 female No MEDICAID Urethrectomy, total, including cystostomy; 53215 male No MEDICAID Excision or fulguration of carcinoma of 53220 urethra No MEDICAID Excision of urethral diverticulum (separate 53230 procedure); female No MEDICAID Excision of urethral diverticulum (separate 53235 procedure); male No MEDICAID Marsupialization of urethral diverticulum, 53240 male or female No MEDICAID Excision of bulbourethral gland (Cowper's 53250 gland) No MEDICAID Excision or fulguration; urethral polyp(s), 53260 distal urethra No MEDICAID Excision or fulguration; urethral caruncle 53265 No MEDICAID Excision or fulguration; Skene's glands 53270 No MEDICAID Excision or fulguration; urethral prolapse 53275 No MEDICAID Urethroplasty; first stage, for fistula, 53400 diverticulum, or stricture (eg, No MEDICAID Urethroplasty; second stage (formation of urethra), including urinary 53405 No MEDICAID Urethroplasty, one-stage reconstruction of male anterior urethra 53410 No MEDICAID Urethroplasty, transpubic or perineal, one 53415 stage, for reconstruction or No MEDICAID Urethroplasty, two-stage reconstruction or 53420 repair of prostatic or No MEDICAID Urethroplasty, two-stage reconstruction or 53425 repair of prostatic or No MEDICAID Urethroplasty, reconstruction of female 53430 urethra No MEDICAID Urethroplasty with tubularization of 53431 posterior urethra and/or lower No MEDICAID Sling operation for correction of male 53440 urinary incontinence (eg, fascia No MEDICAID Removal or revision of sling for male 53442 urinary incontinence (eg, fascia No MEDICAID 53444 Insertion of tandem cuff (dual cuff) No MEDICAID Insertion of inflatable urethral/bladder 53445 neck sphincter, including No MEDICAID Removal of inflatable urethral/bladder neck sphincter, including pump, 53446 No MEDICAID

182 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Removal and replacement of inflatable urethral/bladder neck sphincter 53447 No MEDICAID Removal and replacement of inflatable urethral/bladder neck sphincter 53448 No MEDICAID Repair of inflatable urethral/bladder neck 53449 sphincter, including pump, No MEDICAID Urethromeatoplasty, with mucosal 53450 advancement No MEDICAID Urethromeatoplasty, with partial excision 53460 of distal urethral segment No MEDICAID URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN INCLUDING CYSTOURETHROSCOPY (EG POSTSURGICAL OBSTRUCTION, 53500 SCARRING) No MEDICAID Urethrorrhaphy, suture of urethral wound 53502 or injury, female No MEDICAID Urethrorrhaphy, suture of urethral wound 53505 or injury; penile No MEDICAID Urethrorrhaphy, suture of urethral wound 53510 or injury; perineal No MEDICAID Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous 53515 No MEDICAID Closure of urethrostomy or urethrocutaneous fistula, male (separate 53520 No MEDICAID Dilation of urethral stricture by passage of 53600 sound or urethral dilator, No MEDICAID Dilation of urethral stricture by passage of 53601 sound or urethral dilator, No MEDICAID Dilation of urethral stricture or vesical 53605 neck by passage of sound or No MEDICAID Dilation of urethral stricture by passage of 53620 filiform and follower, No MEDICAID Dilation of urethral stricture by passage of 53621 filiform and follower, No MEDICAID Dilation of female urethra including 53660 suppository and/or instillation; No MEDICAID Dilation of female urethra including 53661 suppository and/or instillation; No MEDICAID Dilation of female urethra, general or 53665 conduction (spinal) anesthesia No MEDICAID Transurethral destruction of prostate 53850 tissue; by microwave thermotherapy No MEDICAID Transurethral destruction of prostate 53852 tissue; by radiofrequency No MEDICAID INSERTION OF A TEMPORARY PROSTATIC URETHRAL STENT, INCLUDING URETHRAL 53855 MEASUREMENT No MEDICAID Transurethral radiofrequency micro- remodeling of the female bladder neck 53860 No and proximal urethra for stress urinary incontinence MEDICAID UNLISTED PROCEDURE, URINARY 53899 SYSTEM Yes MEDICAID Slitting of prepuce, dorsal or lateral 54000 (separate procedure); newborn No MEDICAID Slitting of prepuce, dorsal or lateral 54001 (separate procedure); except No MEDICAID 54015 Incision and drainage of penis, deep No MEDICAID Destruction of lesion(s), penis (eg, 54050 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), penis (eg, 54055 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), penis (eg, 54056 condyloma, papilloma, molluscum No MEDICAID

183 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Destruction of lesion(s), penis (eg, 54057 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), penis (eg, 54060 condyloma, papilloma, molluscum No MEDICAID Destruction of lesion(s), penis (eg, 54065 condyloma, papilloma, molluscum No MEDICAID Biopsy of penis; (separate procedure) 54100 No MEDICAID 54105 Biopsy of penis; deep structures No MEDICAID Excision of penile plaque (Peyronie 54110 disease); No MEDICAID Excision of penile plaque (Peyronie 54111 disease); with graft to 5 cm in No MEDICAID Excision of penile plaque (Peyronie 54112 disease); with graft greater than 5 No MEDICAID Removal foreign body from deep penile 54115 tissue (eg, plastic implant) No MEDICAID 54120 Amputation of penis; partial No MEDICAID 54125 Amputation of penis; complete No MEDICAID Amputation of penis, radical; with bilateral 54130 inguinofemoral No MEDICAID Amputation of penis, radical; in continuity 54135 with bilateral pelvic No MEDICAID Circumcision, using clamp or other 54150 device; newborn No MEDICAID Circumcision, surgical excision other than 54160 clamp, device or dorsal slit; No MEDICAID Circumcision, surgical excision other than 54161 clamp, device or dorsal slit; No MEDICAID Lysis or excision of penile post- 54162 circumcision adhesions No MEDICAID 54163 Repair incomplete circumcision No MEDICAID 54164 Frenulotomy of penis No MEDICAID Injection procedure for Peyronie disease; 54200 No MEDICAID Injection procedure for Peyronie disease; 54205 with surgical exposure of No MEDICAID Irrigation of corpora cavernosa for 54220 priapism No MEDICAID INJECTION PROCEDURE FOR 54230 Yes CORPORA CAVERNOSOGRAPHY MEDICAID DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL 54231 Yes INJECTION OF VASOACTIVE DRUGS (EG, PAPAVERINE, PHENTOLAMINE) MEDICAID Injection of corpora cavernosa with 54235 Yes pharmacologic agent(s) (eg, MEDICAID 54240 Penile plethysmography Yes MEDICAID Nocturnal penile tumescence and/or 54250 rigidity test No MEDICAID Plastic operation of penis for straightening 54300 of chordee (eg, No MEDICAID Plastic operation on penis for correction of 54304 chordee or for first stage No MEDICAID Urethroplasty for second stage 54308 hypospadias repair (including urinary No MEDICAID Urethroplasty for second stage 54312 hypospadias repair (including urinary No MEDICAID Urethroplasty for second stage 54316 hypospadias repair (including urinary No MEDICAID Urethroplasty for third stage hypospadias repair to release penis from 54318 No MEDICAID One stage distal hypospadias repair (with 54322 or without chordee or No MEDICAID One stage distal hypospadias repair (with 54324 or without chordee or No MEDICAID One stage distal hypospadias repair (with 54326 or without chordee or No MEDICAID One stage distal hypospadias repair (with 54328 or without chordee or No MEDICAID

184 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines One stage proximal penile or penoscrotal hypospadias repair requiring 54332 No MEDICAID One stage perineal hypospadias repair requiring extensive dissection to 54336 No MEDICAID Repair of hypospadias complications (ie, 54340 fistula, stricture, No MEDICAID Repair of hypospadias complications (ie, 54344 fistula, stricture, No MEDICAID Repair of hypospadias complications (ie, 54348 fistula, stricture, No MEDICAID Repair of hypospadias cripple requiring 54352 extensive dissection and No MEDICAID Plastic operation on penis to correct 54360 Yes angulation MEDICAID Plastic operation on penis for epispadias distal to external sphincter; 54380 No MEDICAID Plastic operation on penis for epispadias distal to external sphincter; 54385 No MEDICAID Plastic operation on penis for epispadias distal to external sphincter; 54390 No MEDICAID INSERTION OF PENILE PROSTHESIS; 54400 NON-INFLATABLE (SEMI-RIGID) Yes MEDICAID INSERTION OF PENILE PROSTHESIS; 54401 INFLATABLE (SELF-CONTAINED) Yes MEDICAID INSERTION OF INFLATABLE (MULTI- COMPONENT) PENILE PROSTHESIS, 54405 INCLUDING PLACEMENT OF PUMP, Yes CYLINDERS, AND/OR RESERVOIR MEDICAID 54406 REMOVAL OF PENILE PROSTHESIS Yes MEDICAID 54408 REPAIR OF PENILE PROSTHESIS Yes MEDICAID REMOVAL/REPLACEMENT OF PENILE 54410 Yes PROSTHESIS MEDICAID REMOVAL/REPLACEMENT OF PENILE 54411 Yes PROSTHESIS MEDICAID 54415 REMOVAL OF PENILE PROSTHESIS No MEDICAID REMOVAL/REPLACEMENT OF PENILE 54416 Yes PROSTHESIS MEDICAID REMOVAL/REPLACEMENT OF PENILE 54417 Yes PROSTHESIS MEDICAID Corpora cavernosa-saphenous vein shunt 54420 (priapism operation), unilateral No MEDICAID Corpora cavernosa-corpus spongiosum shunt (priapism operation), 54430 No MEDICAID Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter 54435 No MEDICAID 54437 Repair of traumatic corporeal tear(s) No MEDICAID Replantation, penis, complete amputation 54438 including urethral repair No MEDICAID 54440 Plastic operation of penis for injury No MEDICAID FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS 54450 AND STRETCHING No MEDICAID Biopsy of testis, needle (separate 54500 procedure) No * MEDICAID Biopsy of testis, incisional (separate 54505 procedure) No * MEDICAID Excision of extraparenchymal lesion of 54512 testis No MEDICAID Orchiectomy, simple (including subcapsular), with or without testicular 54520 No MEDICAID

185 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 54522 Orchiectomy, partial No MEDICAID Orchiectomy, radical, for tumor; inguinal 54530 approach No MEDICAID Orchiectomy, radical, for tumor; with 54535 abdominal exploration No MEDICAID Exploration for undescended testis 54550 (inguinal or scrotal area) No MEDICAID Exploration for undescended testis with 54560 abdominal exploration No MEDICAID Reduction of torsion of testis, surgical, 54600 with or without fixation of No MEDICAID Fixation of contralateral testis (separate 54620 procedure) No MEDICAID Orchiopexy, inguinal approach, with or 54640 without hernia repair No * MEDICAID Orchiopexy, abdominal approach, for intra- 54650 abdominal testis (eg, No * MEDICAID INSERTION OF TESTICULAR PROSTHESIS (SEPARATE 54660 PROCEDURE) No MEDICAID 54670 Suture or repair of testicular injury No MEDICAID Transplantation of testis(es) to thigh 54680 (because of scrotal destruction) No MEDICAID 54690 Laparoscopy, surgical; orchiectomy No MEDICAID Laparoscopy, surgical; orchiopexy for 54692 intra-abdominal testis No MEDICAID UNLISTED LAPARPSCOPY 54699 PROCEDURE, TESTIS Yes MEDICAID Incision and drainage of epididymis, testis 54700 and/or scrotal space (eg, No MEDICAID 54800 Biopsy of epididymis, needle No * MEDICAID 54830 Excision of local lesion of epididymis No MEDICAID Excision of spermatocele, with or without 54840 epididymectomy No * MEDICAID 54860 Epididymectomy; unilateral No * MEDICAID 54861 Epididymectomy; bilateral No * MEDICAID EXPLORATION OF EPIDIDYMIS, WITH 54865 OR WITHOUT BIOPSY No MEDICAID Epididymovasostomy, anastomosis of 54900 epididymis to vas deferens; No * MEDICAID Epididymovasostomy, anastomosis of 54901 epididymis to vas deferens; No * MEDICAID Puncture aspiration of hydrocele, tunica 55000 vaginalis, with or without No MEDICAID 55040 Excision of hydrocele; unilateral No MEDICAID 55041 Excision of hydrocele; bilateral No MEDICAID Repair of tunica vaginalis hydrocele 55060 (Bottle type) No MEDICAID 55100 Drainage of scrotal wall abscess No MEDICAID 55110 Scrotal exploration No * MEDICAID 55120 Removal of foreign body in scrotum No MEDICAID 55150 Resection of scrotum No MEDICAID 55175 Scrotoplasty; simple No MEDICAID 55180 Scrotoplasty; complicated No MEDICAID Vasotomy, cannulization with or without 55200 incision of vas, unilateral or No MEDICAID Vasectomy, unilateral or bilateral 55250 (separate procedure), including No * MEDICAID Vasotomy for vasograms, seminal 55300 vesiculograms, or epididymograms, No * MEDICAID VASOVASOSTOMY, 55400 VASOVASORRHAPHY Yes MEDICAID Excision of hydrocele of spermatic cord, 55500 unilateral (separate procedure) No MEDICAID Excision of lesion of spermatic cord 55520 (separate procedure) No MEDICAID Excision of varicocele or ligation of 55530 spermatic veins for varicocele; No * MEDICAID Excision of varicocele or ligation of 55535 spermatic veins for varicocele; No * MEDICAID

186 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision of varicocele or ligation of 55540 spermatic veins for varicocele; No * MEDICAID Laparoscopy, surgical, with ligation of 55550 spermatic veins for varicocele No * MEDICAID UNLISTED LAPAROSCOPY 55559 PROCEDURE, SPERMATIC CORD Yes MEDICAID 55600 Vesiculotomy; No MEDICAID 55605 Vesiculotomy; complicated No MEDICAID 55650 Vesiculectomy, any approach No MEDICAID 55680 Excision of Mullerian duct cyst No MEDICAID Biopsy, prostate; needle or punch, single 55700 or multiple, any approach No MEDICAID Biopsy, prostate; incisional, any approach 55705 No MEDICAID Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance 55706 No MEDICAID Prostatotomy, external drainage of 55720 prostatic abscess, any approach; No MEDICAID Prostatotomy, external drainage of 55725 prostatic abscess, any approach; No MEDICAID Prostatectomy, perineal, subtotal 55801 (including control of postoperative No MEDICAID 55810 Prostatectomy, perineal radical; No MEDICAID Prostatectomy, perineal radical; with 55812 lymph node biopsy(s) (limited No MEDICAID Prostatectomy, perineal radical; with 55815 bilateral pelvic lymphadenectomy, No MEDICAID Prostatectomy (including control of 55821 postoperative bleeding, vasectomy, No MEDICAID Prostatectomy (including control of 55831 postoperative bleeding, vasectomy, No MEDICAID Prostatectomy, retropubic radical, with or 55840 without nerve sparing; No MEDICAID PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE SPARING; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC 55842 LYMPHADENECTOMY) No MEDICAID Prostatectomy, retropubic radical, with or 55845 without nerve sparing; with No MEDICAID Exposure of prostate, any approach, for 55860 insertion of radioactive No MEDICAID Exposure of prostate, any approach, for 55862 insertion of radioactive No MEDICAID Exposure of prostate, any approach, for 55865 insertion of radioactive No MEDICAID Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when 55866 performed No MEDICAID 55870 ELECTROEJACULATION Yes MEDICAID CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC GUIDANCE FOR INTERSTITIAL CRYOSURGICAL PROBE PLACEMENT) 55873 No MEDICAID Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed termed code 0438T

55874 No MEDICAID TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS IN 55875 PROSTATE No MEDICAID

187 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple 55876 No MEDICAID UNLISTED PROCEDURE, MALE 55899 GENITAL SYSTEM Yes MEDICAID PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT 55920 APPLICATION No MEDICAID INTERSEX SURGERY; MALE TO 55970 FEMALE Yes MEDICAID INTERSEX SURGERY; FEMALE TO 55980 MALE Yes MEDICAID Incision and drainage of vulva or perineal 56405 abscess No MEDICAID Incision and drainage of Bartholin's gland 56420 abscess No MEDICAID Marsupialization of Bartholin's gland cyst 56440 No MEDICAID 56441 Lysis of labial adhesions No MEDICAID 56442 HYMENOTOMY, SIMPLE INCISION No MEDICAID Destruction of lesion(s), vulva; simple (eg, 56501 laser surgery, No MEDICAID Destruction of lesion(s), vulva; extensive 56515 (eg, laser surgery, No MEDICAID Biopsy of vulva or perineum (separate 56605 procedure); one lesion No MEDICAID Biopsy of vulva or perineum (separate 56606 procedure); each separate No MEDICAID 56620 Vulvectomy simple; partial No MEDICAID 56625 Vulvectomy simple; complete No MEDICAID 56630 Vulvectomy, radical, partial; No MEDICAID Vulvectomy, radical, partial; with unilateral 56631 inguinofemoral No MEDICAID Vulvectomy, radical, partial; with bilateral 56632 inguinofemoral No MEDICAID 56633 Vulvectomy, radical, complete; No MEDICAID Vulvectomy, radical, complete; with 56634 unilateral inguinofemoral No MEDICAID Vulvectomy, radical, complete; with 56637 bilateral inguinofemoral No MEDICAID Vulvectomy, radical, complete, with 56640 inguinofemoral, iliac, and pelvic No MEDICAID Partial hymenectomy or revision of 56700 hymenal ring No MEDICAID 56740 Excision of Bartholin's gland or cyst No MEDICAID 56800 Plastic repair of introitus No MEDICAID 56805 Clitoroplasty for intersex state No MEDICAID Perineoplasty, repair of perineum, 56810 nonobstetrical (separate procedure) No MEDICAID 56820 Colposcopy of the vulva; No MEDICAID Colposcopy of the vulva; with biopsy(s) 56821 No MEDICAID 57000 Colpotomy; with exploration No MEDICAID Colpotomy; with drainage of pelvic 57010 abscess No MEDICAID 57020 Colpocentesis (separate procedure) No MEDICAID Incision and drainage of vaginal 57022 hematoma; obstetrical/postpartum No MEDICAID Incision and drainage of vaginal 57023 hematoma; non-obstetrical (eg, No MEDICAID Destruction of vaginal lesion(s); simple 57061 (eg, laser surgery, No MEDICAID Destruction of vaginal lesion(s); extensive 57065 (eg, laser surgery, No MEDICAID Biopsy of vaginal mucosa; simple 57100 (separate procedure) No MEDICAID

188 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Biopsy of vaginal mucosa; extensive, 57105 requiring suture (including cysts) No MEDICAID Vaginectomy, partial removal of vaginal 57106 wall; No MEDICAID Vaginectomy, partial removal of vaginal 57107 wall; with removal of No MEDICAID Vaginectomy, partial removal of vaginal 57109 wall; with removal of No MEDICAID Vaginectomy, complete removal of 57110 vaginal wall; No MEDICAID Vaginectomy, complete removal of 57111 vaginal wall; with removal of No MEDICAID Vaginectomy, complete removal of 57112 vaginal wall; with removal of No MEDICAID 57120 COLPOCLEISIS (LE FORT TYPE) No MEDICAID 57130 Excision of vaginal septum No MEDICAID 57135 Excision of vaginal cyst or tumor No MEDICAID Irrigation of vagina and/or application of 57150 medicament for treatment of No MEDICAID Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy 57155 No MEDICAID 57156 Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy No MEDICAID Fitting and insertion of pessary or other 57160 intravaginal support device No MEDICAID Diaphragm or cervical cap fitting with 57170 instructions No MEDICAID Introduction of any hemostatic agent or 57180 pack for spontaneous or No MEDICAID Colporrhaphy, suture of injury of vagina 57200 (nonobstetrical) No MEDICAID Colpoperineorrhaphy, suture of injury of 57210 vagina and/or perineum No MEDICAID Plastic operation on urethral sphincter, 57220 vaginal approach (eg, Kelly No MEDICAID 57230 Plastic repair of urethrocele No MEDICAID Anterior colporrhaphy, repair of cystocele 57240 with or without repair of No MEDICAID Posterior colporrhaphy, repair of rectocele 57250 with or without No MEDICAID Combined anteroposterior colporrhaphy; 57260 No MEDICAID Combined anteroposterior colporrhaphy; 57265 with enterocele repair No MEDICAID Insertion of mesh or other prosthesis for 57267 repair of pelvic floor No MEDICAID Repair of enterocele, vaginal approach 57268 (separate procedure) No MEDICAID Repair of enterocele, abdominal approach 57270 (separate procedure) No MEDICAID 57280 Colpopexy, abdominal approach No MEDICAID Colpopexy, vaginal; extra-peritoneal 57282 approach (sacrospinous, No MEDICAID Colpopexy, vaginal; intra-peritoneal 57283 approach (uterosacral, levator No MEDICAID Paravaginal defect repair (including repair 57284 of cystocele, stress urinary No MEDICAID PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED); VAGINAL APPROACH 57285 No MEDICAID Removal or revision of sling for stress 57287 incontinence (eg, fascia or No MEDICAID Sling operation for stress incontinence 57288 (eg, fascia or synthetic) No MEDICAID Pereyra procedure, including anterior 57289 colporrhaphy No MEDICAID Construction of artificial vagina; without 57291 graft No MEDICAID

189 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Construction of artificial vagina; with graft 57292 No MEDICAID 57295 Change vaginal graft No MEDICAID REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN 57296 ABDOMINAL APPROACH No MEDICAID Closure of rectovaginal fistula; vaginal or 57300 transanal approach No MEDICAID Closure of rectovaginal fistula; abdominal 57305 approach No MEDICAID Closure of rectovaginal fistula; abdominal approach, with concomitant 57307 No MEDICAID body reconstruction, with or without 57308 levator plication No MEDICAID 57310 Closure of urethrovaginal fistula; No MEDICAID Closure of urethrovaginal fistula; with 57311 bulbocavernosus transplant No MEDICAID Closure of vesicovaginal fistula; vaginal 57320 approach No MEDICAID Closure of vesicovaginal fistula; 57330 transvesical and vaginal approach No MEDICAID 57335 Vaginoplasty for intersex state Yes MEDICAID 57400 Dilation of vagina under anesthesia No MEDICAID 57410 Pelvic examination under anesthesia No MEDICAID Removal of impacted vaginal foreign body 57415 (separate procedure) under No MEDICAID Colposcopy of the entire vagina, with 57420 cervix if present; No MEDICAID Colposcopy of the entire vagina, with 57421 cervix if present; with biopsy(s) No MEDICAID PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED), LAPAROSCOPIC 57423 APPROACH No MEDICAID LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF 57425 VAGINAL APEX) No MEDICAID REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, 57426 LAPAROSCOPIC APPROACH No MEDICAID Colposcopy of the cervix including 57452 upper/adjacent vagina; No MEDICAID Colposcopy of the cervix including 57454 upper/adjacent vagina; with biopsy(s) No MEDICAID Colposcopy of the cervix including 57455 upper/adjacent vagina; with biopsy(s) No MEDICAID Colposcopy of the cervix including 57456 upper/adjacent vagina; with No MEDICAID Colposcopy of the cervix including 57460 upper/adjacent vagina; with loop No MEDICAID Colposcopy of the cervix including 57461 upper/adjacent vagina; with loop No MEDICAID Biopsy, single or multiple, or local excision 57500 of lesion, with or without No MEDICAID Endocervical curettage (not done as part 57505 of a dilation and curettage) No MEDICAID 57510 Cautery of cervix; electro or thermal No MEDICAID Cautery of cervix; cryocautery, initial or 57511 repeat No MEDICAID 57513 Cautery of cervix; laser ablation No MEDICAID Conization of cervix, with or without 57520 fulguration, with or without No MEDICAID Conization of cervix, with or without 57522 fulguration, with or without No MEDICAID Trachelectomy (cervicectomy), amputation of cervix (separate procedure) 57530 No MEDICAID Radical trachelectomy, with bilateral total 57531 pelvic lymphadenectomy and No MEDICAID

190 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision of cervical stump, abdominal 57540 approach; No MEDICAID Excision of cervical stump, abdominal approach; with pelvic floor repair 57545 No MEDICAID Excision of cervical stump, vaginal 57550 approach; No MEDICAID Excision of cervical stump, vaginal 57555 approach; with anterior and/or No MEDICAID Excision of cervical stump, vaginal 57556 approach; with repair of enterocele No MEDICAID DILATION AND CURETTAGE OF 57558 CERVICAL STUMP No MEDICAID Cerclage of uterine cervix, nonobstetrical 57700 No MEDICAID Trachelorrhaphy, plastic repair of uterine 57720 cervix, vaginal approach No MEDICAID Dilation of cervical canal, instrumental 57800 (separate procedure) No MEDICAID Endometrial sampling (biopsy) with or 58100 without endocervical sampling No * MEDICAID 58110 Bx done w/colposcopy add-on No MEDICAID Dilation and curettage, diagnostic and/or 58120 therapeutic (nonobstetrical) No MEDICAID Myomectomy, excision of fibroid tumor(s) 58140 of uterus, 1 to 4 intramural No MEDICAID Myomectomy, excision of fibroid tumor(s) 58145 of uterus, 1 to 4 intramural No * MEDICAID Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural 58146 No MEDICAID Total abdominal hysterectomy (corpus 58150 and cervix), with or without No MEDICAID Total abdominal hysterectomy (corpus 58152 and cervix), with or without No MEDICAID Supracervical abdominal hysterectomy (subtotal hysterectomy), with or 58180 No MEDICAID Total abdominal hysterectomy, including 58200 partial vaginectomy, with No MEDICAID Radical abdominal hysterectomy, with 58210 bilateral total pelvic No MEDICAID Pelvic exenteration for gynecologic 58240 malignancy, with total abdominal No MEDICAID Vaginal hysterectomy, for uterus 250 58260 grams or less; No MEDICAID Vaginal hysterectomy, for uterus 250 58262 grams or less; with removal of No MEDICAID Vaginal hysterectomy, for uterus 250 58263 grams or less; with removal of No MEDICAID Vaginal hysterectomy, for uterus 250 58267 grams or less; with No MEDICAID Vaginal hysterectomy, for uterus 250 58270 grams or less; with repair of No MEDICAID Vaginal hysterectomy, with total or partial 58275 vaginectomy; No MEDICAID Vaginal hysterectomy, with total or partial 58280 vaginectomy; with repair of No MEDICAID Vaginal hysterectomy, radical (Schauta 58285 type operation) No MEDICAID Vaginal hysterectomy, for uterus greater 58290 than 250 grams; No MEDICAID Vaginal hysterectomy, for uterus greater than 250 grams; with removal of 58291 No MEDICAID Vaginal hysterectomy, for uterus greater than 250 grams; with removal of 58292 No MEDICAID Vaginal hysterectomy, for uterus greater 58293 than 250 grams; with No MEDICAID

191 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Vaginal hysterectomy, for uterus greater than 250 grams; with repair of 58294 No MEDICAID 58300 Insertion of intrauterine device (IUD) No MEDICAID 58301 Removal of intrauterine device (IUD) No MEDICAID ARTIFICIAL INSEMINATION; INTRA- 58321 CERVICAL No MEDICAID ARTIFICIAL INSEMINATION; INTRA- 58322 UTERINE No MEDICAID SPERM WASHING FOR ARTIFICIAL 58323 INSEMINATION No MEDICAID Catheterization and introduction of saline 58340 or contrast material for No * MEDICAID Transcervical introduction of fallopian 58345 tube catheter for diagnosis No * MEDICAID Insertion of Heyman capsules for clinical 58346 brachytherapy No MEDICAID Chromotubation of oviduct, including 58350 materials No * MEDICAID ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTERSCOPIC GUIDANCE 58353 No MEDICAID ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING ENDOMETRIAL CURETTAGE, WHEN 58356 PERFORMED No MEDICAID Uterine suspension, with or without 58400 shortening of round ligaments, with No MEDICAID Uterine suspension, with or without 58410 shortening of round ligaments, with No MEDICAID Hysterorrhaphy, repair of ruptured uterus 58520 (nonobstetrical) No MEDICAID Hysteroplasty, repair of uterine anomaly 58540 (Strassman type) No * MEDICAID LAPAROSCOPY, SURGICAL; 58541 SUPRACERVICAL HYSTERECTOMY No MEDICAID LAPAROSCOPY, SURGICAL; 58542 SUPRACERVICAL HYSTERECTOMY No MEDICAID LAPAROSCOPY, SURGICAL; SUPRACERVICAL HYSTERECTOMY, 58543 FOR UTERUS No MEDICAID LAPAROSCOPY, SURGICAL; SUPRACERVICAL HYSTERECTOMY, 58544 FOR UTERUS No MEDICAID Laparoscopy, surgical, myomectomy, 58545 excision; 1 to 4 intramural No MEDICAID Laparoscopy, surgical, myomectomy, 58546 excision; 5 or more intramural No MEDICAID LAPAROSCOPY, SURGICAL; W/RADICAL HYSTERECTOMY, 58548 W/BILAT TOTAL No MEDICAID Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or 58550 No MEDICAID Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or 58552 No MEDICAID Laparoscopy, surgical, with vaginal 58553 hysterectomy, for uterus greater No MEDICAID Laparoscopy, surgical, with vaginal 58554 hysterectomy, for uterus greater No MEDICAID Hysteroscopy, diagnostic (separate 58555 procedure) No * MEDICAID Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or 58558 No * MEDICAID Hysteroscopy, surgical; with lysis of 58559 intrauterine adhesions (any No * MEDICAID Hysteroscopy, surgical; with division or 58560 resection of intrauterine No * MEDICAID

192 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Hysteroscopy, surgical; with removal of 58561 leiomyomata No * MEDICAID Hysteroscopy, surgical; with removal of 58562 impacted foreign body No * MEDICAID HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, 58563 THERMOABLATION) No * MEDICAID HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF 58565 PERMANENT IMPLANTS No MEDICAID LAPROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR 58570 UTERUS 250G OR LESS No MEDICAID LAPROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR 58571 OVARY(S) No MEDICAID LAPROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR 58572 UTERUS GREATER THAN 250G No MEDICAID LAPROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250G; WITH REMOVAL OF TUBE(S) AND/OR 58573 OVARY(S) No MEDICAID Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed 58575 No MEDICAID UNLISTED LAPAROSCOPY 58578 PROCEDURE, UTERUS Yes MEDICAID UNLISTED HYSTEROSCOPY 58579 PROCEDURE, UTERUS Yes MEDICAID Ligation or transection of fallopian tube(s), 58600 abdominal or vaginal No * MEDICAID Ligation or transection of fallopian tube(s), 58605 abdominal or vaginal No * MEDICAID Ligation or transection of fallopian tube(s) 58611 when done at the time of No * MEDICAID Occlusion of fallopian tube(s) by device 58615 (eg, band, clip, Falope ring) No * MEDICAID Laparoscopy, surgical; with lysis of 58660 adhesions (salpingolysis, No * MEDICAID Laparoscopy, surgical; with removal of 58661 adnexal structures (partial or No MEDICAID Laparoscopy, surgical; with fulguration or excision of lesions of the 58662 No * MEDICAID Laparoscopy, surgical; with fulguration of 58670 oviducts (with or without No * MEDICAID Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, 58671 No * MEDICAID Laparoscopy, surgical; with fimbrioplasty 58672 No * MEDICAID Laparoscopy, surgical; with salpingostomy 58673 (salpingoneostomy) No * MEDICAID Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, 58674 radiofrequency No MEDICAID UNLISTED LAPAROSCOPY 58679 PROCEDURE, OVIDUCT, OVARY Yes MEDICAID

193 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Salpingectomy, complete or partial, 58700 unilateral or bilateral (separate No MEDICAID Salpingo-oophorectomy, complete or 58720 partial, unilateral or bilateral No MEDICAID Lysis of adhesions (salpingolysis, 58740 ovariolysis) No * MEDICAID 58750 TUBOTUBAL ANASTOMOSIS Yes * MEDICAID 58760 Fimbrioplasty No * MEDICAID 58770 Salpingostomy (salpingoneostomy) No * MEDICAID Drainage of ovarian cyst(s), unilateral or 58800 bilateral, (separate No MEDICAID Drainage of ovarian cyst(s), unilateral or 58805 bilateral, (separate No MEDICAID Drainage of ovarian abscess; vaginal 58820 approach, open No MEDICAID Drainage of ovarian abscess; abdominal 58822 approach No MEDICAID 58825 Transposition, ovary(s) No MEDICAID Biopsy of ovary, unilateral or bilateral 58900 (separate procedure) No * MEDICAID Wedge resection or bisection of ovary, 58920 unilateral or bilateral No MEDICAID Ovarian cystectomy, unilateral or bilateral 58925 No MEDICAID Oophorectomy, partial or total, unilateral 58940 or bilateral; No MEDICAID Oophorectomy, partial or total, unilateral 58943 or bilateral; for ovarian, No MEDICAID Resection of ovarian, tubal or primary 58950 peritoneal malignancy with No MEDICAID Resection of ovarian, tubal or primary 58951 peritoneal malignancy with No MEDICAID Resection of ovarian, tubal or primary 58952 peritoneal malignancy with No MEDICAID Bilateral salpingo-oophorectomy with 58953 omentectomy, total abdominal No MEDICAID Bilateral salpingo-oophorectomy with 58954 omentectomy, total abdominal No MEDICAID Bilateral salpingo-oophorectomy with total 58956 omentectomy, total No MEDICAID RESECT (TUMOR DEBULKING) RECURRENT OVARIAN, TUBAL, PRIM 58957 PERITONEAL, No MEDICAID RESECT (TUMOR DEBULKING) RECURRENT OVARIAN, TUBAL, PRIM 58958 PERITONEAL, No MEDICAID Laparotomy, for staging or restaging of 58960 ovarian, tubal or primary No MEDICAID UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM 58999 (NONOBSTETRICAL) Yes MEDICAID 59000 Amniocentesis; diagnostic No MEDICAID Amniocentesis; therapeutic amniotic fluid 59001 reduction (includes ultrasound No MEDICAID Cordocentesis (intrauterine), any method 59012 No MEDICAID Chorionic villus sampling, any method 59015 No MEDICAID 59020 Fetal contraction stress test No MEDICAID 59025 Fetal non-stress test No MEDICAID 59030 Fetal scalp blood sampling No MEDICAID Fetal monitoring during labor by consulting physician (ie, non-attending 59050 No MEDICAID Fetal monitoring during labor by consulting physician (ie, non-attending 59051 No MEDICAID TRANSABDOMINAL AMNIOINFUSION, INCLUDING ULTRASOUND GUIDANCE 59070 No MEDICAID

194 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FETAL UMBILICAL CORD OCCLUSION, INCLUDING ULTRASOUND GUIDANCE 59072 No MEDICAID FETAL FLUID DRAINAGE (EG, VESICOCENTESIS, THORACOCENTESIS, PARACENTESIS) INCLUDING ULTRASOUND GUIDANCE 59074 No MEDICAID FETAL SHUNT PLACEMENT, INCLUDING ULTRASOUND GUIDANCE 59076 No MEDICAID Hysterotomy, abdominal (eg, for 59100 hydatidiform mole, abortion) No MEDICAID Surgical treatment of ectopic pregnancy; 59120 tubal or ovarian, requiring No MEDICAID Surgical treatment of ectopic pregnancy; 59121 tubal or ovarian, without No MEDICAID Surgical treatment of ectopic pregnancy; 59130 abdominal pregnancy No MEDICAID Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy 59135 No MEDICAID Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy 59136 No MEDICAID Surgical treatment of ectopic pregnancy; 59140 cervical, with evacuation No MEDICAID Laparoscopic treatment of ectopic 59150 pregnancy; without salpingectomy No MEDICAID Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or 59151 No MEDICAID 59160 Curettage, postpartum No MEDICAID Insertion of cervical dilator (eg, laminaria, 59200 prostaglandin) (separate No MEDICAID Episiotomy or vaginal repair, by other than 59300 attending physician No MEDICAID Cerclage of cervix, during pregnancy; 59320 vaginal No MEDICAID Cerclage of cervix, during pregnancy; 59325 abdominal No MEDICAID 59350 Hysterorrhaphy of ruptured uterus No MEDICAID Routine obstetric care including antepartum care, vaginal delivery (with 59400 No MEDICAID Vaginal delivery only (with or without 59409 episiotomy and/or forceps); No MEDICAID Vaginal delivery only (with or without 59410 episiotomy and/or forceps); No MEDICAID External cephalic version, with or without 59412 tocolysis No MEDICAID Delivery of placenta (separate procedure) 59414 No MEDICAID 59425 Antepartum care only; 4-6 visits No MEDICAID Antepartum care only; 7 or more visits 59426 No MEDICAID Postpartum care only (separate 59430 procedure) No MEDICAID Routine obstetric care including antepartum care, cesarean delivery, and 59510 No MEDICAID 59514 Cesarean delivery only; No MEDICAID Cesarean delivery only; including 59515 postpartum care No MEDICAID Subtotal or total hysterectomy after 59525 cesarean delivery (List separately No MEDICAID Routine obstetric care including antepartum care, vaginal delivery (with 59610 No MEDICAID Vaginal delivery only, after previous 59612 cesarean delivery (with or without No MEDICAID

195 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Vaginal delivery only, after previous 59614 cesarean delivery (with or without No MEDICAID Routine obstetric care including antepartum care, cesarean delivery, and 59618 No MEDICAID Cesarean delivery only, following 59620 attempted vaginal delivery after No MEDICAID Cesarean delivery only, following 59622 attempted vaginal delivery after No MEDICAID Treatment of incomplete abortion, any 59812 trimester, completed surgically No MEDICAID Treatment of missed abortion, completed 59820 surgically; first trimester No MEDICAID Treatment of missed abortion, completed surgically; second trimester 59821 No MEDICAID Treatment of septic abortion, completed 59830 surgically No MEDICAID INDUCED ABORTION, BY DILATION 59840 AND CURETTAGE Yes * MEDICAID INDUCED ABORTION, BY DILATION 59841 AND EVACUATION Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DE 59850 Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DE 59851 Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAIULED INTRA- AMNIOTIC INJECTION) 59852 Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), 59855 INCL Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), 59856 INCL Yes * MEDICAID INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), 59857 INCL Yes * MEDICAID MULTIFETAL PREGNANCY 59866 REDUCTION(S) (MPR) Yes MEDICAID Uterine evacuation and curettage for 59870 hydatidiform mole No MEDICAID Removal of cerclage suture under 59871 anesthesia (other than local) No MEDICAID UNLISTED FETAL INVASIVE PROCEDURE, INLCUDING 59897 ULTRASOUND GUIDANCE Yes MEDICAID UNLISTED LAPAROSCOPY PROCEDURE, MATERNITY CARE AND 59898 DELIVERY Yes MEDICAID

196 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNLISTED PROCEDURE, MATERNITY 59899 CARE AND DELIVERY Yes MEDICAID Incision and drainage of thyroglossal duct 60000 cyst, infected No MEDICAID Biopsy thyroid, percutaneous core needle 60100 No MEDICAID Excision of cyst or adenoma of thyroid, or 60200 transection of isthmus No MEDICAID Partial thyroid lobectomy, unilateral; with 60210 or without isthmusectomy No MEDICAID Partial thyroid lobectomy, unilateral; with 60212 contralateral subtotal No MEDICAID Total thyroid lobectomy, unilateral; with or 60220 without isthmusectomy No MEDICAID Total thyroid lobectomy, unilateral; with 60225 contralateral subtotal No MEDICAID 60240 Thyroidectomy, total or complete No MEDICAID Thyroidectomy, total or subtotal for 60252 malignancy; with limited neck No MEDICAID Thyroidectomy, total or subtotal for 60254 malignancy; with radical neck No MEDICAID Thyroidectomy, removal of all remaining 60260 thyroid tissue following No MEDICAID Thyroidectomy, including substernal 60270 thyroid; sternal split or No MEDICAID Thyroidectomy, including substernal 60271 thyroid; cervical approach No MEDICAID Excision of thyroglossal duct cyst or sinus; 60280 No MEDICAID Excision of thyroglossal duct cyst or sinus; 60281 recurrent No MEDICAID APIRATION AND/OR INJECTION, 60300 THYROID CYST No MEDICAID Parathyroidectomy or exploration of 60500 parathyroid(s); No MEDICAID Parathyroidectomy or exploration of 60502 parathyroid(s); re-exploration No MEDICAID Parathyroidectomy or exploration of 60505 parathyroid(s); with mediastinal No MEDICAID Parathyroid autotransplantation (List 60512 separately in addition to code for No MEDICAID Thymectomy, partial or total; transcervical 60520 approach (separate No MEDICAID Thymectomy, partial or total; sternal split 60521 or transthoracic approach, No MEDICAID Thymectomy, partial or total; sternal split 60522 or transthoracic approach, No MEDICAID Adrenalectomy, partial or complete, or 60540 exploration of adrenal gland with No MEDICAID Adrenalectomy, partial or complete, or 60545 exploration of adrenal gland with No MEDICAID Excision of carotid body tumor; without 60600 excision of carotid artery No MEDICAID Excision of carotid body tumor; with 60605 excision of carotid artery No MEDICAID Laparoscopy, surgical, with adrenalectomy, partial or complete, or 60650 No MEDICAID UNLISTED LAPAROSCOPY PROCEDURE, ENDOCRINE SYSTEM 60659 Yes MEDICAID UNLISTED PROCEDURE, ENDOCRINE 60699 SYSTEM Yes MEDICAID Subdural tap through fontanelle, or suture, 61000 infant, unilateral or No MEDICAID Subdural tap through fontanelle, or suture, 61001 infant, unilateral or No MEDICAID Ventricular puncture through previous burr 61020 hole, fontanelle, suture, or No MEDICAID Ventricular puncture through previous burr 61026 hole, fontanelle, suture, or No MEDICAID

197 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cisternal or lateral cervical (C1-C2) 61050 puncture; without injection No MEDICAID Cisternal or lateral cervical (C1-C2) 61055 puncture; with injection of No MEDICAID Puncture of shunt tubing or reservoir for 61070 aspiration or injection No MEDICAID Twist drill hole for subdural or ventricular 61105 puncture; No MEDICAID Twist drill hole for subdural or ventricular 61107 puncture; for implanting No MEDICAID Twist drill hole for subdural or ventricular 61108 puncture; for evacuation No MEDICAID Burr hole(s) for ventricular puncture 61120 (including injection of gas, No MEDICAID Burr hole(s) or trephine; with biopsy of 61140 brain or intracranial lesion No MEDICAID Burr hole(s) or trephine; with drainage of 61150 brain abscess or cyst No MEDICAID Burr hole(s) or trephine; with subsequent 61151 tapping (aspiration) of No MEDICAID Burr hole(s) with evacuation and/or 61154 drainage of hematoma, extradural or No MEDICAID Burr hole(s); with aspiration of hematoma 61156 or cyst, intracerebral No MEDICAID Burr hole(s); for implanting ventricular 61210 catheter, reservoir, EEG No MEDICAID Insertion of subcutaneous reservoir, pump 61215 or continuous infusion system No MEDICAID Burr hole(s) or trephine, supratentorial, exploratory, not followed by 61250 No MEDICAID Burr hole(s) or trephine, infratentorial, 61253 unilateral or bilateral No MEDICAID CRANIECTOMY OR CRANIOTOMY, 61304 EXPLORATORY; SUPRATENTORIAL No MEDICAID CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; INFRATENTORIAL 61305 (POSTERIOR FOSSA) No MEDICAID Craniectomy or craniotomy for evacuation of hematoma, supratentorial; 61312 No MEDICAID Craniectomy or craniotomy for evacuation of hematoma, supratentorial; 61313 No MEDICAID Craniectomy or craniotomy for evacuation of hematoma, infratentorial; 61314 No MEDICAID Craniectomy or craniotomy for evacuation of hematoma, infratentorial; 61315 No MEDICAID Incision and subcutaneous placement of 61316 cranial bone graft (List No MEDICAID Craniectomy or craniotomy, drainage of 61320 intracranial abscess; No MEDICAID Craniectomy or craniotomy, drainage of 61321 intracranial abscess; No MEDICAID Craniectomy or craniotomy, decompressive, with or without 61322 duraplasty, No MEDICAID Craniectomy or craniotomy, decompressive, with or without 61323 duraplasty, No MEDICAID Decompression of orbit only, transcranial 61330 approach No MEDICAID Exploration of orbit (transcranial 61332 approach); with biopsy No MEDICAID Exploration of orbit (transcranial 61333 approach); with removal of lesion No MEDICAID Subtemporal cranial decompression 61340 (pseudotumor cerebri, slit ventricle No MEDICAID

198 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Craniectomy, suboccipital with cervical laminectomy for decompression 61343 No MEDICAID OTHER CRANIAL DECOMPRESSION, POSTERIOR FOSSA 61345 No MEDICAID Craniectomy, subtemporal, for section, compression, or decompression 61450 No MEDICAID Craniectomy, suboccipital; for exploration or decompression of cranial 61458 No MEDICAID Craniectomy, suboccipital; for section of 61460 one or more cranial nerves No MEDICAID Craniectomy, suboccipital; for 61480 mesencephalic tractotomy or No MEDICAID Craniectomy; with excision of tumor or 61500 other bone lesion of skull No MEDICAID 61501 Craniectomy; for osteomyelitis No MEDICAID Craniectomy, trephination, bone flap 61510 craniotomy; for excision of brain No MEDICAID Craniectomy, trephination, bone flap 61512 craniotomy; for excision of No MEDICAID Craniectomy, trephination, bone flap 61514 craniotomy; for excision of brain No MEDICAID Craniectomy, trephination, bone flap 61516 craniotomy; for excision or No MEDICAID Implantation of brain intracavitary 61517 chemotherapy agent (List separately No MEDICAID Craniectomy for excision of brain tumor, 61518 infratentorial or posterior No MEDICAID Craniectomy for excision of brain tumor, 61519 infratentorial or posterior No MEDICAID Craniectomy for excision of brain tumor, 61520 infratentorial or posterior No MEDICAID Craniectomy for excision of brain tumor, 61521 infratentorial or posterior No MEDICAID Craniectomy, infratentorial or posterior 61522 fossa; for excision of brain No MEDICAID Craniectomy, infratentorial or posterior 61524 fossa; for excision or No MEDICAID Craniectomy, bone flap craniotomy, 61526 transtemporal (mastoid) for excision No MEDICAID Craniectomy, bone flap craniotomy, 61530 transtemporal (mastoid) for excision No MEDICAID SUBDURAL IMPLANTATION OF STRIP ELECTRODES THROUGH ONE OR MORE BURR OR TREPHINE HOLE(S) FOR LONG TERM SEIZURE 61531 MONITORING No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SUBDURAL IMPLANTATION OF AN ELECTRODE ARRAY, FOR LONG TERM SEIZURE 61533 MONITORING No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF EPILEPTOGENIC FOCUS WITHOUT ELECTROCORTICOGRAPHY DURING 61534 SURGERY No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR REMOVAL OF EPIDURAL OR SUBDURAL ELECTRODE ARRAY, WITHOUT 61535 EXCISION OF CEREBRAL TISSUE ( No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF CEREBRAL EPILEPTOGENIC FOCUS, WITH ELECTROCORTICOGRAPHY DURING SURGERY (IN 61536 No MEDICAID

199 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CRANIOTOMY W ELEVATION OF BONE FLAP; FOR LOBECTOMY, TEMPORAL LOBE, W/O ELECTROCORTICOGRAPHY DURING 61537 SURGERY No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP;FOR LOBECTOMY, TEMPORAL LOBE, WITH ELECTROCORTICOGRAPHY DURING 61538 SURGERY No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY OTHER THAN TEMPORAL LOBE, PARTIAL OR TOTAL, WITH ELECTROCORTICOGRAPHY DURING 61539 SURGERY, No MEDICAID CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR LOBECTOMY, OTHER THAN TEMPORAL LOBE, PARTIAL OR TOTAL, W/O ELECTROCORTICOGRAPHY DRNG 61540 SUG No MEDICAID Craniotomy with elevation of bone flap; for 61541 transection of corpus No MEDICAID CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR PARTIAL OR SUBTOTAL (FUNCTIONAL) 61543 HEMISPHERECTOMY No MEDICAID Craniotomy with elevation of bone flap; for 61544 excision or coagulation of No MEDICAID Craniotomy with elevation of bone flap; for 61545 excision of No MEDICAID Craniotomy for hypophysectomy or 61546 excision of pituitary tumor, No MEDICAID Hypophysectomy or excision of pituitary tumor, transnasal or transseptal 61548 No MEDICAID Craniectomy for craniosynostosis; single 61550 cranial suture No MEDICAID Craniectomy for craniosynostosis; multiple 61552 cranial sutures No MEDICAID Craniotomy for craniosynostosis; frontal or 61556 parietal bone flap No MEDICAID Craniotomy for craniosynostosis; bifrontal 61557 bone flap No MEDICAID Extensive craniectomy for multiple cranial 61558 suture craniosynostosis (eg, No MEDICAID Extensive craniectomy for multiple cranial 61559 suture craniosynostosis (eg, No MEDICAID Excision, intra and extracranial, benign 61563 tumor of cranial bone (eg, No MEDICAID Excision, intra and extracranial, benign 61564 tumor of cranial bone (eg, No MEDICAID CRANIOTOMY W ELEVATION OF BONE FLAP; FOR SELECTIVE 61566 AMYGDALOHIPPOCAMPECTOMY No MEDICAID CRANIOTOMY W ELEVATION OF BONE FLAP; FOR MULTIPLE SUBPIAL TRANSECTIONS, W ELECTROCORTICOGRAPHY DURING 61567 SURGERY No MEDICAID Craniectomy or craniotomy; with excision 61570 of foreign body from brain No MEDICAID Craniectomy or craniotomy; with treatment of penetrating wound of brain 61571 No MEDICAID Transoral approach to skull base, brain 61575 stem or upper spinal cord for No MEDICAID Transoral approach to skull base, brain 61576 stem or upper spinal cord for No MEDICAID

200 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Craniofacial approach to anterior cranial 61580 fossa; extradural, including No MEDICAID Craniofacial approach to anterior cranial 61581 fossa; extradural, including No MEDICAID Craniofacial approach to anterior cranial 61582 fossa; extradural, including No MEDICAID Craniofacial approach to anterior cranial 61583 fossa; intradural, including No MEDICAID Orbitocranial approach to anterior cranial 61584 fossa, extradural, including No MEDICAID Orbitocranial approach to anterior cranial 61585 fossa, extradural, including No MEDICAID Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior 61586 No MEDICAID Infratemporal pre-auricular approach to 61590 middle cranial fossa No MEDICAID Infratemporal post-auricular approach to middle cranial fossa (internal 61591 No MEDICAID Orbitocranial zygomatic approach to 61592 middle cranial fossa (cavernous No MEDICAID Transtemporal approach to posterior 61595 cranial fossa, jugular foramen or No MEDICAID Transcochlear approach to posterior 61596 cranial fossa, jugular foramen or No MEDICAID Transcondylar (far lateral) approach to 61597 posterior cranial fossa, jugular No MEDICAID Transpetrosal approach to posterior 61598 cranial fossa, clivus or foramen No MEDICAID Resection or excision of neoplastic, 61600 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61601 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61605 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61606 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61607 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61608 vascular or infectious lesion of No MEDICAID Transection or ligation, carotid artery in 61610 cavernous sinus; with repair No MEDICAID Transection or ligation, carotid artery in 61611 petrous canal; without repair No MEDICAID Transection or ligation, carotid artery in 61612 petrous canal; with repair by No MEDICAID Obliteration of carotid aneurysm, 61613 arteriovenous malformation, or No MEDICAID Resection or excision of neoplastic, 61615 vascular or infectious lesion of No MEDICAID Resection or excision of neoplastic, 61616 vascular or infectious lesion of No MEDICAID Secondary repair of dura for cerebrospinal fluid leak, anterior, middle 61618 No MEDICAID Secondary repair of dura for cerebrospinal fluid leak, anterior, middle 61619 No MEDICAID ENDOVASCULAR TEMPORARY BALLOON ARTERIAL OCCLUSION, HEAD OR NECK(EXTRACRANIAL/INTRACRANIAL) INCLUDING SELECTIVE 61623 CATHETERIZATION OF No MEDICAID Transcatheter permanent occlusion or 61624 embolization (eg, for tumor No MEDICAID Transcatheter permanent occlusion or 61626 embolization (eg, for tumor No MEDICAID

201 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BALLOON ANGIOPLASTY, INTRACRANIAL (EG, ATHEROSCLEROTIC STENOSIS), 61630 PERCUTANEOUS No MEDICAID TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), INTRACRANIAL (EG, ATHEROSCLEROTIC STENOSIS), INLCUDING BALLOON ANGIOPLASTY, 61635 IF No MEDICAID BALLOON DILATATION OF INTRACRANIAL VASOSPASM, 61640 PERCUTANEOUS; INITIAL VESSEL No MEDICAID BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; EACH ADDITIONAL VESSEL IN SAME VASCULAR FAMILY (LIST SEPARATELY IN ADD 61641 No MEDICAID BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; EACH ADDITIONAL VESSEL IN DIFFERENT VASCULAR FAMILY (LIST SEPARATELY I 61642 No MEDICAID Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s) 61645 No MEDICAID Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory 61650 No MEDICAID Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition to code for primary procedure) 61651 No MEDICAID Surgery of intracranial arteriovenous 61680 malformation; supratentorial, No MEDICAID Surgery of intracranial arteriovenous 61682 malformation; supratentorial, No MEDICAID Surgery of intracranial arteriovenous 61684 malformation; infratentorial, No MEDICAID Surgery of intracranial arteriovenous 61686 malformation; infratentorial, No MEDICAID Surgery of intracranial arteriovenous 61690 malformation; dural, simple No MEDICAID Surgery of intracranial arteriovenous 61692 malformation; dural, complex No MEDICAID Surgery of complex intracranial aneurysm, intracranial approach; carotid 61697 No MEDICAID Surgery of complex intracranial aneurysm, 61698 intracranial approach; No MEDICAID Surgery of simple intracranial aneurysm, intracranial approach; carotid 61700 No MEDICAID Surgery of simple intracranial aneurysm, 61702 intracranial approach; No MEDICAID Surgery of intracranial aneurysm, cervical 61703 approach by application of No MEDICAID Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; 61705 No MEDICAID

202 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; 61708 No MEDICAID Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; 61710 No MEDICAID Anastomosis, arterial, extracranial- 61711 intracranial (eg, middle No MEDICAID Creation of lesion by stereotactic method, 61720 including burr hole(s) and No MEDICAID Creation of lesion by stereotactic method, 61735 including burr hole(s) and No MEDICAID Stereotactic biopsy, aspiration, or 61750 excision, including burr hole(s), No MEDICAID Stereotactic biopsy, aspiration, or 61751 excision, including burr hole(s), No MEDICAID Stereotactic implantation of depth 61760 electrodes into the cerebrum for long No MEDICAID STEREOTACTIC LOCALIZATION, ANY METHOD, INCLUDING BURR HOLE(S), WITH INSERTION OF CATHETER(S) FOR BRACHYTHERAPY 61770 No MEDICAID 61781 Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure) No MEDICAID 61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) No MEDICAID 61783 Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure) No MEDICAID CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); G 61790 No MEDICAID Creation of lesion by stereotactic method, 61791 percutaneous, by neurolytic No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 61796 simple cranial lesion No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) 61797 No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 61798 complex cranial lesion No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) 61799 No MEDICAID Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) 61800 No MEDICAID Twist drill or burr hole(s) for implantation 61850 of neurostimulator No MEDICAID

203 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, CEREBRAL; CORTICAL 61860 No MEDICAID TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY W STEREOTACTIC IMPLNTN OF NEUROSTIMULATOR ELECTRODE 61863 ARRAY IN SUBCORTICAL SITE No MEDICAID TWIST DRILL, BURR HOLE CRANIOTOMY, OR CRANIECTOMY W STEROTACTIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE 61864 ARRAY IN SUBCORTICAL SIT No MEDICAID TWIST DRILL BURR HOLE, CRANIOTOMY, OR CRANIECTOMY W STEREOTACTIC IMPLNTN OF NEUROSTMLTR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG TH 61867 No MEDICAID TWIST DRILL BURR HOLE, CRANIOTOMY, OR CRANIECTOMY W STEREOTACTIC IMPLNTN OF NEUROSTMLTR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG TH 61868 No MEDICAID Craniectomy for implantation of neurostimulator electrodes, cerebellar; 61870 Yes MEDICAID REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR 61880 ELECTRODES No MEDICAID INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE 61885 GENERATOR OR RECEIVER, DIRECT Yes OR INDUCTIVE COUPLING W/1 ARRAY MEDICAID INSRT/REPLACE OF CRANIAL NEUROSTIMULATOR PULSE GENERAT/REC, DIRECT OR 61886 INDUCTIVE COUPLING W/CONN TO Yes TWO OR MORE EXECTRODE ARRAYS MEDICAID REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE 61888 GENERATOR OR RECEIVER No MEDICAID Elevation of depressed skull fracture; 62000 simple, extradural No MEDICAID Elevation of depressed skull fracture; 62005 compound or comminuted, No MEDICAID Elevation of depressed skull fracture; with 62010 repair of dura and/or No MEDICAID Craniotomy for repair of dural/cerebrospinal fluid leak, including 62100 No MEDICAID Reduction of craniomegalic skull (eg, 62115 treated hydrocephalus); not No MEDICAID Reduction of craniomegalic skull (eg, 62117 treated hydrocephalus); requiring No MEDICAID Repair of encephalocele, skull vault, 62120 including cranioplasty No MEDICAID Craniotomy for repair of encephalocele, 62121 skull base No MEDICAID Cranioplasty for skull defect; up to 5 cm 62140 diameter No MEDICAID Cranioplasty for skull defect; larger than 5 62141 cm diameter No MEDICAID Removal of bone flap or prosthetic plate 62142 of skull No MEDICAID

204 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Replacement of bone flap or prosthetic 62143 plate of skull No MEDICAID Cranioplasty for skull defect with 62145 reparative brain surgery No MEDICAID Cranioplasty with autograft (includes 62146 obtaining bone grafts); up to 5 cm No MEDICAID Cranioplasty with autograft (includes 62147 obtaining bone grafts); larger No MEDICAID Incision and retrieval of subcutaneous 62148 cranial bone graft for No MEDICAID NEUROENDOSCOPY, INTRACRANIAL, FOR PLACEMENT OR REPLACEMENT OF VENTRICULAR CATHETER & ATTACHMENT TO SHUNT SYS OR EXTERNAL DRAINAGE 62160 No MEDICAID NEUROENDOSCOPY, INTRACRANIAL; W/ DISSECTION OF ADHESIONS, FENESTRATION OF SEPTUM PELLUCIDUM OR INTRAVENTRICULAR CYSTS(INCLUDING PL 62161 No MEDICAID NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR EXCISION OF COLLOID CYST, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE 62162 No MEDICAID NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY 62163 No MEDICAID NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF BRAIN TUMOR, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE 62164 No MEDICAID NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY TUMOR, TRANSNASAL OR TRANSSPHENOIDAL APPROACH 62165 No MEDICAID Ventriculocisternostomy (Torkildsen type 62180 operation) No MEDICAID Creation of shunt; subarachnoid/subdural- atrial, -jugular, -auricular 62190 No MEDICAID Creation of shunt; subarachnoid/subdural- peritoneal, -pleural, other 62192 No MEDICAID Replacement or irrigation, 62194 subarachnoid/subdural catheter No MEDICAID Ventriculocisternostomy, third ventricle; 62200 No MEDICAID Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic 62201 No MEDICAID Creation of shunt; ventriculo-atrial, - 62220 jugular, -auricular No MEDICAID Creation of shunt; ventriculo-peritoneal, - 62223 pleural, other terminus No MEDICAID Replacement or irrigation, ventricular 62225 catheter No MEDICAID Replacement or revision of cerebrospinal fluid shunt, obstructed valve, 62230 No MEDICAID Reprogramming of programmable 62252 cerebrospinal shunt No MEDICAID Removal of complete cerebrospinal fluid 62256 shunt system; without No MEDICAID

205 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Removal of complete cerebrospinal fluid 62258 shunt system; with replacement No MEDICAID Percutaneous lysis of epidural adhesions 62263 using solution injection (eg, No MEDICAID Percutaneous lysis of epidural adhesions 62264 using solution injection (eg, No MEDICAID Percutaneous aspiration within nucleus pulpous, intervertebral disc, or paravertebral tissue for diagnostic 62267 purposes No MEDICAID Percutaneous aspiration, spinal cord cyst 62268 or syrinx No MEDICAID Biopsy of spinal cord, percutaneous 62269 needle No MEDICAID 62270 Spinal puncture, lumbar, diagnostic No MEDICAID Spinal puncture, therapeutic, for drainage 62272 of cerebrospinal fluid (by No MEDICAID Injection, epidural, of blood or clot patch 62273 No MEDICAID Injection/infusion of neurolytic substance 62280 No (eg, alcohol, phenol, iced MEDICAID Injection/infusion of neurolytic substance 62281 No (eg, alcohol, phenol, iced MEDICAID Injection/infusion of neurolytic substance 62282 No (eg, alcohol, phenol, iced MEDICAID INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, SPINAL (OTHER THAN C1-C2 AND POSTERIOR FOSSA) 62284 No MEDICAID ASPIRATION OR DECOMPRESSION PROCEDURE,PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISK, ANY METHHOD, SINGLE OR MULTIPLE LE 62287 No MEDICAID Injection procedure for diskography, each 62290 level; lumbar No MEDICAID Injection procedure for diskography, each 62291 level; cervical or thoracic No MEDICAID Injection procedure for chemonucleolysis, including diskography, 62292 No MEDICAID Injection procedure, arterial, for occlusion 62294 of arteriovenous No MEDICAID Myelography via lumbar injection, including radiological supervision and 62302 interpretation; cervical No MEDICAID Myelography via lumbar injection, including radiological supervision and 62303 interpretation; thoracic No MEDICAID Myelography via lumbar injection, including radiological supervision and 62304 interpretation; lumbosacral No MEDICAID Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical) 62305 No MEDICAID Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62320 No MEDICAID

206 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62321 No MEDICAID Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62322 No MEDICAID Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

62323 No MEDICAID Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62324 No MEDICAID Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62325 No MEDICAID Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62326 No MEDICAID Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

62327 No MEDICAID IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED 62350 INTRATHECAL OR EPIDURALl Yes MEDICAID Implantation, revision or repositioning of tunneled intrathecal or epidural 62351 Yes MEDICAID Removal of previously implanted 62355 intrathecal or epidural catheter No MEDICAID Implantation or replacement of device for 62360 intrathecal or epidural drug Yes MEDICAID Implantation or replacement of device for 62361 intrathecal or epidural drug Yes MEDICAID

207 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Implantation or replacement of device for 62362 intrathecal or epidural drug Yes MEDICAID Removal of subcutaneous reservoir or 62365 pump, previously implanted for No MEDICAID Electronic analysis of programmable, 62367 implanted pump for intrathecal or No MEDICAID Electronic analysis of programmable, 62368 implanted pump for intrathecal or No MEDICAID Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 62369 and refill No MEDICAID Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring physician's skill) 62370 No MEDICAID Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar 62380 No MEDICAID Laminectomy with exploration and/or 63001 decompression of spinal cord No MEDICAID Laminectomy with exploration and/or 63003 decompression of spinal cord No MEDICAID Laminectomy with exploration and/or 63005 decompression of spinal cord No MEDICAID Laminectomy with exploration and/or 63011 decompression of spinal cord No MEDICAID Laminectomy with removal of abnormal 63012 facets and/or pars No MEDICAID Laminectomy with exploration and/or 63015 decompression of spinal cord No MEDICAID Laminectomy with exploration and/or 63016 decompression of spinal cord No MEDICAID Laminectomy with exploration and/or 63017 decompression of spinal cord No MEDICAID Laminotomy (hemilaminectomy), with 63020 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63030 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63035 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63040 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63042 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63043 decompression of nerve root(s), No MEDICAID Laminotomy (hemilaminectomy), with 63044 decompression of nerve root(s), No MEDICAID Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63045 No MEDICAID Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63046 No MEDICAID Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63047 No MEDICAID Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with 63048 No MEDICAID

208 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, TWO OR MORE VERTEBRAL 63050 SEGMENTS No MEDICAID LAMINOPLASTY, CERVICAL, W/DECOMPRESSION OF SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; W/ RECONSTRUCTION 63051 OF POSTERIOR BONY ELEMENTS No MEDICAID Transpedicular approach with decompression of spinal cord, equina 63055 No MEDICAID Transpedicular approach with decompression of spinal cord, equina 63056 No MEDICAID Transpedicular approach with decompression of spinal cord, equina 63057 No MEDICAID Costovertebral approach with decompression of spinal cord or nerve 63064 No MEDICAID Costovertebral approach with decompression of spinal cord or nerve 63066 No MEDICAID Diskectomy, anterior, with decompression of spinal cord and/or nerve 63075 No MEDICAID Diskectomy, anterior, with decompression of spinal cord and/or nerve 63076 No MEDICAID Diskectomy, anterior, with decompression of spinal cord and/or nerve 63077 No MEDICAID Diskectomy, anterior, with decompression of spinal cord and/or nerve 63078 No MEDICAID Vertebral corpectomy (vertebral body 63081 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63082 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63085 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63086 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63087 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63088 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63090 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63091 resection), partial or complete, No MEDICAID VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION) PARTIAL/COMPLETE, LATERAL EXTRACAVITARY APPRCH W DECMPRSN OR SPINAL CORD 63101 AND/OR NE No MEDICAID VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION( PARTIAL/COMPLETE LATERAL EXTRACAVITARY APPRCH W DECMPRESN OF SPINAL CORD 63102 AND/OR NE No MEDICAID VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL/COMPLETE, LATERAL EXTRACAVITARY APPROACH W/DECOMPRESSION OF SPINAL 63103 CORD A No MEDICAID

209 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Laminectomy with myelotomy (eg, Bischof 63170 or DREZ type), cervical, No MEDICAID Laminectomy with drainage of 63172 intramedullary cyst/syrinx; to No MEDICAID Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal 63173 No MEDICAID Laminectomy and section of dentate 63180 ligaments, with or without dural No MEDICAID Laminectomy and section of dentate 63182 ligaments, with or without dural No MEDICAID Laminectomy with rhizotomy; one or two 63185 segments No MEDICAID Laminectomy with rhizotomy; more than 63190 two segments No MEDICAID Laminectomy with section of spinal 63191 accessory nerve No MEDICAID Laminectomy with cordotomy, with section 63194 of one spinothalamic tract, No MEDICAID Laminectomy with cordotomy, with section 63195 of one spinothalamic tract, No MEDICAID Laminectomy with cordotomy, with section 63196 of both spinothalamic tracts, No MEDICAID Laminectomy with cordotomy, with section 63197 of both spinothalamic tracts, No MEDICAID Laminectomy with cordotomy with section 63198 of both spinothalamic tracts, No MEDICAID Laminectomy with cordotomy with section 63199 of both spinothalamic tracts, No MEDICAID Laminectomy, with release of tethered 63200 spinal cord, lumbar No MEDICAID Laminectomy for excision or occlusion of arteriovenous malformation of 63250 No MEDICAID Laminectomy for excision or occlusion of arteriovenous malformation of 63251 No MEDICAID Laminectomy for excision or occlusion of arteriovenous malformation of 63252 No MEDICAID Laminectomy for excision or evacuation of intraspinal lesion other than 63265 No MEDICAID Laminectomy for excision or evacuation of intraspinal lesion other than 63266 No MEDICAID Laminectomy for excision or evacuation of intraspinal lesion other than 63267 No MEDICAID Laminectomy for excision or evacuation of intraspinal lesion other than 63268 No MEDICAID Laminectomy for excision of intraspinal lesion other than neoplasm, 63270 No MEDICAID Laminectomy for excision of intraspinal lesion other than neoplasm, 63271 No MEDICAID Laminectomy for excision of intraspinal lesion other than neoplasm, 63272 No MEDICAID Laminectomy for excision of intraspinal lesion other than neoplasm, 63273 No MEDICAID Laminectomy for biopsy/excision of 63275 intraspinal neoplasm; extradural, No MEDICAID Laminectomy for biopsy/excision of 63276 intraspinal neoplasm; extradural, No MEDICAID Laminectomy for biopsy/excision of 63277 intraspinal neoplasm; extradural, No MEDICAID

210 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Laminectomy for biopsy/excision of 63278 intraspinal neoplasm; extradural, No MEDICAID Laminectomy for biopsy/excision of 63280 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63281 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63282 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63283 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63285 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63286 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63287 intraspinal neoplasm; intradural, No MEDICAID Laminectomy for biopsy/excision of 63290 intraspinal neoplasm; combined No MEDICAID 63295 REPAIR OF LAMINECTOMY DEFECT No MEDICAID Vertebral corpectomy (vertebral body 63300 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63301 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63302 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63303 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63304 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63305 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63306 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63307 resection), partial or complete, No MEDICAID Vertebral corpectomy (vertebral body 63308 resection), partial or complete, No MEDICAID Creation of lesion of spinal cord by 63600 stereotactic method, percutaneous, No MEDICAID Stereotactic stimulation of spinal cord, 63610 percutaneous, separate No MEDICAID Stereotactic biopsy, aspiration, or excision 63615 of lesion, spinal cord No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal 63620 lesion No MEDICAID Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) 63621 No MEDICAID PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE 63650 ARRAY, EPIDURAL No MEDICAID LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, 63655 EPIDURAL No MEDICAID REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN 63661 PERFORMED No MEDICAID REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCL FLUROSCOPY, WHEN 63662 PERFORMED No MEDICAID

211 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REVISION INCL REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCL 63663 FLUOROSCOPY, WHEN PERFO No MEDICAID REVISION, INCLUD REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S), INCL FLUOROSCOPY, WHEN PERFORMD 63664 No MEDICAID INSERTION OR REPLCMNT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING 63685 Yes MEDICAID REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE 63688 GENERATOR OR RECEIVER No MEDICAID Repair of meningocele; less than 5 cm 63700 diameter No MEDICAID Repair of meningocele; larger than 5 cm 63702 diameter No MEDICAID Repair of myelomeningocele; less than 5 63704 cm diameter No MEDICAID Repair of myelomeningocele; larger than 63706 5 cm diameter No MEDICAID Repair of dural/cerebrospinal fluid leak, 63707 not requiring laminectomy No MEDICAID Repair of dural/cerebrospinal fluid leak or 63709 pseudomeningocele, with No MEDICAID 63710 Dural graft, spinal No MEDICAID Creation of shunt, lumbar, subarachnoid- peritoneal, -pleural, or other; 63740 No MEDICAID Creation of shunt, lumbar, subarachnoid- peritoneal, -pleural, or other; 63741 No MEDICAID Replacement, irrigation or revision of 63744 lumbosubarachnoid shunt No MEDICAID Removal of entire lumbosubarachnoid shunt system without replacement 63746 No MEDICAID Injection, anesthetic agent; trigeminal 64400 nerve, any division or branch No MEDICAID Injection, anesthetic agent; facial nerve 64402 No MEDICAID Injection, anesthetic agent; greater 64405 occipital nerve No MEDICAID Injection, anesthetic agent; vagus nerve 64408 No MEDICAID Injection, anesthetic agent; phrenic nerve 64410 No MEDICAID Injection, anesthetic agent; cervical plexus 64413 No MEDICAID Injection, anesthetic agent; brachial 64415 plexus, single No MEDICAID Injection, anesthetic agent; brachial 64416 plexus, continuous infusion by No MEDICAID Injection, anesthetic agent; axillary nerve 64417 No MEDICAID Injection, anesthetic agent; suprascapular 64418 nerve No MEDICAID Injection, anesthetic agent; intercostal 64420 nerve, single No MEDICAID Injection, anesthetic agent; intercostal 64421 nerves, multiple, regional No MEDICAID Injection, anesthetic agent; ilioinguinal, 64425 iliohypogastric nerves No MEDICAID

212 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection, anesthetic agent; pudendal 64430 nerve No MEDICAID Injection, anesthetic agent; paracervical 64435 (uterine) nerve No MEDICAID Injection, anesthetic agent; sciatic nerve, 64445 single No MEDICAID Injection, anesthetic agent; sciatic nerve, 64446 continuous infusion by No MEDICAID Injection, anesthetic agent; femoral nerve, 64447 single No MEDICAID Injection, anesthetic agent; femoral nerve, 64448 continuous infusion by No MEDICAID INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR APPRCH, CONT INFUSION BY CATHETER (INCLD CATHETER 64449 PLCMNT) INCLDDAILY MGMT FO No MEDICAID Injection, anesthetic agent; other 64450 peripheral nerve or branch No MEDICAID Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) 64455 (eg, Morton's neuroma) No MEDICAID Paravertebral block (PVB) (paraspinous block), thoraic; single injection site (includes imaging guidance, when performed) 64461 No MEDICAID Paravertebral block (PVB) (paraspinous block), thoraic; single injection site (includes imaging guidance, when performed); second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure)

64462 No MEDICAID Paravertebral block (PVB) (paraspinous block), thoraic; single injection site (includes imaging guidance, when performed); continuous infusion by catheter (includes imaging guidance, when performed) 64463 No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); 64479 cervical or thoracic, single level No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64480 No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); 64483 lumbar or sacral, single level No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 64484 No MEDICAID Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed) 64486 No MEDICAID Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when 64487 performed) No MEDICAID

213 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) 64488 No MEDICAID Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when 64489 performed) No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET WITH IMAGE GUIDANCE, CERVICAL OR THORACIC; 64490 SINGLE LEVEL No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET WITH IMAGE GUIDANCE, CERVICAL OR THORACIC; 64491 SECOND LEVEL (LIST S No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET W/IMAGE GUIDANCE, CERVICAL OR THORACIC; THIRD & ANY ADDL LEVEL 64492 No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JOINT WITH IMAGE GUIDANCE, LUMBAR OR 64493 SACRAL; SINGLE LEVEL No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JOINT WITH IMAGE GUIDANCE, LUMBAR OR 64494 SACRAL; SECOND LEVEL (LIST No MEDICAID INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JOINT W/IMAGE GUIDANCE, LUMBAR OR 64495 SACRAL; 3RD & ANY ADDL LEVELS No MEDICAID Injection, anesthetic agent; 64505 sphenopalatine ganglion No MEDICAID Injection, anesthetic agent; carotid sinus 64508 (separate procedure) No MEDICAID Injection, anesthetic agent; stellate 64510 ganglion (cervical sympathetic) No MEDICAID INJECTION, ANESTHETIC AGENT; 64517 SUPERIOR HYPOGASTRIC PLEXUS No MEDICAID Injection, anesthetic agent; lumbar or 64520 thoracic (paravertebral No MEDICAID Injection, anesthetic agent; celiac plexus, 64530 with or without radiologic No MEDICAID Application of surface (transcutaneous) 64550 neurostimulator No MEDICAID PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 64553 CRANIAL NERVE Yes MEDICAID PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; PERIPHERAL NERVE 64555 No MEDICAID PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES 64561 No MEDICAID 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming No MEDICAID

214 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator No MEDICAID 64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator No MEDICAID 64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator No MEDICAID Incision for implantation of neurostimulator electrodes; peripheral 64575 No MEDICAID Incision for implantation of neurostimulator electrodes; neuromuscular 64580 No MEDICAID INCISIONAL IMPLANTATION OF SACRAL NERVE NEUROSTIMULATOR 64581 No MEDICAID REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR 64585 ELECTRODES No MEDICAID INSERT OR REPLACE PERIPHERAL OR GASTRIC NEUROSTIMULATOR 64590 PULSE GENERATOR OR RECEIVER, Yes DIRECT OR INDUCTIVE COUPLING MEDICAID REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE 64595 GENERATOR OR RECEIVER No MEDICAID Destruction by neurolytic agent, trigeminal 64600 nerve; supraorbital, No MEDICAID Destruction by neurolytic agent, trigeminal 64605 nerve; second and third No MEDICAID Destruction by neurolytic agent, trigeminal 64610 nerve; second and third No MEDICAID 64611 Chemodenervation of parotid and submandibular salivary glands, bilateral No MEDICAID Chemodenervation of muscle(s); 64612 muscle(s) innervated by facial nerve No MEDICAID Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, 64615 cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) No MEDICAID 64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) No MEDICAID 64617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed No MEDICAID Destruction by neurolytic agent, 64620 intercostal nerve No MEDICAID Destruction by neurolytic agent; pudendal 64630 nerve No MEDICAID Destruction by neurolytic agent; plantar 64632 common digital nerve No MEDICAID Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64633 No MEDICAID

215 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64634 No MEDICAID Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64635 No MEDICAID Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) 64636 No MEDICAID Destruction by neurolytic agent; other 64640 peripheral nerve or branch No MEDICAID 64642 Chemodenervation of one extremity; 1-4 muscle(s) No MEDICAID 64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) No MEDICAID 64644 Chemodenervation of one extremity; 5 or more muscle(s) No MEDICAID 64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure) No MEDICAID 64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) No MEDICAID 64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) No MEDICAID CHEMODENERVATION OF ECCRINE 64650 GLANDS; BOTH AXILAE No MEDICAID CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY 64653 No MEDICAID Destruction by neurolytic agent, with or 64680 without radiologic monitoring; No MEDICAID DESTRUCTION BY NEUROLYTIC AGENT, W/W/O RADIOLOGIC MONITORING; SUPERIOR 64681 HYPOGASTRIC PLEXUS No MEDICAID Neuroplasty; digital, one or both, same 64702 digit No MEDICAID 64704 Neuroplasty; nerve of hand or foot No MEDICAID Neuroplasty, major peripheral nerve, arm 64708 or leg, open; other than specified No MEDICAID Neuroplasty, major peripheral nerve, arm 64712 or leg, open; sciatic nerve No MEDICAID Neuroplasty, major peripheral nerve, arm 64713 or leg, open; brachial plexus No MEDICAID Neuroplasty, major peripheral nerve, arm 64714 or leg, open; lumbar plexus No MEDICAID Neuroplasty and/or transposition; cranial 64716 nerve (specify) No MEDICAID Neuroplasty and/or transposition; ulnar 64718 nerve at elbow No MEDICAID Neuroplasty and/or transposition; ulnar 64719 nerve at wrist No MEDICAID Neuroplasty and/or transposition; median 64721 nerve at carpal tunnel No MEDICAID Decompression; unspecified nerve(s) 64722 (specify) No MEDICAID 64726 Decompression; plantar digital nerve No MEDICAID

216 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Internal neurolysis, requiring use of 64727 operating microscope (List No MEDICAID Transection or avulsion of; supraorbital 64732 nerve No MEDICAID Transection or avulsion of; infraorbital 64734 nerve No MEDICAID Transection or avulsion of; mental nerve 64736 No MEDICAID Transection or avulsion of; inferior 64738 alveolar nerve by osteotomy No MEDICAID Transection or avulsion of; lingual nerve 64740 No MEDICAID Transection or avulsion of; facial nerve, 64742 differential or complete No MEDICAID Transection or avulsion of; greater 64744 occipital nerve No MEDICAID Transection or avulsion of; phrenic nerve 64746 No MEDICAID Transection or avulsion of; vagus nerves 64755 limited to proximal stomach No MEDICAID Transection or avulsion of; vagus nerve 64760 (vagotomy), abdominal No MEDICAID Transection or avulsion of obturator 64763 nerve, extrapelvic, with or without No MEDICAID Transection or avulsion of obturator 64766 nerve, intrapelvic, with or without No MEDICAID Transection or avulsion of other cranial 64771 nerve, extradural No MEDICAID Transection or avulsion of other spinal 64772 nerve, extradural No MEDICAID Excision of neuroma; cutaneous nerve, 64774 surgically identifiable No MEDICAID Excision of neuroma; digital nerve, one or 64776 both, same digit No MEDICAID Excision of neuroma; digital nerve, each 64778 additional digit (List No MEDICAID Excision of neuroma; hand or foot, except 64782 digital nerve No MEDICAID Excision of neuroma; hand or foot, each 64783 additional nerve, except same No MEDICAID Excision of neuroma; major peripheral 64784 nerve, except sciatic No MEDICAID 64786 Excision of neuroma; sciatic nerve No MEDICAID Implantation of nerve end into bone or 64787 muscle (List separately in No MEDICAID Excision of neurofibroma or 64788 neurolemmoma; cutaneous nerve No MEDICAID Excision of neurofibroma or neurolemmoma; major peripheral nerve 64790 No MEDICAID Excision of neurofibroma or 64792 neurolemmoma; extensive (including No MEDICAID 64795 Biopsy of nerve No MEDICAID 64802 Sympathectomy, cervical No MEDICAID 64804 Sympathectomy, cervicothoracic No MEDICAID SYMPATHECTOMY, 64809 No THORACOLUMBAR MEDICAID 64818 Sympathectomy, lumbar No MEDICAID Sympathectomy; digital arteries, each digit 64820 No MEDICAID 64821 Sympathectomy; radial artery No MEDICAID 64822 Sympathectomy; ulnar artery No MEDICAID Sympathectomy; superficial palmar arch 64823 No MEDICAID Suture of digital nerve, hand or foot; one 64831 nerve No MEDICAID Suture of digital nerve, hand or foot; each 64832 additional digital nerve No MEDICAID Suture of one nerve, hand or foot; 64834 common sensory nerve No MEDICAID

217 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Suture of one nerve, hand or foot; median 64835 motor thenar No MEDICAID Suture of one nerve, hand or foot; ulnar 64836 motor No MEDICAID Suture of each additional nerve, hand or 64837 foot (List separately in No MEDICAID 64840 Suture of posterior tibial nerve No MEDICAID Suture of major peripheral nerve, arm or 64856 leg, except sciatic; including No MEDICAID Suture of major peripheral nerve, arm or 64857 leg, except sciatic; without No MEDICAID 64858 Suture of sciatic nerve No MEDICAID Suture of each additional major peripheral 64859 nerve (List separately in No MEDICAID 64861 Suture of; brachial plexus No MEDICAID 64862 Suture of; lumbar plexus No MEDICAID 64864 Suture of facial nerve; extracranial No MEDICAID Suture of facial nerve; infratemporal, with 64865 or without grafting No MEDICAID Anastomosis; facial-spinal accessory 64866 No MEDICAID 64868 Anastomosis; facial-hypoglossal No MEDICAID Suture of nerve; requiring secondary or 64872 delayed suture (List separately No MEDICAID Suture of nerve; requiring extensive 64874 mobilization, or transposition of No MEDICAID Suture of nerve; requiring shortening of 64876 bone of extremity (List No MEDICAID Nerve graft (includes obtaining graft), 64885 head or neck; up to 4 cm in No MEDICAID Nerve graft (includes obtaining graft), 64886 head or neck; more than 4 cm No MEDICAID Nerve graft (includes obtaining graft), 64890 single strand, hand or foot; up No MEDICAID Nerve graft (includes obtaining graft), 64891 single strand, hand or foot; No MEDICAID Nerve graft (includes obtaining graft), 64892 single strand, arm or leg; up to No MEDICAID Nerve graft (includes obtaining graft), 64893 single strand, arm or leg; more No MEDICAID Nerve graft (includes obtaining graft), 64895 multiple strands (cable), hand No MEDICAID Nerve graft (includes obtaining graft), 64896 multiple strands (cable), hand No MEDICAID Nerve graft (includes obtaining graft), 64897 multiple strands (cable), arm or No MEDICAID Nerve graft (includes obtaining graft), 64898 multiple strands (cable), arm or No MEDICAID Nerve graft, each additional nerve; single 64901 strand (List separately in No MEDICAID Nerve graft, each additional nerve; 64902 multiple strands (cable) (List No MEDICAID 64905 Nerve pedicle transfer; first stage No MEDICAID 64907 Nerve pedicle transfer; second stage No MEDICAID NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT, EACH 64910 NERVE No MEDICAID NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT, EACH NERVE 64911 No MEDICAID Nerve repair; with nerve allograft, each 64912 nerve, first strand (cable) No MEDICAID Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure) 64913 No MEDICAID UNLISTED PROCEDURE, NERVOUS 64999 SYSTEM Yes MEDICAID Evisceration of ocular contents; without 65091 implant No MEDICAID

218 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Evisceration of ocular contents; with 65093 implant No MEDICAID 65101 Enucleation of eye; without implant No MEDICAID Enucleation of eye; with implant, muscles 65103 not attached to implant No MEDICAID Enucleation of eye; with implant, muscles 65105 attached to implant No MEDICAID Exenteration of orbit (does not include 65110 skin graft), removal of orbital No MEDICAID Exenteration of orbit (does not include 65112 skin graft), removal of orbital No MEDICAID Exenteration of orbit (does not include 65114 skin graft), removal of orbital No MEDICAID Modification of ocular implant with 65125 placement or replacement of pegs No MEDICAID Insertion of ocular implant secondary; after evisceration, in scleral 65130 No MEDICAID Insertion of ocular implant secondary; after enucleation, muscles not 65135 No MEDICAID Insertion of ocular implant secondary; after enucleation, muscles 65140 No MEDICAID Reinsertion of ocular implant; with or 65150 without conjunctival graft No MEDICAID Reinsertion of ocular implant; with use of 65155 foreign material for No MEDICAID 65175 Removal of ocular implant No MEDICAID Removal of foreign body, external eye; 65205 conjunctival superficial No MEDICAID Removal of foreign body, external eye; conjunctival embedded (includes 65210 No MEDICAID Removal of foreign body, external eye; 65220 corneal, without slit lamp No MEDICAID Removal of foreign body, external eye; 65222 corneal, with slit lamp No MEDICAID Removal of foreign body, intraocular; from 65235 anterior chamber of eye or No MEDICAID Removal of foreign body, intraocular; from 65260 posterior segment, magnetic No MEDICAID Removal of foreign body, intraocular; from 65265 posterior segment, No MEDICAID Repair of laceration; conjunctiva, with or 65270 without nonperforating No MEDICAID Repair of laceration; conjunctiva, by 65272 mobilization and rearrangement, No MEDICAID Repair of laceration; conjunctiva, by 65273 mobilization and rearrangement, No MEDICAID Repair of laceration; cornea, nonperforating, with or without removal 65275 No MEDICAID Repair of laceration; cornea and/or sclera, 65280 perforating, not involving No MEDICAID Repair of laceration; cornea and/or sclera, 65285 perforating, with reposition No MEDICAID Repair of laceration; application of tissue 65286 glue, wounds of cornea No MEDICAID Repair of wound, extraocular muscle, 65290 tendon and/or Tenon's capsule No MEDICAID Excision of lesion, cornea (keratectomy, lamellar, partial), except 65400 No MEDICAID 65410 Biopsy of cornea No MEDICAID Excision or transposition of pterygium; 65420 without graft No MEDICAID Excision or transposition of pterygium; 65426 with graft No MEDICAID Scraping of cornea, diagnostic, for smear 65430 and/or culture No MEDICAID

219 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Removal of corneal epithelium; with or 65435 without chemocauterization No MEDICAID Removal of corneal epithelium; with 65436 application of chelating agent (eg, No MEDICAID Destruction of lesion of cornea by 65450 cryotherapy, photocoagulation or No MEDICAID Multiple punctures of anterior cornea (eg, 65600 for corneal erosion, tattoo) No MEDICAID Keratoplasty (corneal transplant); anterior 65710 lamellar No * MEDICAID KERATOPLASTY (CORNEAL TRANSPLANT) PENETRATING 65730 (EXCEPT IN APHAKIA) No * MEDICAID KERATOPLASTY (CORNEAL TRANSPLANT) PENETRATING (IN 65750 APHAKIA) No MEDICAID KERATOPLASTY (CORNEAL TRANSPLANT) PENETRATING (IN 65755 PSEUDOPHAKIA) No MEDICAID Keratoplasty (corneal transplant); 65756 endothelial No MEDICAID Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure) 65757 No MEDICAID 65760 KERATOMILEUSIS No MEDICAID 65765 Keratophakia Not Covered MEDICAID 65767 EPIKERATOPLASTY No MEDICAID 65770 KERATOPROSTHESIS No MEDICAID 65771 RADIAL KERATOTOMY Not Covered MEDICAID CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY 65772 INDUCED ASTIGMATISM No MEDICAID CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM 65775 No MEDICAID 65778 Placement of amniotic membrane on the ocular surface for wound healing; self- retaining No ExGEN MEDICAID 65779 Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured No ExGEN MEDICAID Ocular surface reconstruction; amniotic membrane transplantation, multiple layers 65780 No ExGEN MEDICAID OCULAR SURFACE RECONSTRUCTION; LIMBAL STEM CELL ALLOGRAFT (EG, CADAVERIC 65781 OR LIVING DONOR) No ExGEN MEDICAID OCULAR SURFACE RECONSTRUCTION; LIMBAL CONJUNCTIVAL AUTOGRAFT 65782 (INCLUDES OBTAINING GRAFT) No ExGEN MEDICAID Implantation of intrastromal corneal ring 65785 segments No MEDICAID Paracentesis of anterior chamber of eye 65800 (separate procedure); with No MEDICAID Paracentesis of anterior chamber of eye 65810 (separate procedure); with No MEDICAID Paracentesis of anterior chamber of eye 65815 (separate procedure); with No MEDICAID 65820 Goniotomy No MEDICAID 65850 Incision of eye No MEDICAID Trabeculoplasty by laser surgery, one or 65855 more sessions (defined No MEDICAID Severing adhesions of anterior segment, 65860 laser technique (separate No MEDICAID Severing adhesions of anterior segment 65865 of eye, incisional technique No MEDICAID

220 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Severing adhesions of anterior segment 65870 of eye, incisional technique No MEDICAID Severing adhesions of anterior segment 65875 of eye, incisional technique No MEDICAID Severing adhesions of anterior segment 65880 of eye, incisional technique No MEDICAID Removal of epithelial downgrowth, 65900 anterior chamber of eye No MEDICAID Removal of implanted material, anterior 65920 segment of eye No MEDICAID Removal of blood clot, anterior segment 65930 of eye No MEDICAID Injection, anterior chamber of eye 66020 (separate procedure); air or liquid No MEDICAID Injection, anterior chamber of eye 66030 (separate procedure); medication No MEDICAID 66130 Excision of lesion, sclera No MEDICAID Fistulization of sclera for glaucoma; 66150 trephination with iridectomy No MEDICAID Fistulization of sclera for glaucoma; 66155 thermocauterization with No MEDICAID Fistulization of sclera for glaucoma; 66160 sclerectomy with punch or No MEDICAID Fistulization of sclera for glaucoma; 66170 trabeculectomy ab externo in No MEDICAID Fistulization of sclera for glaucoma; 66172 trabeculectomy ab externo with No MEDICAID 66174 Transluminal dilation of aqueous outflow canal; without retention of device or stent No MEDICAID 66175 Transluminal dilation of aqueous outflow canal; with retention of device or stent No MEDICAID Aqueous shunt to extraocular equatorial plate reservoir, external approach; without 66179 graft No MEDICAID Aqueous shunt to extraocular reservoir 66180 (eg, Molteno, Schocket, No MEDICAID 66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach No MEDICAID Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft 66184 No MEDICAID Revision of aqueous shunt to extraocular 66185 reservoir No MEDICAID Repair of scleral staphyloma; without graft 66220 No MEDICAID Repair of scleral staphyloma; with graft 66225 No MEDICAID Revision or repair of operative wound of 66250 anterior segment, any type, No MEDICAID Iridotomy by stab incision (separate 66500 procedure); except transfixion No MEDICAID Iridotomy by stab incision (separate 66505 procedure); with transfixion as for No MEDICAID Iridectomy, with corneoscleral or corneal 66600 section; for removal of lesion No MEDICAID Iridectomy, with corneoscleral or corneal 66605 section; with cyclectomy No MEDICAID Iridectomy, with corneoscleral or corneal 66625 section; peripheral for No MEDICAID Iridectomy, with corneoscleral or corneal 66630 section; sector for glaucoma No MEDICAID Iridectomy, with corneoscleral or corneal 66635 section; optical (separate No MEDICAID Repair of iris, ciliary body (as for 66680 iridodialysis) No MEDICAID Suture of iris, ciliary body (separate 66682 procedure) with retrieval of No MEDICAID

221 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CILIARY BODY DESTRUCTION; 66700 DIATHERMY No MEDICAID CILIARY BODY DESTRUCTION; 66710 CYCLOPHOTOCOAGULATION No MEDICAID Ciliary body destruction; 66711 cyclophotocoagulation, endoscopic No MEDICAID CILIARY BODY DESTRUCTION; 66720 CRYOTHERAPY No MEDICAID 66740 Ciliary body destruction; cyclodialysis No MEDICAID Iridotomy/iridectomy by laser surgery (eg, 66761 for glaucoma) (per session) No MEDICAID Iridoplasty by photocoagulation (one or 66762 more sessions) (eg, for No MEDICAID Destruction of cyst or lesion iris or ciliary 66770 body (nonexcisional No MEDICAID Discission of secondary membranous cataract (opacified posterior lens 66820 No MEDICAID Discission of secondary membranous cataract (opacified posterior lens 66821 No MEDICAID Repositioning of intraocular lens 66825 prosthesis, requiring an incision No MEDICAID Removal of secondary membranous 66830 cataract (opacified posterior lens No MEDICAID Removal of lens material; aspiration 66840 technique, one or more stages No MEDICAID Removal of lens material; phacofragmentation technique 66850 (mechanical or No * MEDICAID Removal of lens material; pars plana 66852 approach, with or without No MEDICAID Removal of lens material; intracapsular 66920 No MEDICAID Removal of lens material; intracapsular, 66930 for dislocated lens No MEDICAID Removal of lens material; extracapsular (other than 66840, 66850, 66852) 66940 No MEDICAID Extracapsular cataract removal with 66982 insertion of intraocular lens No MEDICAID Intracapsular cataract extraction with 66983 insertion of intraocular lens No MEDICAID Extracapsular cataract removal with 66984 insertion of intraocular lens No MEDICAID Insertion of intraocular lens prosthesis 66985 (secondary implant), not No MEDICAID 66986 Exchange of intraocular lens No MEDICAID Use of ophthalmic endoscope (List 66990 separately in addition to code for No MEDICAID UNLISTED PROCEDURE, ANTERIOR 66999 SEGMENT OF EYE Yes MEDICAID Removal of vitreous, anterior approach (open sky technique or limbal 67005 No MEDICAID Removal of vitreous, anterior approach (open sky technique or limbal 67010 No MEDICAID Aspiration or release of vitreous, 67015 subretinal or choroidal fluid, pars No MEDICAID Injection of vitreous substitute, pars plana 67025 or limbal approach, No MEDICAID Implantation of intravitreal drug delivery 67027 system (eg, ganciclovir No MEDICAID Intravitreal injection of a pharmacologic agent (separate procedure) 67028 No MEDICAID Discission of vitreous strands (without removal), pars plana approach 67030 No MEDICAID

222 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Severing of vitreous strands, vitreous face 67031 adhesions, sheets, membranes No MEDICAID Vitrectomy, mechanical, pars plana 67036 approach; No MEDICAID Vitrectomy, mechanical, pars plana 67039 approach; with focal endolaser No MEDICAID Vitrectomy, mechanical, pars plana 67040 approach; with endolaser panretinal No MEDICAID VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER) 67041 No MEDICAID VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR TUBE HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR 67042 SILICONE OIL) No MEDICAID VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE OF RETINA (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER 67043 PHOTOCOAGULATION No MEDICAID Repair of retinal detachment, one or more 67101 sessions; cryotherapy or No MEDICAID Repair of retinal detachment, one or more 67105 sessions; photocoagulation, No MEDICAID Repair of retinal detachment; scleral 67107 buckling (such as lamellar scleral No MEDICAID Repair of retinal detachment; with 67108 vitrectomy, any method, with or No MEDICAID Repair of retinal detachment; by injection 67110 of air or other gas (eg, No MEDICAID REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, MAY INCLUDE AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AN/OR REMOVAL OF LENS 67113 No MEDICAID Release of encircling material (posterior 67115 segment) No MEDICAID Removal of implanted material, posterior 67120 segment; extraocular No MEDICAID Removal of implanted material, posterior 67121 segment; intraocular No MEDICAID Prophylaxis of retinal detachment (eg, 67141 retinal break, lattice No MEDICAID Prophylaxis of retinal detachment (eg, 67145 retinal break, lattice No MEDICAID Destruction of localized lesion of retina 67208 (eg, macular edema, tumors), No MEDICAID Destruction of localized lesion of retina 67210 (eg, macular edema, tumors), No MEDICAID

223 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Destruction of localized lesion of retina 67218 (eg, macular edema, tumors), No MEDICAID Destruction of localized lesion of choroid 67220 (eg, choroidal No MEDICAID PHOTODYNAMIC THERAPY (INCLUDES INTRAVENOUS INFUSION) 67221 No MEDICAID OCULAR PHOTODYNAMIC THERAPY 67225 No MEDICAID Destruction of extensive or progressive 67227 retinopathy (eg, diabetic No MEDICAID Destruction of extensive or progressive 67228 retinopathy (eg, diabetic No MEDICAID TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE OR MORE SESSIONS; PRETERM INFANT (LESS THAN 37 WEEKS GESTATION AT BIRTH), PERFORMED FORM BIRTH UP TO 1 YEAR OF AGE (EG, RETINOPATHY OF PREMATURITY), PHOTOCOAGULATION OR 67229 CRYOTHERAPY No MEDICAID Scleral reinforcement (separate 67250 procedure); without graft No MEDICAID Scleral reinforcement (separate 67255 procedure); with graft No MEDICAID UNLISTED PROCEDURE, POSTERIOR 67299 SEGMENT Yes MEDICAID Strabismus surgery, recession or 67311 resection procedure; one horizontal No MEDICAID Strabismus surgery, recession or 67312 resection procedure; two horizontal No MEDICAID Strabismus surgery, recession or 67314 resection procedure; one vertical No MEDICAID Strabismus surgery, recession or 67316 resection procedure; two or more No MEDICAID Strabismus surgery, any procedure, 67318 superior oblique muscle No MEDICAID Transposition procedure (eg, for paretic 67320 extraocular muscle), any No MEDICAID Strabismus surgery on patient with 67331 previous eye surgery or injury that No MEDICAID Strabismus surgery on patient with 67332 scarring of extraocular muscles (eg, No MEDICAID Strabismus surgery by posterior fixation 67334 suture technique, with or No MEDICAID Placement of adjustable suture(s) during 67335 strabismus surgery, including No MEDICAID Strabismus surgery involving exploration 67340 and/or repair of detached No MEDICAID Release of extensive scar tissue without 67343 detaching extraocular muscle No MEDICAID CHEMODENERVATION OF 67345 EXTRAOCULAR MUSCLE No MEDICAID BIOPSY OF EXTRAOCULAR MUSCLE 67346 No MEDICAID UNLISTED PROCEDURE, OCULAR 67399 MUSCLE Yes MEDICAID Orbitotomy without bone flap (frontal or 67400 transconjunctival approach); No MEDICAID Orbitotomy without bone flap (frontal or 67405 transconjunctival approach); No MEDICAID Orbitotomy without bone flap (frontal or 67412 transconjunctival approach); No MEDICAID Orbitotomy without bone flap (frontal or 67413 transconjunctival approach); No MEDICAID Orbitotomy without bone flap (frontal or 67414 transconjunctival approach); No MEDICAID Fine needle aspiration of orbital contents 67415 No MEDICAID

224 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Orbitotomy with bone flap or window, 67420 lateral approach (eg, Kroenlein); No MEDICAID Orbitotomy with bone flap or window, 67430 lateral approach (eg, Kroenlein); No MEDICAID Orbitotomy with bone flap or window, 67440 lateral approach (eg, Kroenlein); No MEDICAID Orbitotomy with bone flap or window, 67445 lateral approach (eg, Kroenlein); No MEDICAID Orbitotomy with bone flap or window, 67450 lateral approach (eg, Kroenlein); No MEDICAID Retrobulbar injection; medication (separate procedure, does not include 67500 No MEDICAID RETROBULBAR INJECTION ALCOHOL 67505 No MEDICAID Injection of medication or other substance 67515 into Tenon's capsule No MEDICAID 67550 ORBITAL IMPLANT; INSERTION No MEDICAID ORBITAL IMPLANT; REMOVAL OR 67560 REVISION No MEDICAID Optic nerve decompression (eg, incision 67570 or fenestration of optic nerve No MEDICAID 67599 UNLISTED PROCEDURE, ORBIT Yes MEDICAID Blepharotomy, drainage of abscess, 67700 eyelid No MEDICAID 67710 Severing of tarsorrhaphy No MEDICAID 67715 Canthotomy (separate procedure) No MEDICAID 67800 Excision of chalazion; single No MEDICAID Excision of chalazion; multiple, same lid 67801 No MEDICAID Excision of chalazion; multiple, different 67805 lids No MEDICAID Excision of chalazion; under general 67808 anesthesia and/or requiring No MEDICAID 67810 Biopsy of eyelid No MEDICAID Correction of trichiasis; epilation, by 67820 forceps only No MEDICAID Correction of trichiasis; epilation by other 67825 than forceps (eg, by No MEDICAID Correction of trichiasis; incision of lid 67830 margin No MEDICAID Correction of trichiasis; incision of lid 67835 margin, with free mucous No MEDICAID Excision of lesion of eyelid (except 67840 chalazion) without closure or with No MEDICAID Destruction of lesion of lid margin (up to 1 67850 cm) No MEDICAID Temporary closure of eyelids by suture 67875 (eg, Frost suture) No MEDICAID CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR 67880 CANTHORRHAPHY; No MEDICAID Construction of intermarginal adhesions, 67882 median tarsorrhaphy, or No MEDICAID REPAIR OF BROW PTOSIS 67900 (SUPRACILIARY, MID-FOREHEAD OR Yes CORONAL APPROACH) MEDICAID REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE 67901 Yes WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA) MEDICAID REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE 67902 WITH AUTOLOGOUS FASCIAL SLING Yes (INCLUDES OBTAINING FASCIA) MEDICAID REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR RESECTION OR 67903 Yes ADVANCEMENT, INTERNAL APPROACH MEDICAID

225 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR RESECTION OR 67904 Yes ADVANCEMENT, EXTERNAL APPROACH MEDICAID REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE 67906 Yes WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA) MEDICAID REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S 67908 Yes MUSCLE- LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE) MEDICAID REDUCTION OF OVERCORRECTION 67909 Yes OF PTOSIS MEDICAID 67911 CORRECTION OF LID RETRACTION Yes MEDICAID CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER 67912 Yes EYELID LID LOAD (EG, GOLD WEIGHT) MEDICAID 67914 Repair of ectropion; suture No MEDICAID Repair of ectropion; thermocauterization 67915 No MEDICAID 67916 EXCISION TARSAL WEDGE No MEDICAID EXTENSIVE (EG, TARSAL STRIP 67917 OPERATIONS) No MEDICAID 67921 Repair of entropion; suture No MEDICAID Repair of entropion; thermocauterization 67922 No MEDICAID REPAIR OF ENTROPION; BLEPHAROPLASTY, EXCISION 67923 TARSAL WEDGE No MEDICAID REPAIR OF ENTROPION; BLEPHAROPLASTY, EXTENSIVE (EG, 67924 WHEELER OPERATION) No MEDICAID Suture of recent wound, eyelid, involving 67930 lid margin, tarsus, and/or No MEDICAID Suture of recent wound, eyelid, involving 67935 lid margin, tarsus, and/or No MEDICAID Removal of embedded foreign body, 67938 eyelid No MEDICAID Canthoplasty (reconstruction of canthus) 67950 Yes MEDICAID Excision and repair of eyelid, involving lid 67961 margin, tarsus, No MEDICAID Excision and repair of eyelid, involving lid 67966 margin, tarsus, No MEDICAID Reconstruction of eyelid, full thickness by 67971 transfer of No MEDICAID Reconstruction of eyelid, full thickness by 67973 transfer of No MEDICAID Reconstruction of eyelid, full thickness by 67974 transfer of No MEDICAID Reconstruction of eyelid, full thickness by 67975 transfer of No MEDICAID 67999 UNLISTED PROCEDURE, EYELIDS Yes MEDICAID Incision of conjunctiva, drainage of cyst 68020 No MEDICAID Expression of conjunctival follicles (eg, for 68040 trachoma) No MEDICAID 68100 Biopsy of conjunctiva No MEDICAID Excision of lesion, conjunctiva; up to 1 cm 68110 No MEDICAID Excision of lesion, conjunctiva; over 1 cm 68115 No MEDICAID Excision of lesion, conjunctiva; with 68130 adjacent sclera No MEDICAID 68135 Destruction of lesion, conjunctiva No MEDICAID 68200 Subconjunctival injection No MEDICAID Conjunctivoplasty; with conjunctival graft 68320 or extensive rearrangement No MEDICAID

226 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Conjunctivoplasty; with buccal mucous 68325 membrane graft (includes No MEDICAID Conjunctivoplasty, reconstruction cul-de- 68326 sac; with conjunctival graft or No MEDICAID Conjunctivoplasty, reconstruction cul-de- 68328 sac; with buccal mucous No MEDICAID Repair of symblepharon; 68330 conjunctivoplasty, without graft No MEDICAID Repair of symblepharon; with free graft 68335 conjunctiva or buccal mucous No MEDICAID Repair of symblepharon; division of 68340 symblepharon, with or without No MEDICAID Conjunctival flap; bridge or partial 68360 (separate procedure) No MEDICAID Conjunctival flap; total (such as 68362 Gunderson thin flap or purse string No MEDICAID HARVEST CONJUNCTIVAL 68371 Yes ALLOGRAFT, LIVING DONOR MEDICAID UNLISTED PROCEDURE, 68399 CONJUNCTIVA Yes MEDICAID 68400 Incision, drainage of lacrimal gland No MEDICAID Incision, drainage of lacrimal sac 68420 (dacryocystotomy or No MEDICAID 68440 Snip incision of lacrimal punctum No MEDICAID Excision of lacrimal gland (dacryoadenectomy), except for tumor; 68500 total No MEDICAID Excision of lacrimal gland (dacryoadenectomy), except for tumor; 68505 partial No MEDICAID 68510 Biopsy of lacrimal gland No MEDICAID Excision of lacrimal sac 68520 (dacryocystectomy) No MEDICAID 68525 Biopsy of lacrimal sac No MEDICAID Removal of foreign body or dacryolith, 68530 lacrimal passages No MEDICAID Excision of lacrimal gland tumor; frontal 68540 approach No MEDICAID Excision of lacrimal gland tumor; involving 68550 osteotomy No MEDICAID 68700 Plastic repair of canaliculi No MEDICAID Correction of everted punctum, cautery 68705 No MEDICAID Dacryocystorhinostomy (fistulization of 68720 lacrimal sac to nasal cavity) No MEDICAID Conjunctivorhinostomy (fistulization of 68745 conjunctiva to nasal cavity); No MEDICAID Conjunctivorhinostomy (fistulization of 68750 conjunctiva to nasal cavity); No MEDICAID Closure of the lacrimal punctum; by 68760 thermocauterization, ligation, or No MEDICAID Closure of the lacrimal punctum; by plug, 68761 each No MEDICAID Closure of lacrimal fistula (separate 68770 procedure) No MEDICAID Dilation of lacrimal punctum, with or 68801 without irrigation No MEDICAID Probing of nasolacrimal duct, with or 68810 without irrigation; No MEDICAID Probing of nasolacrimal duct, with or 68811 without irrigation; requiring No MEDICAID Probing of nasolacrimal duct, with or 68815 without irrigation; with insertion No MEDICAID PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON 68816 CATHETER DILATION No MEDICAID Probing of lacrimal canaliculi, with or 68840 without irrigation No MEDICAID Injection of contrast medium for 68850 dacryocystography No MEDICAID

227 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNLISTED PROCEDURE, LACRIMAL 68899 SYSTEM Yes MEDICAID Drainage external ear, abscess or 69000 hematoma; simple No MEDICAID Drainage external ear, abscess or 69005 hematoma; complicated No MEDICAID Drainage external auditory canal, abscess 69020 No MEDICAID 69090 EAR PIERCING Not Covered MEDICAID 69100 Biopsy external ear No MEDICAID 69105 Biopsy external auditory canal No MEDICAID Excision external ear; partial, simple 69110 repair No MEDICAID Excision external ear; complete 69120 amputation No MEDICAID Excision exostosis(es), external auditory 69140 canal No MEDICAID Excision soft tissue lesion, external 69145 auditory canal No MEDICAID Radical excision external auditory canal 69150 lesion; without neck dissection No MEDICAID Radical excision external auditory canal 69155 lesion; with neck dissection No MEDICAID Removal foreign body from external 69200 auditory canal; without general No MEDICAID Removal foreign body from external 69205 auditory canal; with general No MEDICAID Removal impacted cerumen using 69209 irrigation/lavage, unilateral No MEDICAID Removal impacted cerumen (separate procedure), one or both ears 69210 No MEDICAID Debridement, mastoidectomy cavity, 69220 simple (eg, routine cleaning) No MEDICAID Debridement, mastoidectomy cavity, 69222 complex (eg, with anesthesia or No MEDICAID OTOPLASTY, PROTRUDING EAR, 69300 WITH OR WITHOUT SIZE REDUCTION Yes MEDICAID Reconstruction of external auditory canal 69310 (meatoplasty) (eg, for No MEDICAID Reconstruction external auditory canal for 69320 congenital atresia, single No MEDICAID UNLISTED PROCEDURE, EXTERNAL 69399 EAR Yes MEDICAID Myringotomy including aspiration and/or 69420 eustachian tube inflation No MEDICAID Myringotomy including aspiration and/or 69421 eustachian tube inflation No MEDICAID Ventilating tube removal requiring general 69424 anesthesia No MEDICAID Tympanostomy (requiring insertion of 69433 ventilating tube), local or topical No MEDICAID Tympanostomy (requiring insertion of 69436 ventilating tube), general No MEDICAID Middle ear exploration through 69440 postauricular or ear canal incision No MEDICAID 69450 Tympanolysis, transcanal No MEDICAID Transmastoid antrotomy (simple 69501 mastoidectomy) No MEDICAID 69502 Mastoidectomy; complete No MEDICAID 69505 Mastoidectomy; modified radical No MEDICAID 69511 Mastoidectomy; radical No MEDICAID Petrous apicectomy including radical 69530 mastoidectomy No MEDICAID Resection temporal bone, external 69535 approach No MEDICAID 69540 Excision aural polyp No MEDICAID Excision aural glomus tumor; transcanal 69550 No MEDICAID

228 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Excision aural glomus tumor; 69552 transmastoid No MEDICAID Excision aural glomus tumor; extended 69554 (extratemporal) No MEDICAID Revision mastoidectomy; resulting in 69601 complete mastoidectomy No MEDICAID Revision mastoidectomy; resulting in 69602 modified radical mastoidectomy No MEDICAID Revision mastoidectomy; resulting in 69603 radical mastoidectomy No MEDICAID Revision mastoidectomy; resulting in 69604 tympanoplasty No MEDICAID Revision mastoidectomy; with apicectomy 69605 No MEDICAID Tympanic membrane repair, with or 69610 without site preparation of No MEDICAID Myringoplasty (surgery confined to 69620 drumhead and donor area) No MEDICAID Tympanoplasty without mastoidectomy (including canalplasty, atticotomy 69631 No MEDICAID Tympanoplasty without mastoidectomy (including canalplasty, atticotomy 69632 No MEDICAID Tympanoplasty without mastoidectomy (including canalplasty, atticotomy 69633 No MEDICAID Tympanoplasty with antrotomy or 69635 mastoidotomy (including canalplasty, No MEDICAID Tympanoplasty with antrotomy or 69636 mastoidotomy (including canalplasty, No MEDICAID Tympanoplasty with antrotomy or 69637 mastoidotomy (including canalplasty, No MEDICAID Tympanoplasty with mastoidectomy 69641 (including canalplasty, middle ear No MEDICAID Tympanoplasty with mastoidectomy 69642 (including canalplasty, middle ear No MEDICAID Tympanoplasty with mastoidectomy 69643 (including canalplasty, middle ear No MEDICAID Tympanoplasty with mastoidectomy 69644 (including canalplasty, middle ear No MEDICAID Tympanoplasty with mastoidectomy 69645 (including canalplasty, middle ear No MEDICAID Tympanoplasty with mastoidectomy 69646 (including canalplasty, middle ear No MEDICAID 69650 Stapes mobilization No MEDICAID Stapedectomy or stapedotomy with 69660 reestablishment of ossicular No MEDICAID Stapedectomy or stapedotomy with 69661 reestablishment of ossicular No MEDICAID Revision of stapedectomy or stapedotomy 69662 No MEDICAID 69666 Repair oval window fistula No MEDICAID 69667 Repair round window fistula No MEDICAID Mastoid obliteration (separate procedure) 69670 No MEDICAID 69676 Tympanic neurectomy No MEDICAID Closure postauricular fistula, mastoid 69700 (separate procedure) No MEDICAID Implantation or replacement of 69710 electromagnetic bone conduction hearing Yes MEDICAID Removal or repair of electromagnetic 69711 bone conduction hearing device in No MEDICAID Implantation, osseointegrated implant, temporal bone, with percutaneous 69714 No MEDICAID Implantation, osseointegrated implant, temporal bone, with percutaneous 69715 No MEDICAID

229 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Replacement (including removal of 69717 existing device), osseointegrated No MEDICAID Replacement (including removal of 69718 existing device), osseointegrated No MEDICAID Decompression facial nerve, 69720 intratemporal; lateral to geniculate No MEDICAID Decompression facial nerve, 69725 intratemporal; including medial to No MEDICAID Suture facial nerve, intratemporal, with or 69740 without graft or No MEDICAID Suture facial nerve, intratemporal, with or 69745 without graft or No MEDICAID UNLISTED PROCEDURE, MIDDLE EAR 69799 Yes MEDICAID Labyrinthotomy, with perfusion of 69801 vestibuloactive drug(s); transcanal No MEDICAID Endolymphatic sac operation; without 69805 shunt No MEDICAID Endolymphatic sac operation; with shunt 69806 No MEDICAID 69905 Labyrinthectomy; transcanal No MEDICAID 69910 Labyrinthectomy; with mastoidectomy No MEDICAID Vestibular nerve section, translabyrinthine 69915 approach No MEDICAID COCHLEAR DEVICE IMPLANTATION, 69930 WITH OR WITHOUT MASTOIDECTOMY Yes MEDICAID UNLISTED PROCEDURE, INNER EAR 69949 Yes MEDICAID Vestibular nerve section, transcranial 69950 approach No MEDICAID Total facial nerve decompression and/or 69955 repair (may include graft) No MEDICAID Decompression internal auditory canal 69960 No MEDICAID 69970 Removal of tumor, temporal bone No MEDICAID UNLISTED PROCEDURE, TEMPORAL BONE, MIDDLE FOSSA APPROACH 69979 Yes MEDICAID Microsurgical techniques, requiring use of 69990 operating microscope (List No MEDICAID Myelography, posterior fossa, radiological 70010 supervision and No MEDICAID Cisternography, positive contrast, 70015 radiological supervision and No MEDICAID Radiologic examination, eye, for detection 70030 of foreign body No MEDICAID Radiologic examination, mandible; partial, 70100 less than four views No MEDICAID Radiologic examination, mandible; 70110 complete, minimum of four views No MEDICAID Radiologic examination, mastoids; less 70120 than three views per side No MEDICAID Radiologic examination, mastoids; complete, minimum of three views per 70130 No MEDICAID Radiologic examination, internal auditory 70134 meati, complete No MEDICAID Radiologic examination, facial bones; less 70140 than three views No MEDICAID Radiologic examination, facial bones; complete, minimum of three views 70150 No MEDICAID Radiologic examination, nasal bones, complete, minimum of three views 70160 No MEDICAID Dacryocystography, nasolacrimal duct, 70170 radiological supervision and No MEDICAID Radiologic examination; optic foramina 70190 No MEDICAID

230 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiologic examination; orbits, complete, 70200 minimum of four views No MEDICAID Radiologic examination, sinuses, 70210 paranasal, less than three views No MEDICAID Radiologic examination, sinuses, paranasal, complete, minimum of three 70220 No MEDICAID 70240 Radiologic examination, sella turcica No MEDICAID Radiologic examination, skull; less than 70250 four views No MEDICAID Radiologic examination, skull; complete, 70260 minimum of four views No MEDICAID Radiologic examination, teeth; single view 70300 No MEDICAID Radiologic examination, teeth; partial 70310 examination, less than full mouth No MEDICAID Radiologic examination, teeth; complete, 70320 full mouth No MEDICAID Radiologic examination, temporomandibular joint, open and closed 70328 No MEDICAID Radiologic examination, temporomandibular joint, open and closed 70330 No MEDICAID TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL 70332 No SUPERVISION AND INTERPRETATION MEDICAID MAGNETIC RESONANCE (EG, 70336 PROTON) IMAGING, No TEMPOROMANDIBULAR JOINT MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, 70336 TEMPOROMANDIBULAR JOINT Yes MEDICAID MAGNETIC RESONANCE (EG, 70336 PROTON) IMAGING, No TEMPOROMANDIBULAR JOINT MEDICAID 70350 CEPHALOGRAM, ORTHODONTIC No MEDICAID 70355 ORTHOPANTOGRAM No MEDICAID Radiologic examination; neck, soft tissue 70360 No MEDICAID Radiologic examination; pharynx or 70370 larynx, including fluoroscopy and/or No MEDICAID COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE 70371 OR VIDEO RECORDING No MEDICAID Radiologic examination, salivary gland for 70380 calculus No MEDICAID Sialography, radiological supervision and 70390 interpretation No MEDICAID COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST 70450 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; 70460 WITH CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 70470 SECTIONS No MEDICAID COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; 70480 WITHOUT CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH 70481 CONTRAST MATERIAL(S) No MEDICAID

231 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT 70482 CONTRAST MATERIAL, FOLLOWE No MEDICAID COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT 70486 CONTRAST MATERIAL No * MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) 70487 No * MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTION 70488 No * MEDICAID COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST 70490 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) 70491 No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 70492 SECTIONS No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGGRAPHY, HEAD, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS, INCL 70496 No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS, INCLU 70498 No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, 70540 AND NECK No MEDICAID 70542 MRI ORBIT/FACE/NECK W/DYE No MEDICAID 70543 MRI ORBT/FAC/NCK W/O&W DYE No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT 70544 CONTRAST MATERIAL No MEDICAID 70545 MR ANGIOGRAPHY HEAD W/DYE No MEDICAID MR ANGIOGRAPH HEAD W/O&W DYE 70546 No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT 70547 CONTRAST MATERIAL(S) No MEDICAID 70548 MR ANGIOGRAPHY NECK W/DYE No MEDICAID MR ANGIOGRAPH NECK W/O&W DYE 70549 No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT 70551 CONTRAST MATERIAL No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH 70552 CONTRAST MATERIAL(S) No MEDICAID

232 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) 70553 No MEDICAID MAGNETIC RESONANCE IMAGEING, BRAIN, FUNCTIONAL MRI; INCL TEST SELECTION/ADMINISTRATION OF MOVEMENT/VISUAL STIM, NOT REQ 70554 PHYS ADMIN No MEDICAID MAGNETIC RESONANCE IMAGEING, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMIN OF ENTIRE 70555 NEUROFUNCTIONAL TESTING No MEDICAID MAGNETIC RESONANCE (EG PROTON) IMAGING, BRAIN (INCLD BRAN STEM & SKULL BASE) DURNG OPEN INTRACRANIAL PROC (EG ACCESS FOR RESIDUAL T 70557 No MEDICAID MAGNETIC RESONANCE (EG PROTON) IMAGING, BRAIN (INCLDG 70558 BRAIN STEM & SKULL BASE) DRNG Yes OPEN INTRACRANIAL PROC (EG TO ASSESS FOR RESID MEDICAID MAGNETIC RESONANCE (EG PROTON) IMAGING, BRAIN (INCLDNG 70559 BRAIN STEM & SKULL BASE) DRNG Yes OPEN INTRACRANIAL PROC (EG TO ASSESS FOR RESI MEDICAID Radiologic examination, chest; single view 71045 No MEDICAID Radiologic examination, chest; 2 views 71046 No MEDICAID Radiologic examination, chest; 3 views 71047 No MEDICAID Radiologic examination, chest; 4 or more 71048 views No MEDICAID Radiologic examination, ribs, unilateral; 71100 two views No MEDICAID Radiologic examination, ribs, unilateral; 71101 including posteroanterior No MEDICAID Radiologic examination, ribs, bilateral; 71110 three views No MEDICAID Radiologic examination, ribs, bilateral; 71111 including posteroanterior No MEDICAID Radiologic examination; sternum, 71120 minimum of two views No MEDICAID Radiologic examination; sternoclavicular joint or joints, minimum of 71130 No MEDICAID COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL 71250 No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH 71260 CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND 71270 FURTHER SECTIONS No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST, (NONCORON) W/O CONTRAST MATERIAL(S), THEN W/ CONTRAST & FURTHER SEQUENCES (RVSD 010107) 71275 No MEDICAID

233 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND 71550 MEDIASTINAL LYMPHADENOPATHY) No MEDICAID 71551 MRI CHEST W/DYE No MEDICAID 71552 MRI CHEST W/O&W DYE No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) 71555 No MEDICAID Radiologic examination, spine, single 72020 Yes view, specify level MEDICAID Radiologic examination, spine, cervical; 72040 Yes two or three views MEDICAID Radiologic examination, spine, cervical; 72050 Yes minimum of four views MEDICAID Radiologic examination, spine, cervical; 72052 complete, including oblique and Yes MEDICAID Radiologic examination, spine; thoracic, 72070 Yes two views MEDICAID Radiologic examination, spine; thoracic, 72072 Yes three views MEDICAID Radiologic examination, spine; thoracic, 72074 Yes minimum of four views MEDICAID Radiologic examination, spine; 72080 Yes thoracolumbar, two views MEDICAID Radiologic examination, spine, entire thoraic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view 72081 No MEDICAID Radiologic examination, spine, entire thoraic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views 72082 No MEDICAID Radiologic examination, spine, entire thoraic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views 72083 No MEDICAID Radiologic examination, spine, entire thoraic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 72084 views No MEDICAID Radiologic examination, spine, 72100 Yes lumbosacral; two or three views MEDICAID Radiologic examination, spine, 72110 Yes lumbosacral; minimum of four views MEDICAID Radiologic examination, spine, 72114 lumbosacral; complete, including bending Yes MEDICAID Radiologic examination, spine, 72120 Yes lumbosacral, bending views only, MEDICAID COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT 72125 CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; 72126 WITH CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 72127 SECTIONS No MEDICAID

234 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT 72128 CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; 72129 WITH CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 72130 SECTIONS No MEDICAID COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST 72131 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITH 72132 CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 72133 SECTIONS No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; 72141 WITHOUT CONTRAST MATERIAL No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH 72142 CONTRAST MATERIAL(S) No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; 72146 WITHOUT CONTRAST MATERIAL No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH 72147 CONTRAST MATERIAL(S) No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT 72148 CONTRAST MATERIAL No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH 72149 CONTRAST MATERIAL(S) No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72156 CONTRAST MATERIAL(S) AN No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72157 CONTRAST MATERIAL(S) AN No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72158 CONTRAST MATERIAL(S) AN No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT 72159 CONTRAST MATERIAL(S) No MEDICAID Radiologic examination, pelvis; one or two 72170 Yes views MEDICAID Radiologic examination, pelvis; complete, 72190 Yes minimum of three views MEDICAID

235 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS, INC 72191 No MEDICAID COMPUTED TOMOGRAPHY, PELVIS; 72192 WITHOUT CONTRAST MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH 72193 CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND 72194 FURTHER SECTIONS No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 72195 CONTRAST MATERIAL(S) No MEDICAID MAGNETIC RESONANCE (EG, 72196 PROTON) IMAGING, PELVIS No MEDICAID 72197 MRI PELVIS W/O & W DYE No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR 72198 WITHOUT CONTRAST MATERIAL(S) No MEDICAID Radiologic examination, sacroiliac joints; 72200 Yes less than three views MEDICAID Radiologic examination, sacroiliac joints; 72202 Yes three or more views MEDICAID Radiologic examination, sacrum and 72220 Yes coccyx, minimum of two views MEDICAID Myelography, cervical, radiological 72240 supervision and interpretation No MEDICAID Myelography, thoracic, radiological 72255 supervision and interpretation No MEDICAID Myelography, lumbosacral, radiological supervision and interpretation 72265 No MEDICAID MYELOGRAPHY, TWO OR MORE REGIONS (EG, LUMBAR/THORACIC,CERV/THOR, LUMB/CERV, LUMB/THOR/ CERV) RADIOL SUPERVISION & 72270 INTERPRETION No MEDICAID Epidurography, radiological supervision 72275 and interpretation No MEDICAID Diskography, cervical or thoracic, 72285 radiological supervision and No MEDICAID Diskography, lumbar, radiological 72295 supervision and interpretation No MEDICAID Radiologic examination; clavicle, complete 73000 No MEDICAID Radiologic examination; scapula, 73010 complete No MEDICAID Radiologic examination, shoulder; one 73020 view No MEDICAID Radiologic examination, shoulder; 73030 complete, minimum of two views No MEDICAID Radiologic examination, shoulder, arthrography, radiological supervision 73040 No MEDICAID Radiologic examination; acromioclavicular joints, bilateral, with or 73050 No MEDICAID Radiologic examination; humerus, 73060 minimum of two views No MEDICAID Radiologic examination, elbow; two views 73070 No MEDICAID Radiologic examination, elbow; complete, 73080 minimum of three views No MEDICAID

236 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiologic examination, elbow, arthrography, radiological supervision 73085 No MEDICAID Radiologic examination; forearm, two 73090 views No MEDICAID Radiologic examination; upper extremity, infant, minimum of two views 73092 No MEDICAID Radiologic examination, wrist; two views 73100 No MEDICAID Radiologic examination, wrist; complete, 73110 minimum of three views No MEDICAID Radiologic examination, wrist, arthrography, radiological supervision 73115 No MEDICAID Radiologic examination, hand; two views 73120 No MEDICAID Radiologic examination, hand; minimum 73130 of three views No MEDICAID Radiologic examination, finger(s), 73140 minimum of two views No MEDICAID COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST 73200 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; 73201 WITH CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 73202 SECTIONS No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQU 73206 No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT, 73218 WITHOUT CONTRAST MATERIAL(S) No MEDICAID 73219 MRI UPPER EXTREMITY W/DYE No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER 73220 EXTREMITY, OTHER THAN JOINT No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF 73221 UPPER EXTREMITY No MEDICAID 73222 MRI JOINT UPR EXTREM W/ DYE No MEDICAID 73223 MRI JOINT UPR EXTR W/O&W DYE No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST 73225 MATERIAL(S) No MEDICAID Radiologic examination, hip, unilateral, with 73501 pelvis when performed; 1 view No MEDICAID Radiologic examination, hip, unilateral, with 73502 pelvis when performed; 2-3 views No MEDICAID Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views 73503 No MEDICAID Radiologic examination, hips, bilateral, with 73521 pelvis when performed; 2 views No MEDICAID Radiologic examination, hips, bilateral, with 73522 pelvis when performed; 3-4 views No MEDICAID Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views 73523 No MEDICAID

237 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiologic examination, hip, arthrography, radiological supervision and 73525 No MEDICAID 73551 Radiologic examination, femur; 1 view No MEDICAID Radiologic examination, femur; minimum 2 73552 views No MEDICAID Radiologic examination, knee; one or two 73560 views No MEDICAID Radiologic examination, knee; three views 73562 No MEDICAID Radiologic examination, knee; complete, 73564 four or more views No MEDICAID Radiologic examination, knee; both 73565 knees, standing, anteroposterior No MEDICAID Radiologic examination, knee, arthrography, radiological supervision and 73580 No MEDICAID Radiologic examination; tibia and fibula, 73590 two views No MEDICAID Radiologic examination; lower extremity, infant, minimum of two views 73592 No MEDICAID Radiologic examination, ankle; two views 73600 No MEDICAID Radiologic examination, ankle; complete, 73610 minimum of three views No MEDICAID Radiologic examination, ankle, arthrography, radiological supervision 73615 No MEDICAID Radiologic examination, foot; two views 73620 No MEDICAID Radiologic examination, foot; complete, 73630 minimum of three views No MEDICAID Radiologic examination; calcaneus, 73650 minimum of two views No MEDICAID Radiologic examination; toe(s), minimum 73660 of two views No MEDICAID COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST 73700 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; 73701 WITH CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 73702 SECTIONS No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECT 73706 No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; 73718 WITHOUT CONTRAST MATERIAL(S) No MEDICAID 73719 MRI LOWER EXTREMITY W/DYE No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER 73720 EXTREMITY, OTHER THAN JOINT No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF 73721 LOWER EXTREMITY No MEDICAID 73722 MRI JOINT OF LWR EXTR W/DYE No MEDICAID 73723 MRI JOINT LWR EXTR W/O&W DYE No MEDICAID

238 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST 73725 MATERIAL(S) No MEDICAID Radiologic examination, abdomen; 1 view 74018 No MEDICAID Radiologic examination, abdomen; 2 74019 views No MEDICAID Radiologic examination, abdomen; 3 or 74021 more views No MEDICAID Radiologic examination, abdomen; 74022 complete acute abdomen series, No MEDICAID COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST 74150 MATERIAL No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH 74160 CONTRAST MATERIAL(S) No MEDICAID COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 74170 No MEDICAID Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing 74174 No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS, IN 74175 No MEDICAID 74176 Computed tomography, abdomen and pelvis; without contrast material No MEDICAID 74177 Computed tomography, abdomen and pelvis; with contrast material(s) No MEDICAID 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions No MEDICAID MAGNETIC RESONANCE (EG, 74181 PROTON) IMAGING, ABDOMEN No MEDICAID 74182 MRI ABDOMEN W/DYE No MEDICAID 74183 MRI ABDOMEN W/O & W/DYE No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S) 74185 No MEDICAID Peritoneogram (eg, after injection of air or 74190 contrast), radiological No MEDICAID Radiologic examination; pharynx and/or 74210 cervical esophagus No MEDICAID 74220 Radiologic examination; esophagus No MEDICAID Swallowing function, with 74230 cineradiography/videoradiography No MEDICAID Removal of foreign body(s), esophageal, with use of balloon catheter, 74235 No MEDICAID Radiologic examination, gastrointestinal tract, upper; with or without 74240 No MEDICAID Radiologic examination, gastrointestinal tract, upper; with or without 74241 No MEDICAID Radiologic examination, gastrointestinal tract, upper; with small 74245 No MEDICAID

239 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiological examination, gastrointestinal tract, upper, air contrast, 74246 No MEDICAID Radiological examination, gastrointestinal tract, upper, air contrast, 74247 No MEDICAID Radiological examination, gastrointestinal tract, upper, air contrast, 74249 No MEDICAID Radiologic examination, small intestine, includes multiple serial films; 74250 No MEDICAID Radiologic examination, small intestine, includes multiple serial films; 74251 No MEDICAID 74260 Duodenography, hypotonic No MEDICAID COMPUTED TOMOGRAPHIC COLONGRAPHY; DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT 74261 CONTRAST MATERIAL No MEDICAID COMPUTED TOMOGRAPHIC COLONGRAPHY; DIAGNOSTIC, INCL IMAGE POSTPROCESSING; W/CONTRAST MATERIAL(S) INCL NON- 74262 CONTRAST IMAGES, IF PERFO No MEDICAID COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY; SCREENING, INCLUDING IMAGE POSTPROCESSING 74263 Yes MEDICAID Radiologic examination, colon; barium 74270 enema, with or without KUB No MEDICAID Radiologic examination, colon; air 74280 contrast with specific high density No MEDICAID Therapeutic enema, contrast or air, for 74283 reduction of intussusception or No MEDICAID 74290 Cholecystography, oral contrast; No MEDICAID Cholangiography and/or pancreatography; intraoperative, radiological 74300 No MEDICAID Cholangiography and/or pancreatography; additional set intraoperative, 74301 No MEDICAID Endoscopic catheterization of the biliary 74328 ductal system, radiological No MEDICAID Endoscopic catheterization of the pancreatic ductal system, radiological 74329 No MEDICAID Combined endoscopic catheterization of the biliary and pancreatic ductal 74330 No MEDICAID Introduction of long gastrointestinal tube 74340 (eg, Miller-Abbott), No MEDICAID Percutaneous placement of enteroclysis tube, radiological supervision 74355 No MEDICAID Intraluminal dilation of strictures and/or 74360 obstructions (eg, esophagus), No MEDICAID Percutaneous transhepatic dilation of 74363 biliary duct stricture with or No MEDICAID Urography (pyelography), intravenous, with or without KUB, with or 74400 No MEDICAID Urography, infusion, drip technique and/or 74410 bolus technique; No MEDICAID Urography, infusion, drip technique and/or 74415 bolus technique; with No MEDICAID Urography, retrograde, with or without 74420 KUB No MEDICAID

240 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Urography, antegrade, (pyelostogram, nephrostogram, loopogram), 74425 No MEDICAID Cystography, minimum of three views, 74430 radiological supervision and No MEDICAID Vasography, vesiculography, or epididymography, radiological supervision 74440 No * MEDICAID Corpora cavernosography, radiological supervision and interpretation 74445 No MEDICAID Urethrocystography, retrograde, 74450 radiological supervision and No MEDICAID Urethrocystography, voiding, radiological supervision and interpretation 74455 No MEDICAID Radiologic examination, renal cyst study, 74470 translumbar, contrast No MEDICAID Dilation of nephrostomy, ureters, or 74485 urethra, radiological supervision No MEDICAID Pelvimetry, with or without placental 74710 localization No MEDICAID Magnetic resonance (e.g., proton) imaging fetal, including placental and maternal pelvic imaging when performed; single or first gestation 74712 No MEDICAID Magnetic resonance (e.g., proton) imaging fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary 74713 procedure) No MEDICAID Hysterosalpingography, radiological 74740 supervision and interpretation No * MEDICAID Transcervical catheterization of fallopian 74742 tube, radiological No * MEDICAID Perineogram (eg, vaginogram, for sex 74775 determination or extent of No MEDICAID CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST 75557 MATERIAL No MEDICAID CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST 75559 MATERIAL; WITH STRESS IMAGING No MEDICAID CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND 75561 FURTHER SEQUENCES No MEDICAID CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH 75563 STRESS IMAGING No MEDICAID CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 75565 PROCEDURE) No MEDICAID COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST MATERIAL, WITH QUANTITATIVE EVALUATION OF 75571 CORONARY CALCIUM Not Covered MEDICAID COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST MATERIAL, 75571 No WITH QUANTITATIVE EVALUATION OF CORONARY CALCIUM MEDICAID

241 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY 75572 (INCL 3D IMAGE POSTPROC...) No MEDICAID COMPUTED TOMOGRAPHY, HEART, W/CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE/MORPHOLOGY IN SETTING OF CONGENITAL HEART DIS 75573 No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART, CORONARY ARTERIES&BYPASS GRAFTS, W/CONTRAST MAT, INCL 3D POSTPROC, EVAL CARDIAC 75574 STRUCTURE No MEDICAID Aortography, thoracic, without serialography, radiological supervision 75600 No MEDICAID Aortography, thoracic, by serialography, radiological supervision and 75605 No MEDICAID Aortography, abdominal, by serialography, radiological supervision and 75625 No MEDICAID Aortography, abdominal plus bilateral 75630 iliofemoral lower extremity, No MEDICAID COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF, RADIOLOGICAL SUPERVISION AND I 75635 No MEDICAID Angiography, spinal, selective, 75705 radiological supervision and No MEDICAID Angiography, extremity, unilateral, 75710 radiological supervision and No MEDICAID Angiography, extremity, bilateral, 75716 radiological supervision and No MEDICAID Angiography, visceral, selective or 75726 supraselective, (with or without No MEDICAID Angiography, adrenal, unilateral, 75731 selective, radiological supervision No MEDICAID Angiography, adrenal, bilateral, selective, radiological supervision and 75733 No MEDICAID Angiography, pelvic, selective or 75736 supraselective, radiological No MEDICAID Angiography, pulmonary, unilateral, 75741 selective, radiological supervision No MEDICAID Angiography, pulmonary, bilateral, 75743 selective, radiological supervision No MEDICAID Angiography, pulmonary, by nonselective catheter or venous injection, 75746 No MEDICAID Angiography, internal mammary, 75756 radiological supervision and No MEDICAID Angiography, selective, each additional 75774 vessel studied after basic No MEDICAID Angiography, arteriovenous shunt (eg, 75790 dialysis patient), radiological No MEDICAID Lymphangiography, extremity only, 75801 unilateral, radiological supervision No MEDICAID Lymphangiography, extremity only, 75803 bilateral, radiological supervision No MEDICAID Lymphangiography, pelvic/abdominal, unilateral, radiological supervision 75805 No MEDICAID

242 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Lymphangiography, pelvic/abdominal, bilateral, radiological supervision 75807 No MEDICAID Shuntogram for investigation of previously placed indwelling nonvascular 75809 No MEDICAID Splenoportography, radiological 75810 supervision and interpretation No MEDICAID Venography, extremity, unilateral, 75820 radiological supervision and No MEDICAID Venography, extremity, bilateral, 75822 radiological supervision and No MEDICAID Venography, caval, inferior, with serialography, radiological supervision 75825 No MEDICAID Venography, caval, superior, with serialography, radiological supervision 75827 No MEDICAID Venography, renal, unilateral, selective, radiological supervision and 75831 No MEDICAID Venography, renal, bilateral, selective, radiological supervision and 75833 No MEDICAID Venography, adrenal, unilateral, selective, radiological supervision and 75840 No MEDICAID Venography, adrenal, bilateral, selective, radiological supervision and 75842 No MEDICAID Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, 75860 No MEDICAID Venography, superior sagittal sinus, 75870 radiological supervision and No MEDICAID Venography, epidural, radiological 75872 supervision and interpretation No MEDICAID Venography, orbital, radiological 75880 supervision and interpretation No MEDICAID Percutaneous transhepatic portography with hemodynamic evaluation, 75885 No MEDICAID Percutaneous transhepatic portography without hemodynamic evaluation, 75887 No MEDICAID Hepatic venography, wedged or free, with 75889 hemodynamic evaluation, No MEDICAID Hepatic venography, wedged or free, 75891 without hemodynamic evaluation, No MEDICAID Venous sampling through catheter, with or 75893 without angiography (eg, for No MEDICAID TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND 75894 INTERPRETATION No MEDICAID Angiography through existing catheter for 75898 follow-up study for No MEDICAID Mechanical removal of pericatheter 75901 obstructive material (eg, fibrin No MEDICAID Mechanical removal of intraluminal 75902 (intracatheter) obstructive material No MEDICAID 75956 Xray, endovasc thor ao repr No MEDICAID 75957 Xray, endovasc thor ao repr No MEDICAID 75958 Xray, place prox ext thor ao No MEDICAID 75959 Xray, place dist ext thor ao No MEDICAID Change of percutaneous tube or drainage 75984 catheter with contrast No MEDICAID Radiological guidance (ie, fluoroscopy, 75989 ultrasound, or computed No MEDICAID Fluoroscopy (separate procedure), up to 76000 one hour physician time, other No MEDICAID

243 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NON- RADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, 76001 No MEDICAID Radiologic examination from nose to 76010 rectum for foreign body, single No MEDICAID Radiologic examination, abscess, fistula 76080 or sinus tract study, No MEDICAID Radiological examination, surgical 76098 specimen No MEDICAID Radiologic examination, single plane body 76100 section (eg, tomography), No MEDICAID Radiologic examination, complex motion 76101 (ie, hypercycloidal) body No MEDICAID Radiologic examination, complex motion 76102 (ie, hypercycloidal) body No MEDICAID Cineradiography/videoradiography, except 76120 where specifically included No MEDICAID Cineradiography/videoradiography to 76125 complement routine examination No MEDICAID Consultation on x-ray examination made 76140 elsewhere, written report No MEDICAID 76376 3D RENDER W/O POSTPROCESS No MEDICAID 76377 3D RENDERING W/POSTPROCESS No MEDICAID 76380 CT SCAN FOLLOWUP STUDY, LIM No MEDICAID MAGNETIC RESONANCE 76390 No SPECTROSCOPY MEDICAID UNLISTED FLUROSCOPIC PROCEDURE (EG, DIAGNOSTIC, 76496 INTERVENTIONAL Yes MEDICAID UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (EG, DIAGNOSTIC, 76497 INTERVENTIONAL) Yes MEDICAID UNLISTED DIAGNOSTIC 76498 RADIOGRAPHIC PROCEDURE Yes MEDICAID UNLISTED DIAGNOSTIC RADIOLOGIC 76499 PROCEDURE Yes MEDICAID Echoencephalography, B-scan and/or real 76506 time with image No MEDICAID OPTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE A-SCAN PERFORMED DURING THE SAME PATIENT 76510 ENCOUNTER No MEDICAID Ophthalmic ultrasound, diagnostic; 76511 quantitative A-scan only No MEDICAID Ophthalmic ultrasound, diagnostic; B-scan 76512 (with or without superimposed No MEDICAID Ophthalmic ultrasound, diagnostic; 76513 anterior segment ultrasound, No MEDICAID OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; 76514 CORNEAL PACHYMETRY No MEDICAID Ophthalmic biometry by ultrasound 76516 echography, A-scan; No MEDICAID Ophthalmic biometry by ultrasound 76519 echography, A-scan; with intraocular No MEDICAID Ophthalmic ultrasonic foreign body 76529 localization No MEDICAID Ultrasound, soft tissues of head and neck 76536 (eg, thyroid, parathyroid, No MEDICAID Ultrasound, chest, B-scan (includes 76604 mediastinum) and/or real time with No MEDICAID Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76641 No MEDICAID

244 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited 76642 No MEDICAID Ultrasound, abdominal, B-scan and/or real 76700 time with image No MEDICAID Ultrasound, abdominal, B-scan and/or real 76705 time with image No MEDICAID 76706 Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) No MEDICAID Ultrasound, retroperitoneal (eg, renal, 76770 aorta, nodes), B-scan and/or No MEDICAID Ultrasound, retroperitoneal (eg, renal, 76775 aorta, nodes), B-scan and/or No MEDICAID ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX 76776 DOPPLER WITH No MEDICAID Ultrasound, spinal canal and contents 76800 No MEDICAID Ultrasound, pregnant uterus, real time 76801 with image documentation, fetal No MEDICAID Ultrasound, pregnant uterus, real time 76802 with image documentation, fetal No MEDICAID Ultrasound, pregnant uterus, real time 76805 with image documentation, fetal No MEDICAID Ultrasound, pregnant uterus, real time 76810 with image documentation, fetal No MEDICAID Ultrasound, pregnant uterus, real time 76811 with image documentation, fetal No MEDICAID Ultrasound, pregnant uterus, real time 76812 with image documentation, fetal No MEDICAID ULTRASOUND, PREGNANT UTERUS, REAL TIME W/IMAGE DOC., 1ST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASURE, TRANSABD/VAG; SINGLE/1ST GES 76813 No MEDICAID ULTRASOUND, PREGNANT UTERUS, REAL TIME W/IMAGE DOC., 1ST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASURE, TRANSABD/VAG; EA ADDL GESTAT 76814 No MEDICAID Ultrasound, pregnant uterus, real time with image documentation, limited 76815 No MEDICAID Ultrasound, pregnant uterus, real time 76816 with image documentation, No MEDICAID Ultrasound, pregnant uterus, real time 76817 with image documentation, No MEDICAID Fetal biophysical profile; with non-stress 76818 testing No MEDICAID Fetal biophysical profile; without non- 76819 stress testing No MEDICAID Doppler velocimetry, fetal; umbilical artery 76820 No MEDICAID Doppler velocimetry, fetal; middle cerebral 76821 artery No MEDICAID ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE 76825 RECORDING; No MEDICAID ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR 76826 REPEAT STUDY No MEDICAID

245 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; 76827 COMPLETE No MEDICAID DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR REPEAT STUDY 76828 No MEDICAID 76830 Ultrasound, transvaginal No MEDICAID Saline infusion sonohysterography (SIS), 76831 including color flow Doppler, No MEDICAID Ultrasound, pelvic (nonobstetric), B-scan 76856 and/or real time with image No MEDICAID Ultrasound, pelvic (nonobstetric), B-scan 76857 and/or real time with image No MEDICAID 76870 Ultrasound, scrotum and contents No MEDICAID 76872 Ultrasound, transrectal; No MEDICAID Ultrasound, transrectal; prostate volume 76873 study for brachytherapy No MEDICAID 76881 Ultrasound, extremity, nonvascular, real- time with image documentation; complete No MEDICAID 76882 Ultrasound, extremity, nonvascular, real- time with image documentation; limited, anatomic specific No MEDICAID Ultrasound, infant hips, real time with 76885 imaging documentation; dynamic No MEDICAID Ultrasound, infant hips, real time with 76886 imaging documentation; limited, No MEDICAID Ultrasonic guidance for 76930 pericardiocentesis, imaging supervision Yes and MEDICAID Ultrasonic guidance for endomyocardial biopsy, imaging supervision and 76932 No MEDICAID Ultrasound guided compression repair of 76936 arterial pseudoaneurysm or No MEDICAID Ultrasound guidance for vascular access requiring ultrasound evaluation 76937 No MEDICAID Ultrasound guidance for, and monitoring 76940 of, visceral tissue ablation No MEDICAID Ultrasonic guidance for intrauterine fetal 76941 transfusion or cordocentesis, No MEDICAID Ultrasonic guidance for needle placement 76942 (eg, biopsy, aspiration, No MEDICAID Ultrasonic guidance for chorionic villus 76945 sampling, imaging supervision No MEDICAID Ultrasonic guidance for amniocentesis, imaging supervision and 76946 No MEDICAID Ultrasonic guidance for aspiration of ova, 76948 imaging supervision and Not Covered MEDICAID Ultrasonic guidance for interstitial 76965 radioelement application No MEDICAID 76970 Ultrasound study follow-up (specify) No MEDICAID Gastrointestinal endoscopic ultrasound, supervision and interpretation 76975 No MEDICAID ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL 76977 SITE(S), ANY METHOD No MEDICAID ULTRASOUND GUIDANCE, 76998 INTRAOPERATIVE No MEDICAID UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, 76999 INTERVENTIONAL) Yes MEDICAID

246 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FLUROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE 77001 PLACEMENT, No MEDICAID FLUOROSCOPIC GUIDANCE FOR 77002 NEEDLE PLACEMENT No MEDICAID Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction 77003 No MEDICAID COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC 77011 LOCALIZATION No MEDICAID COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT 77012 No MEDICAID 77013 CT GUIDE PARENCHYMAL ABLATE No MEDICAID 77014 CT GUIDE PLACE RADIATION FLD No MEDICAID MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT 77021 No MEDICAID MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, 77022 PARENCHYMAL No MEDICAID MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, 77053 RADIOLOGICAL No MEDICAID MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 77054 RADIOLOGICAL No MEDICAID MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); 77058 UNILATERAL No MEDICAID MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIAL(S); BILATERAL 77059 No MEDICAID Digital breast tomosynthesis; unilateral 77061 No MEDICAID Digital breast tomosynthesis; bilateral 77062 No MEDICAID Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) 77063 No MEDICAID 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral No MEDICAID 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral No MEDICAID 77067 Screening mammography, bilateral (2- view study of each breast), including computer-aided detection (CAD) when performed No MEDICAID MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR 77071 JOINT No MEDICAID 77072 BONE AGE STUDIES No MEDICAID BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, 77073 SCANOGRAM) No MEDICAID RADIOLOGIC EXAMINATION, 77074 OSSEOUS SURVEY; LIMITED No MEDICAID RADIOLOGIC EXAMINATION, 77075 OSSEOUS SURVEY; COMPLETE No MEDICAID RADIOLOGIC EXAMINATION, 77076 OSSEOUS SURVEY, INFANT No MEDICAID

247 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines JOINT SURVEY, SINGLE VIEW, 2 OR 77077 MORE JOINTS (SPECIFY) No MEDICAID COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, 77078 HIPS, PELVIS, SPINE) No MEDICAID DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, 77080 SPINE) No MEDICAID DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON 77081 (PERIPHERAL) (EG, RADIUS, WRIST No MEDICAID MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW 77084 BLOOD SUPPLY No MEDICAID Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment 77085 No MEDICAID Vertebral fracture assessment via dual- energy X-ray absorptiometry (DXA) 77086 No MEDICAID Therapeutic radiology treatment planning; 77261 simple No MEDICAID Therapeutic radiology treatment planning; 77262 intermediate No MEDICAID Therapeutic radiology treatment planning; 77263 complex No MEDICAID Therapeutic radiology simulation-aided 77280 field setting; simple No MEDICAID Therapeutic radiology simulation-aided 77285 field setting; intermediate No MEDICAID THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 77290 COMPLEX No MEDICAID 77293 Respiratory motion management simulation (List separately in addition to code for primary procedure) No MEDICAID Therapeutic radiology simulation-aided 77295 field setting; three-dimensional No MEDICAID UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY CLINICAL 77299 TREATMENT PLANNING Yes MEDICAID Basic radiation dosimetry calculation, 77300 central axis depth dose No MEDICAID Intensity modulated radiotherapy plan, including dose-volume histograms 77301 No MEDICAID Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry 77306 calculation(s) No MEDICAID Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) 77307 No MEDICAID Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry 77316 calculation(s) No MEDICAID

248 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2- 12 channels), includes basic dosimetry calculation(s) 77317 No MEDICAID Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) 77318 No MEDICAID Special teletherapy port plan, particles, 77321 hemibody, total body No MEDICAID SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE 77331 TREATING PHYSICIAN No MEDICAID Treatment devices, design and construction; simple (simple block, simple 77332 No MEDICAID Treatment devices, design and 77333 construction; intermediate (multiple No MEDICAID Treatment devices, design and construction; complex (irregular blocks, 77334 No MEDICAID Continuing medical physics consultation, including assessment of 77336 No MEDICAID MULTI-LEAF COLLIMATOR (MLC) DEVICE(S) FOR INTENSITY MODULATED RADIATION THERAPY (IMRT), DESIGN AND CONSTRUCTION 77338 PER IMRT PLAN No MEDICAID Special medical radiation physics 77370 consultation No MEDICAID RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURG (SRS), FULL COURSE TX OF CEREBRAL LESION(S), 1 SESSION; MULTI- 77371 SOURCE COBALT60 No MEDICAID RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURG (SRS), FULL COURSE TX OF CEREBRAL LESION(S), 1 SESSION; LINEAR 77372 ACCELER-BASED No MEDICAID STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCL IMAGE GUIDANCE, 77373 ENTIRE COURSE > 5 No MEDICAID Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple 77385 No MEDICAID Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex 77386 No MEDICAID Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed 77387 No MEDICAID UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES, AND 77399 SPECIAL SERVICES Yes MEDICAID Radiation treatment delivery, superficial 77401 and/or ortho voltage No MEDICAID

249 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiation treatment delivery, single 77402 treatment area, single port or No MEDICAID Radiation treatment delivery, two separate 77407 treatment areas, three or No MEDICAID Radiation treatment delivery, three or 77412 more separate treatment areas, No MEDICAID 77417 Therapeutic radiology port film(s) No MEDICAID HIGH ENERY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE 77423 ISOCENTER(S) WITH COPLANAR OR Yes NON-COPLANAR GEOMETRY WITH BLOCKING AND/O MEDICAID Intraoperative radiation treatment delivery, x-ray, single treatment session 77424 No MEDICAID Intraoperative radiation treatment delivery, electrons, single treatment session 77425 No MEDICAID Radiation treatment management, five 77427 treatments No MEDICAID RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF THERAPY CONSISTING OF ONE OR TWO FRACTIONS ONLY 77431 No MEDICAID Stereotactic radiation treatment 77432 management of cerebral lesion(s) No MEDICAID STEREOTACTIC BODY RADIATION THERAPY, TX MGMT, PER TX COURSE, TO 1 OR MORE LESIONS, INCL IMAGE GUIDANCE, ENTIRE 77435 COURSE > 5 FRACTION No MEDICAID Intraoperative radiation treatment 77469 management No MEDICAID SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, HEMIBODY IRRADIATION, PER ORAL, VAGINAL CONE IRRADIATION) 77470 No MEDICAID UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY 77499 TREATMENT MANAGEMENT Yes MEDICAID PROTON BEAM DELIVERY TO A SINGLE TREATMENT AREA, SINGLE PORT, CUSTOM BLOCK, W/ OR W/O COMPENSATION, W/ TREATMENT SET- 77520 UP AND VERIFI Yes MEDICAID PROTON TREATMENT DELIVERY; 77522 SIMPLE, WITH COMPENSATION. Yes MEDICAID PROTON BEAM DELIVERY TO 1 OR 2 TREATMENT AREAS, 2 OR MORE PORTS, 2 OR MORE CUSTOM BLOCKS, & 2 OR MORE COMPENSATORS, W/ TREATMENT S 77523 Yes MEDICAID PROTON TREATMENT DELIVERY; 77525 COMPLEX Yes MEDICAID Hyperthermia, externally generated; 77600 superficial (ie, heating to a depth No MEDICAID Hyperthermia, externally generated; deep 77605 (ie, heating to depths greater No MEDICAID Hyperthermia generated by interstitial 77610 probe(s); 5 or fewer interstitial No MEDICAID Hyperthermia generated by interstitial 77615 probe(s); more than 5 No MEDICAID Hyperthermia generated by intracavitary 77620 probe(s) No MEDICAID Infusion or instillation of radioelement solution (includes three months 77750 No MEDICAID

250 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Intracavitary radiation source application; 77761 simple No MEDICAID Intracavitary radiation source application; 77762 intermediate No MEDICAID Intracavitary radiation source application; 77763 complex No MEDICAID Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm and 1 channel 77767 No MEDICAID Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 and 2 or more channels, or multiple 77768 lesions No MEDICAID Remote afterloading high dose rate radionuclide interstitial or intracavity brachytherapy, includes basic dosimetry, when performed; 1 channel 77770 No MEDICAID Remote afterloading high dose rate radionuclide interstitial or intracavity brachytherapy, includes basic dosimetry, when performed; 2-12 77771 channels No MEDICAID Remote afterloading high dose rate radionuclide interstitial or intracavity brachytherapy, includes basic dosimetry, when performed; over 12 77772 channels No MEDICAID Interstitial radiation source application; 77778 complex No MEDICAID Surface application of radiation source 77789 No MEDICAID Supervision, handling, loading of radiation 77790 source No MEDICAID Unlisted procedure, clinical brachytherapy 77799 Yes MEDICAID Thyroid uptake, single or multiple quantitative measurement(s) (including 78012 stimulation, suppression, or discharge, when performed) No MEDICAID Thyroid imaging (including vascular flow, 78013 when performed); No MEDICAID Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) 78014 (including stimulation, suppression, or discharge, when performed) No MEDICAID Thyroid carcinoma metastases imaging; limited area (eg, neck and chest 78015 No MEDICAID Thyroid carcinoma metastases imaging; 78016 with additional studies (eg, No MEDICAID Thyroid carcinoma metastases imaging; 78018 whole body No MEDICAID Thyroid carcinoma metastases uptake (List separately in addition to code 78020 No MEDICAID 78070 Parathyroid imaging No MEDICAID Parathyroid planar imaging (including subtraction, when performed); with 78071 tomographic (SPECT) No MEDICAID Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently 78072 acquired computed tomography (CT) for anatomical localization No MEDICAID Adrenal imaging, cortex and/or medulla 78075 No MEDICAID

251 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78099 Yes MEDICAID 78102 Bone marrow imaging; limited area No MEDICAID Bone marrow imaging; multiple areas 78103 No MEDICAID 78104 Bone marrow imaging; whole body No MEDICAID Plasma Volume, Radiopharmaceutical Volume-Dilution Technique (Sep Proc); 78110 Single Sample No MEDICAID Plasma volume, radiopharmaceutical volume-dilution technique (separate 78111 No MEDICAID RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE 78120 SAMPLING No MEDICAID RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS 78121 No MEDICAID WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIOPHARMACEUTICAL 78122 VOLUME- No MEDICAID 78130 RED CELL SURVIVAL STUDY No MEDICAID RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS, (EG, SPLENIC AND/OR 78135 HEPATIC SEQUESTRATION) No MEDICAID LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE, (EG, SPLENIC 78140 AND/OR HEPATIC) No MEDICAID Spleen imaging only, with or without 78185 vascular flow No MEDICAID 78191 Platelet survival study No MEDICAID Lymphatics and lymph nodes imaging 78195 No MEDICAID UNLISTED HEMATOPOIETIC, RETICULOENDOTHELIAL AND LYMPHATIC PROCEDURE, 78199 DIAGNOSTIC NUCLEAR MEDICINE Yes MEDICAID 78201 Liver imaging; static only No MEDICAID 78202 Liver imaging; with vascular flow No MEDICAID 78205 LIVER IMAGING (SPECT); No MEDICAID LIVER IMAGINE (SPECT); WITH 78206 VASCULAR FLOW No MEDICAID 78215 Liver and spleen imaging; static only No MEDICAID Liver and spleen imaging; with vascular 78216 flow No MEDICAID Hepatobiliary system imaging, including 78226 gallbladder when present; No MEDICAID Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when 78227 performed No MEDICAID 78230 Salivary gland imaging; No MEDICAID Salivary gland imaging; with serial images 78231 No MEDICAID 78232 Salivary gland function study No MEDICAID 78258 Esophageal motility No MEDICAID 78261 Gastric mucosa imaging No MEDICAID 78262 Gastroesophageal reflux study No MEDICAID 78264 Gastric emptying study No MEDICAID Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel transit 78265 No MEDICAID

252 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon 78266 transit, multiple days No MEDICAID Urea breath test, C-14 (isotopic); 78267 acquisition for analysis No MEDICAID Urea breath test, C-14 (isotopic); analysis 78268 No MEDICAID VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT 78270 INTRINSIC FACTOR No MEDICAID VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH 78271 INTRINSIC FACTOR No MEDICAID VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT 78272 INTRINSIC FACTOR No MEDICAID Acute gastrointestinal blood loss imaging 78278 No MEDICAID 78282 Gastrointestinal protein loss No MEDICAID Intestine imaging (eg, ectopic gastric 78290 mucosa, Meckel's localization, No MEDICAID Peritoneal-venous shunt patency test (eg, 78291 for LeVeen, Denver shunt) No MEDICAID UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC NUCLEAR 78299 MEDICINE Yes MEDICAID Bone and/or joint imaging; limited area 78300 No MEDICAID Bone and/or joint imaging; multiple areas 78305 No MEDICAID Bone and/or joint imaging; whole body 78306 No MEDICAID Bone and/or joint imaging; three phase 78315 study No MEDICAID Bone and/or joint imaging; tomographic 78320 (SPECT) No MEDICAID BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE 78350 No SITES; SINGLE PHOTON ABSORPTIOMETRY MEDICAID BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; DUAL PHOTON ABSORPTIOMETRY, ONE OR MORE 78351 SITES Not Covered MEDICAID UNLISTED MUSCULOSKELETAL PROCEDURE, DIAGNOSTIC NUCLEAR 78399 MEDICINE Yes MEDICAID Determination of central c-v hemodynamics (non-imaging) (eg, 78414 ejection No MEDICAID 78428 Cardiac shunt detection No MEDICAID Non-cardiac vascular flow imaging (ie, 78445 angiography, venography) No MEDICAID MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCL ATTENUATION CORR, QUAL/QUANT WALL MOTION); SINGLE STUDY, AT 78451 REST OR STRESS No MEDICAID MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT); MULTIPLE STUDIES, AT REST OR STRESS &/OR REDISTRIBUTION &/OR REST 78452 REINJECTION No MEDICAID MYOCARDIAL PERFUSION IMAGING, PLANAR (INCL QUAL/QUANT WALL MOTION, EJECTION FRACTION QUANT); SINGLE STUDY, AT REST OR 78453 STRESS No MEDICAID

253 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MYOCARDIAL PERFUSION IMAGING, PLANAR; MULTIPLE STUDY, AT REST OR STRESS &/OR REDISTRIBUTION &/OR REST REINJECTION 78454 No MEDICAID Acute venous thrombosis imaging, 78456 peptide No MEDICAID Venous thrombosis imaging, venogram; 78457 unilateral No MEDICAID Venous thrombosis imaging, venogram; 78458 bilateral No MEDICAID MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 78459 METABOLIC EVALUATION No MEDICAID MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR 78466 QUANTITATIVE No MEDICAID MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS 78468 TECHNIQUE No MEDICAID MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION 78469 No MEDICAID CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; PLANAR, SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR 78472 PHARMACOLOGIC), WALL MOTION No MEDICAID CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, AT REST AND 78473 STRESS (EXE No MEDICAID CARDIAC BLOOD POOL IMAGING, (PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS (EXERCISE AND/OR 78481 PHARMACOLOGIC), No MEDICAID CARDIAC BLOOD POOL IMAGING, (PLANAR), FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE AND/OR PHARMACOLOG 78483 No MEDICAID MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST 78491 OR STRESS No MEDICAID MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT 78492 REST AND/OR STRESS No MEDICAID CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR 78494 WITHOUT QUANTITAT No MEDICAID 78496 NUCLEAR BLOOD POOL IMAGING No MEDICAID UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR 78499 MEDICINE Yes MEDICAID Pulmonary ventilation imaging (eg, 78579 aerosol or gas) No MEDICAID Pulmonary perfusion imaging, particulate 78580 No MEDICAID Pulmonary ventilation imaging (eg, 78582 aerosol or gas) No MEDICAID

254 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Quantitative differential pulmonary perfusion, including imaging when 78597 performed No MEDICAID Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed 78598 No MEDICAID UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR 78599 MEDICINE Yes MEDICAID BRAIN IMAGING, LIMITED 78600 PROCEDURE; STATIC No MEDICAID BRAIN IMAGING, LIMITED PROCEDURE; WITH VASCULAR FLOW 78601 No MEDICAID BRAIN IMAGING, COMPLETE STUDY; 78605 STATIC No MEDICAID BRAIN IMAGING, COMPLETE STUDY; 78606 WITH VASCULAR FLOW No MEDICAID BRAIN IMAGING, COMPLETE STUDY; 78607 TOMOGRAPHIC (SPECT) No MEDICAID BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC 78608 EVALUATION No MEDICAID BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION 78609 EVALUATION Not Covered MEDICAID BRAIN IMAGING, POSITRON EMISSION 78609 TOMOGRAPHY (PET); PERFUSION Yes EVALUATION MEDICAID BRAIN IMAGING, VASCULAR FLOW 78610 ONLY No MEDICAID CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); 78630 CISTERNOGRAPHY No MEDICAID Cerebrospinal fluid flow, imaging (not 78635 including introduction of No MEDICAID Cerebrospinal fluid flow, imaging (not 78645 including introduction of No MEDICAID CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); 78647 TOMOGRAPHIC (SPECT) No MEDICAID Cerebrospinal fluid leakage detection and 78650 localization No MEDICAID Radiopharmaceutical dacryocystography 78660 No MEDICAID UNLISTED NERVOUS SYSTEM PROCEDURE, DIAGNOSTIC NUCLEAR 78699 MEDICINE Yes MEDICAID 78700 KIDNEY IMAGING MORPHOLOGY No MEDICAID KIDNEY IMAGING MORPHOLOGY; 78701 WITH VASCULAR FLOW No MEDICAID KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW & FUNCTION, SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION 78707 No MEDICAID KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW & FUNCTION, SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION 78708 No MEDICAID KIDNEY IMAGING MORPHOLOGY; W/VASCULAR FLOW & FUNCTION; MULTIPLE STUDIES, W & WO PHARMACOLOGICAL INTERVENTION 78709 No MEDICAID KIDNEY IMAGING MORHPOLOGY; 78710 TOMOGRAPHIC (SPECT) No MEDICAID

255 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines KIDNEY FUNCTION STUDY, NON- 78725 IMAGING RADIOISOTOPIC STUDY No MEDICAID URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 78730 No MEDICAID URETERAL REFLUX STUDY (RADIOPHARMACEUTICAL VOIDING 78740 CYSTOGRAM) No MEDICAID TESTICULAR IMAGING WITH 78761 VASCULAR FLOW No MEDICAID UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR 78799 MEDICINE Yes MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR; LIMITED 78800 AREA No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR; MULTIPLE 78801 AREAS No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR; WHOLE 78802 BODY, SINGLE DAY IMAGING No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR; 78803 TOMOGRAPHIC (SPECT) No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING 2 OR 78804 MORE DAYS IM No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF ABSCESS; LIMITED 78805 AREA No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF ABSCESS; WHOLE 78806 BODY No MEDICAID RADIOPHARMACEUTICAL LOCALIZATION OF ABSCESS; 78807 TOMOGRAPHIC (SPECT) No MEDICAID Injection procedure for radiopharmaceutical localization by non- imaging probe study; intravenous (eg, parathyroid adenoma) 78808 No MEDICAID TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMITED AREA (EG, CHEST, 78811 HEAD/NECK) No MEDICAID TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); 78812 SKULL BASE TO MID-THIGH No MEDICAID TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); 78813 WHOLE BODY No MEDICAID TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED CT SCAN; FOR ATTENUATION 78814 CORRECTION; LIMITED AREA No MEDICAID TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) W/CONCURRENTLY ACQUIRED CT SCAN FOR ATTNEUATION CORRCTN; SKULL BASE TO MID-THIGH 78815 No MEDICAID

256 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) W/CONCURRENTLY ACQUIRED CT SCAN FOR ATTENUATION 78816 CORRECTION; WHOLE BODY No MEDICAID UNLISTED MISCELLANEOUS PROCEDURE, DIAGNOSTIC NUCLEAR 78999 MEDICINE Yes MEDICAID Radiopharmaceutical therapy, by oral 79005 administration No MEDICAID Radiopharmaceutical therapy, by 79101 intravenous administration No MEDICAID Radiopharmaceutical therapy, by 79200 intracavitary administration No MEDICAID Radiopharmaceutical therapy, by 79300 interstitial radioactive colloid No MEDICAID RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL ANTIBODY BY INTRAVENOUS 79403 INFUSION No MEDICAID Radiopharmaceutical therapy, by intra- 79440 articular administration No MEDICAID Radiopharmaceutical therapy, by intra- 79445 arterial particulate No MEDICAID Radiopharmaceutical therapy, unlisted 79999 Yes procedure MEDICAID BASIC METABOLIC PANEL (CALCIUM, 80047 IONIZED) No MEDICAID 80048 Basic metabolic panel No MEDICAID 80050 General health panel No MEDICAID 80051 Electrolyte panel No MEDICAID 80053 Comprehensive metabolic panel No MEDICAID 80055 Obstetric panel No MEDICAID 80061 Lipid panel No * MEDICAID 80069 Renal function panel No MEDICAID 80074 Acute hepatitis panel No MEDICAID 80076 Hepatic function panel No MEDICAID 80081 Obstetric panel (including HIV testing) No MEDICAID 80150 Amikacin No MEDICAID 80155 Caffeine No MEDICAID 80156 Carbamazepine; total No MEDICAID 80157 Carbamazepine; free No MEDICAID 80158 Cyclosporine No MEDICAID 80159 Clozapine No MEDICAID 80162 Digoxin No MEDICAID 80163 Digoxin; free No MEDICAID 80164 Dipropylacetic acid (valproic acid) No MEDICAID Valproic acid (dipropylacetic acid); free 80165 No MEDICAID 80168 Ethosuximide No MEDICAID 80169 Everolimus No MEDICAID 80170 Gentamicin No MEDICAID 80171 Gabapentin No MEDICAID 80173 Haloperidol No MEDICAID 80175 Lamotrigine No MEDICAID 80176 Lidocaine No MEDICAID 80177 Levetiracetam No MEDICAID 80178 Lithium No MEDICAID 80180 Mycophenolate (mycophenolic acid) No MEDICAID 80183 Oxcarbazepine No MEDICAID 80184 Phenobarbital No MEDICAID 80185 Phenytoin; total No MEDICAID 80186 Phenytoin; free No MEDICAID 80188 Primidone No MEDICAID 80190 Procainamide; No MEDICAID Procainamide; with metabolites (eg, n- 80192 acetyl procainamide) No MEDICAID 80194 Quinidine No MEDICAID 80195 Assay of sirolimus No MEDICAID

257 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 80197 Tacrolimus No MEDICAID 80198 Theophylline No MEDICAID 80199 Tiagabine No MEDICAID 80200 Tobramycin No MEDICAID 80201 Topiramate No MEDICAID 80202 Vancomycin No MEDICAID 80203 Zonisamide No MEDICAID Quantitation of drug, not elsewhere 80299 specified No MEDICAID 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service

No MEDICAID 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); read by instrument assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

No MEDICAID 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC- MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service No MEDICAID 80320 Alcohols No MEDICAID 80321 Alcohol biomarkers; 1 or 2 No MEDICAID 80322 Alcohol biomarkers; 3 or more No MEDICAID 80323 Alkaloids, not otherwise specified No MEDICAID 80324 Amphetamines; 1 or 2 No MEDICAID 80325 Amphetamines; 3 or 4 No MEDICAID 80326 Amphetamines; 5 or more No MEDICAID 80327 Anabolic steroids; 1 or 2 No MEDICAID 80328 Anabolic steroids; 3 or more No MEDICAID 80329 Analgesics, non-opioid; 1 or 2 No MEDICAID 80330 Analgesics, non-opioid; 3-5 No MEDICAID 80331 Analgesics, non-opioid; 6 or more No MEDICAID Antidepressants, serotonergic class; 1 or 80332 2 No MEDICAID Antidepressants, serotonergic class; 3-5 80333 No MEDICAID Antidepressants, serotonergic class; 6 or 80334 more No MEDICAID Antidepressants, tricyclic and other 80335 cyclicals; 1 or 2 No MEDICAID Antidepressants, tricyclic and other 80336 cyclicals; 3-5 No MEDICAID Antidepressants, tricyclic and other 80337 cyclicals; 6 or more No MEDICAID Antidepressants, not otherwise specified 80338 No MEDICAID Antiepileptics, not otherwise specified; 1-3 80339 No MEDICAID Antiepileptics, not otherwise specified; 4-6 80340 No MEDICAID

258 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Antiepileptics, not otherwise specified; 7 80341 or more No MEDICAID Antipsychotics, not otherwise specified; 1- 80342 3 No MEDICAID Antipsychotics, not otherwise specified; 4- 80343 6 No MEDICAID Antipsychotics, not otherwise specified; 7 80344 or more No MEDICAID 80345 Barbiturates No MEDICAID 80346 Benzodiazepines; 1-12 No MEDICAID 80347 Benzodiazepines; 13 or more No MEDICAID 80348 Buprenorphine No MEDICAID 80349 Cannabinoids, natural No MEDICAID 80350 Cannabinoids, synthetic; 1-3 No MEDICAID 80351 Cannabinoids, synthetic; 4-6 No MEDICAID 80352 Cannabinoids, synthetic; 7 or more No MEDICAID 80353 Cocaine No MEDICAID 80354 Fentanyl No MEDICAID 80355 Gabapentin, non-blood No MEDICAID 80356 Heroin metabolite No MEDICAID 80357 Ketamine and norketamine No MEDICAID 80358 Methadone No MEDICAID Methylenedioxyamphetamines (MDA, 80359 MDEA, MDMA) No MEDICAID 80360 Methylphenidate No MEDICAID 80361 Opiates, 1 or more No MEDICAID 80362 Opioids and opiate analogs; 1 or 2 No MEDICAID 80363 Opioids and Opiate analogs; 3 or 4 No MEDICAID Opioids and Opiate analogs; 5 or more 80364 No MEDICAID 80365 Oxycodone No MEDICAID 80366 Pregabalin No MEDICAID 80367 Propoxyphene No MEDICAID Sedative hypnotics (non- 80368 benzodiazepines) No MEDICAID 80369 Skeletal muscle relaxants; 1 or 2 No MEDICAID 80370 Skeletal muscle relaxants; 3 or more No MEDICAID 80371 Stimulants, synthetic No MEDICAID 80372 Tapentadol No MEDICAID 80373 Tramadol No MEDICAID Stereoisomer (enantiomer) analysis, 80374 single drug class No MEDICAID Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise 80375 specified; 1-3 No MEDICAID Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise 80376 specified; 4-6 No MEDICAID Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise 80377 specified; 7 or more No MEDICAID ACTH stimulation panel; for adrenal 80400 insufficiency No MEDICAID ACTH stimulation panel; for 21 80402 hydroxylase deficiency No * MEDICAID ACTH stimulation panel; for 3 beta- 80406 hydroxydehydrogenase deficiency No * MEDICAID Aldosterone suppression evaluation panel 80408 (eg, saline infusion) No MEDICAID Calcitonin stimulation panel (eg, calcium, 80410 pentagastrin) No MEDICAID Corticotropic releasing hormone (CRH) 80412 stimulation panel No MEDICAID Chorionic gonadotropin stimulation panel; 80414 testosterone response No * MEDICAID Chorionic gonadotropin stimulation panel; 80415 estradiol response No * MEDICAID Renal vein renin stimulation panel (eg, 80416 captopril) No MEDICAID

259 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Peripheral vein renin stimulation panel 80417 (eg, captopril) No MEDICAID Combined rapid anterior pituitary 80418 evaluation panel No * MEDICAID Dexamethasone suppression panel, 48 80420 hour No MEDICAID Glucagon tolerance panel; for insulinoma 80422 No MEDICAID Glucagon tolerance panel; for 80424 pheochromocytoma No MEDICAID Gonadotropin releasing hormone 80426 stimulation panel No * MEDICAID Growth hormone stimulation panel (eg, 80428 arginine infusion, l-dopa No MEDICAID Growth hormone suppression panel 80430 (glucose administration) No MEDICAID Insulin-induced C-peptide suppression 80432 panel No MEDICAID Insulin tolerance panel; for ACTH 80434 insufficiency No MEDICAID Insulin tolerance panel; for growth 80435 hormone deficiency No MEDICAID 80436 Metyrapone panel No MEDICAID Thyrotropin releasing hormone (TRH) 80438 stimulation panel; one hour No MEDICAID Thyrotropin releasing hormone (TRH) 80439 stimulation panel; two hour No MEDICAID Clinical pathology consultation; limited, 80500 without review of patient's No MEDICAID Clinical pathology consultation; comprehensive, for a complex diagnostic 80502 No MEDICAID Urinalysis, by dip stick or tablet reagent 81000 for bilirubin, glucose, No MEDICAID Urinalysis, by dip stick or tablet reagent 81001 for bilirubin, glucose, No MEDICAID Urinalysis, by dip stick or tablet reagent 81002 for bilirubin, glucose, No MEDICAID Urinalysis, by dip stick or tablet reagent 81003 for bilirubin, glucose, No MEDICAID Urinalysis; qualitative or semiquantitative, except immunoassays 81005 No MEDICAID Urinalysis; bacteriuria screen, except by 81007 culture or dipstick No MEDICAID 81015 Urinalysis; microscopic only No MEDICAID 81020 Urinalysis; two or three glass test No MEDICAID Urine pregnancy test, by visual color 81025 comparison methods No MEDICAID Volume measurement for timed collection, 81050 each No MEDICAID UNLISTED URINALYSIS PROCEDURE 81099 Yes MEDICAID Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-1a/b (L33P) 81105 Yes MEDICAID Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib [platelet], alpha polypeptide [GPIba]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-2a/b 81106 (T145M) Yes MEDICAID

260 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b 81107 (I843S) Yes MEDICAID Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) 81108 Yes MEDICAID Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505E)) 81109 Yes MEDICAID Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3 [platelet glycoprotein IIIa, antigen CD61] [GPIIIa]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-6a/b (R489Q) 81110 Yes MEDICAID Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex, antigen CD41] [GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b 81111 (V837M) Yes MEDICAID Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 molecule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b 81112 (S682Y) Yes MEDICAID IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) 81120 Yes MEDICAID IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M 81121 Yes MEDICAID DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, 81161 No and duplication analysis, if performed MEDICAID BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (i.e., exon 13 del 3.83kb, exon 13 dup 6kb, exon 14- 20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb); full sequence analysis and full duplication/deletion analysis

81162 Yes MEDICAID ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kionase) (e.g., acquired imatinab tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain 81170 No MEDICAID

261 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kionase) (e.g., acquired imatinab 81170 tyrosine kinase inhibitor resistance), gene Yes analysis, variants in the kinase domain MEDICAID ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; 81175 full gene sequence Yes MEDICAID ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) 81176 Yes MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation 81206 Yes analysis; major breakpoint, qualitative or quantitative MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or 81207 quantitative No MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation 81207 Yes analysis; minor breakpoint, qualitative or quantitative MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or 81208 quantitative No MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation 81208 Yes analysis; other breakpoint, qualitative or quantitative MEDICAID BRAF (v-raf murine sarcoma viral oncogene homolog B1) (eg, colon cancer), gene analysis, V600E variant 81210 No MEDICAID BRAF (v-raf murine sarcoma viral oncogene homolog B1) (eg, colon 81210 Yes cancer), gene analysis, V600E variant MEDICAID BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)

81211 Yes MEDICAID BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 81212 6174delT variants Yes MEDICAID BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon 81213 duplication/deletion variants Yes MEDICAID BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) 81214 Yes MEDICAID

262 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; 81215 known familial variant Yes MEDICAID BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis 81216 Yes MEDICAID BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; 81217 known familial variant Yes MEDICAID CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myloid leukemia), gene analysis, full gene 81218 sequence No MEDICAID CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myloid 81218 Yes leukemia), gene analysis, full gene sequence MEDICAID CALR (calreticulin) (e.g., myeloproliferative disorders), gene 81219 analysis, common variants in exon 9 No MEDICAID CALR (calreticulin) (e.g., 81219 myeloproliferative disorders), gene Yes analysis, common variants in exon 9 MEDICAID CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) 81220 No MEDICAID CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) 81225 Yes MEDICAID CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) 81226 Yes MEDICAID CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common 81227 variants (eg, *2, *3, *5, *6) Yes MEDICAID CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common 81230 variant(s) (eg, *2, *22) Yes MEDICAID CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) 81231 Yes MEDICAID DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6)

81232 Yes MEDICAID EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 81235 LREA deletion, L858R, T790M, G719A, G719S, L861Q) No MEDICAID EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 81235 LREA deletion, L858R, T790M, G719A, Yes G719S, L861Q) MEDICAID

263 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines F9 (coagulation factor IX) (eg, hemophilia 81238 B), full gene sequence Yes MEDICAID FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants 81245 (ie, exons 14, 15) No MEDICAID FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis, 81245 Yes internal tandem duplication (ITD) variants (ie, exons 14, 15) MEDICAID FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants 81246 (eg, D835, I836) No MEDICAID G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common 81247 variant(s) (eg, A, A-) Yes MEDICAID G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial 81248 variant(s) Yes MEDICAID G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene 81249 sequence Yes MEDICAID HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant 81258 Yes MEDICAID HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence 81259 Yes MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) 81261 No MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to 81261 detect abnormal clonal population(s); Yes amplified methodology (eg, polymerase chain reaction) MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) 81262 No MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to 81262 detect abnormal clonal population(s); Yes direct probe methodology (eg, Southern blot) MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B- cell), variable region somatic mutation 81263 analysis No MEDICAID

264 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B- 81263 Yes cell), variable region somatic mutation analysis MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B- cell), variable region somatic mutation 81264 analysis No MEDICAID IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B- 81264 Yes cell), variable region somatic mutation analysis MEDICAID Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre- transplant recipient and donor germline testing, post-transplant non-hematopoietic recipient germline [eg, buccal swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells)

81265 No MEDICAID Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre- transplant recipient and donor germline testing, post-transplant non-hematopoietic 81265 recipient germline [eg, buccal swab or Yes other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells)

MEDICAID Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in multiple birth pregnancies) (List separately in addition to code for primary procedure)

81266 No MEDICAID Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in 81266 multiple birth pregnancies) (List separately Yes in addition to code for primary procedure)

MEDICAID Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes comparison to previously performed baseline analyses; without cell selection 81267 No MEDICAID Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes 81267 comparison to previously performed Yes baseline analyses; without cell selection MEDICAID

265 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes comparison to previously performed baseline analyses; with cell selection (eg, 81268 CD3, CD33), each cell type No MEDICAID Chimerism (engraftment) analysis, post transplantation specimen (eg, hematopoietic stem cell), includes 81268 comparison to previously performed Yes baseline analyses; with cell selection (eg, CD3, CD33), each cell type MEDICAID HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants 81269 Yes MEDICAID JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant 81270 No MEDICAID JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, 81270 Yes p.Val617Phe (V617F) variant MEDICAID KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g. gastrointestinal stromal tumor [GIST}, acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13,17, 18) 81272 No MEDICAID KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g. gastrointestinal stromal tumor [GIST}, 81272 acute myeloid leukemia, melanoma), gene Yes analysis, targeted sequence analysis (e.g., exons 8, 11, 13,17, 18) MEDICAID KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g.., mastocytosis), gene analysis, D816 81273 variant(s) No MEDICAID KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g.., 81273 Yes mastocytosis), gene analysis, D816 variant(s) MEDICAID KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) (eg, carcinoma) gene analysis, variants in codons 12 and 13 81275 No MEDICAID KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) (eg, carcinoma) gene analysis, 81275 Yes variants in codons 12 and 13 MEDICAID KRAS (Kirsten rat sarcoma viral oncogene homolog)(e.g. carcinoma) gene analysis; variants in exon 2 (e.g. codons 12 and 13); additional variant(s) (e.g. 81276 codon 61, codon 146) No MEDICAID KRAS (Kirsten rat sarcoma viral oncogene homolog)(e.g. carcinoma) gene 81276 analysis; variants in exon 2 (e.g. codons Yes 12 and 13); additional variant(s) (e.g. codon 61, codon 146) MEDICAID IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 81283 variant Yes MEDICAID

266 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis No MEDICAID Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed 81301 No MEDICAID Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for 81301 mismatch repair deficiency (eg, BAT25, Yes BAT26), includes comparison of neoplastic and normal tissue, if performed MEDICAID NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 81310 variants No MEDICAID NPM1 (nucleophosmin) (eg, acute 81310 myeloid leukemia) gene analysis, exon 12 Yes variants MEDICAID NRAS (neuroblastoma RAS viral [v- ras] oncogene homolog) (e.g., colorectal carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and exon 81311 3 (e.g., codon 61) No MEDICAID NRAS (neuroblastoma RAS viral [v- ras] oncogene homolog) (e.g., colorectal 81311 carcinoma), gene analysis, variants in Yes exon 2 (e.g., codons 12 and 13) and exon 3 (e.g., codon 61) MEDICAID PDGFRA (platelet-derived growth factor receptor, alpha polypeptide)(e.g., gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12, 18) 81314 No MEDICAID PDGFRA (platelet-derived growth factor receptor, alpha polypeptide)(e.g., gastrointestinal stromal tumor [GIST]), 81314 gene analysis, targeted sequence Yes analysis (e.g., exons 12, 18) MEDICAID PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; common breakpoints (eg, intron 3 and intron 6), qualitative or quantitative

81315 No MEDICAID PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation 81315 analysis; common breakpoints (eg, intron Yes 3 and intron 6), qualitative or quantitative

MEDICAID PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or 81316 quantitative No MEDICAID PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation 81316 analysis; single breakpoint (eg, intron 3, Yes intron 6 or exon 6), qualitative or quantitative MEDICAID

267 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) 81328 Yes MEDICAID RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) 81334 Yes MEDICAID TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) 81335 Yes MEDICAID TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, 81340 polymerase chain reaction) No MEDICAID TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect 81340 abnormal clonal population(s); using Yes amplification methodology (eg, polymerase chain reaction) MEDICAID TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) 81341 No MEDICAID TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect 81341 abnormal clonal population(s); using direct Yes probe methodology (eg, Southern blot) MEDICAID TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) 81342 No MEDICAID TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene 81342 rearrangement analysis, evaluation to Yes detect abnormal clonal population(s) MEDICAID TYMS (thymidylate synthetase) (eg, 5- fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem 81346 repeat variant) Yes MEDICAID HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) 81361 (eg, HbS, HbC, HbE) Yes MEDICAID HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial 81362 variant(s) Yes MEDICAID HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion 81363 variant(s) Yes MEDICAID HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence 81364 Yes MEDICAID

268 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, -C, - DRB1/3/4/5, and -DQB1 81370 Yes MEDICAID HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, and - DRB1/3/4/5 (eg, verification typing) 81371 Yes MEDICAID HLA Class I typing, low resolution (eg, antigen equivalents); complete (ie, HLA-A, 81372 -B, and -C) Yes MEDICAID HLA Class I typing, low resolution (eg, antigen equivalents); one locus (eg, HLA- 81373 A, -B, or -C), each Yes MEDICAID HLA Class I typing, low resolution (eg, antigen equivalents); one antigen 81374 equivalent (eg, B*27), each Yes MEDICAID HLA Class II typing, low resolution (eg, antigen equivalents); HLA-DRB1/3/4/5 81375 and -DQB1 Yes MEDICAID HLA Class II typing, low resolution (eg, antigen equivalents); one locus (eg, HLA- DRB1/3/4/5, -DQB1, -DQA1, -DPB1, or - 81376 DPA1), each Yes MEDICAID HLA Class II typing, low resolution (eg, antigen equivalents); one antigen 81377 equivalent, each Yes MEDICAID HLA Class I and II typing, high resolution (ie, alleles or allele groups), HLA-A, -B, - 81378 C, and -DRB1 Yes MEDICAID HLA Class I typing, high resolution (ie, alleles or allele groups); complete (ie, 81379 HLA-A, -B, and -C) Yes MEDICAID HLA Class I typing, high resolution (ie, alleles or allele groups); 1 locus (eg, HLA- 81380 A, -B, or -C), each Yes MEDICAID HLA Class I typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, B*57:01P), each 81381 Yes MEDICAID HLA Class II typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-DRB1, -DRB3, -DRB4, -DRB5, - DQB1, -DQA1, -DPB1, or -DPA1), each 81382 Yes MEDICAID HLA Class II typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, HLA-DQB1*06:02P), 81383 each Yes MEDICAID Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81445 No MEDICAID Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) 81448 Yes MEDICAID

269 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81455 No MEDICAID Autoimmune (rheumatoid arthritis), analysis of 12 biomarks using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score 81490 Yes MEDICAID 81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as tissue similarity scores Not Covered MEDICAID Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score 81519 No MEDICAID Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed 81519 paraffin embedded tissue, algorithm Yes reported as recurrence score MEDICAID Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score 81520 Yes MEDICAID Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 81520 housekeeping), utilizing formalin-fixed No paraffin-embedded tissue, algorithm reported as a recurrence risk score MEDICAID Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 81520 housekeeping), utilizing formalin-fixed No paraffin-embedded tissue, algorithm reported as a recurrence risk score MEDICAID Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 81520 housekeeping), utilizing formalin-fixed No paraffin-embedded tissue, algorithm reported as a recurrence risk score MEDICAID Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis 81521 Yes MEDICAID

270 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed 81521 paraffin-embedded tissue, algorithm No reported as index related to risk of distant metastasis MEDICAID Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed 81521 paraffin-embedded tissue, algorithm No reported as index related to risk of distant metastasis MEDICAID Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed 81521 paraffin-embedded tissue, algorithm No reported as index related to risk of distant metastasis MEDICAID Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a recurrence score 81525 Yes MEDICAID Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result 81528 No MEDICAID Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination 81535 Yes MEDICAID Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination; each additional single drug or drug combination (List separately in addition to code for primary procedure) 81536 Yes MEDICAID Oncology (lung), mass spectrometric 8- protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival 81538 Yes MEDICAID Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 81539 [hK2]), utilizing plasma or serum, prognostic Yes algorithm reported as a probability score MEDICAID Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality 81541 risk score Yes MEDICAID

271 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat 81551 biopsy Yes MEDICAID Unlisted multianalyte assay with 81599 No algorithmic analysis MEDICAID Unlisted multianalyte assay with 81599 No algorithmic analysis MEDICAID Unlisted multianalyte assay with 81599 No algorithmic analysis MEDICAID Acetone or other ketone bodies, serum; 82009 qualitative No MEDICAID Acetone or other ketone bodies, serum; 82010 quantitative No MEDICAID 82013 Acetylcholinesterase No MEDICAID Acylcarnitines; qualitative, each specimen 82016 No MEDICAID Acylcarnitines; quantitative, each 82017 specimen No MEDICAID 82024 Adrenocorticotropic hormone (ACTH) No MEDICAID Adenosine, 5-monophosphate, cyclic 82030 (cyclic AMP) No MEDICAID 82040 Albumin; serum No MEDICAID Albumin; urine or other source, 82042 quantitative, each specimen No MEDICAID Albumin; urine, microalbumin, quantitative 82043 No MEDICAID Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay) 82044 No MEDICAID 82045 Albumin; ischemia modified No MEDICAID 82075 Alcohol (ethanol); breath No MEDICAID 82085 Aldolase No MEDICAID 82088 Aldosterone No MEDICAID 82103 Alpha-1-antitrypsin; total No MEDICAID 82104 Alpha-1-antitrypsin; phenotype No MEDICAID 82105 Alpha-fetoprotein; serum No MEDICAID 82106 Alpha-fetoprotein; amniotic fluid No MEDICAID ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP 82107 No MEDICAID 82108 Aluminum No MEDICAID 82120 Amines, vaginal fluid, qualitative No MEDICAID Amino acids; single, qualitative, each 82127 specimen No MEDICAID Amino acids; multiple, qualitative, each 82128 specimen No MEDICAID Amino acids; single, quantitative, each 82131 specimen No MEDICAID 82135 Aminolevulinic acid, delta (ALA) No MEDICAID Amino acids, 2 to 5 amino acids, 82136 quantitative, each specimen No MEDICAID Amino acids, 6 or more amino acids, 82139 quantitative, each specimen No MEDICAID 82140 Ammonia No MEDICAID Amniotic fluid scan (spectrophotometric) 82143 No MEDICAID 82150 Amylase No MEDICAID 82154 Androstanediol glucuronide No MEDICAID 82157 Androstenedione No * MEDICAID 82160 Androsterone No MEDICAID 82163 Angiotensin II No MEDICAID Angiotensin I - converting enzyme (ACE) 82164 No MEDICAID 82172 Apolipoprotein, each No MEDICAID 82175 Arsenic No MEDICAID 82180 Ascorbic acid (Vitamin C), blood No MEDICAID

272 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Atomic absorption spectroscopy, each 82190 analyte No MEDICAID 82232 Beta-2 microglobulin No MEDICAID 82239 Bile acids; total No MEDICAID 82240 Bile acids; cholylglycine No MEDICAID 82247 Bilirubin; total No MEDICAID 82248 Bilirubin; direct No MEDICAID 82252 Bilirubin; feces, qualitative No MEDICAID 82261 Biotinidase, each specimen No MEDICAID Blood, occult, by peroxidase activity (eg, 82270 guaiac), qualitative; feces, No MEDICAID 82271 Occult blood, feces, single No MEDICAID 82272 Blood occult peroxidase No MEDICAID Blood, occult, by fecal hemoglobin 82274 determination by immunoassay, No MEDICAID 82286 Bradykinin No MEDICAID 82300 Cadmium No MEDICAID 82306 Calcifediol (25-OH Vitamin D-3) No MEDICAID 82308 Calcitonin No MEDICAID 82310 Calcium; total No MEDICAID 82330 Calcium; ionized No MEDICAID 82331 Calcium; after calcium infusion test No MEDICAID Calcium; urine quantitative, timed 82340 specimen No MEDICAID 82355 Calculus; qualitative analysis No MEDICAID Calculus; quantitative analysis, chemical 82360 No MEDICAID 82365 Calculus; infrared spectroscopy No MEDICAID 82370 Calculus; x-ray diffraction No MEDICAID 82373 Carbohydrate deficient transferrin No MEDICAID 82374 Carbon dioxide (bicarbonate) No MEDICAID Carbon monoxide, (carboxyhemoglobin); 82375 quantitative No MEDICAID Carbon monoxide, (carboxyhemoglobin); 82376 qualitative No MEDICAID 82378 Carcinoembryonic antigen (CEA) No MEDICAID Carnitine (total and free), quantitative, 82379 each specimen No MEDICAID 82380 Carotene No MEDICAID 82382 Catecholamines; total urine No MEDICAID 82383 Catecholamines; blood No MEDICAID 82384 Catecholamines; fractionated No MEDICAID 82387 CATHEPSIN-D Not covered MEDICAID 82390 Ceruloplasmin No MEDICAID 82397 Chemiluminescent assay No MEDICAID 82415 Chloramphenicol No MEDICAID 82435 Chloride; blood No MEDICAID 82436 Chloride; urine No MEDICAID 82438 Chloride; other source No MEDICAID 82441 Chlorinated hydrocarbons, screen No MEDICAID Cholesterol, serum or whole blood, total 82465 No MEDICAID 82480 Cholinesterase; serum No MEDICAID 82482 Cholinesterase; RBC No MEDICAID 82485 Chondroitin B sulfate, quantitative No MEDICAID 82495 Chromium No MEDICAID 82507 Citrate No MEDICAID COLLAGEN CROSS LINKS, ANY 82523 METHOD No MEDICAID 82525 Copper No MEDICAID 82528 Corticosterone No MEDICAID 82530 Cortisol; free No MEDICAID 82533 Cortisol; total No MEDICAID 82540 Creatine No MEDICAID Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), 82542 No MEDICAID 82550 Creatine kinase (CK), (CPK); total No MEDICAID

273 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Creatine kinase (CK), (CPK); isoenzymes 82552 No MEDICAID Creatine kinase (CK), (CPK); MB fraction 82553 only No MEDICAID Creatine kinase (CK), (CPK); isoforms 82554 No MEDICAID 82565 Creatinine; blood No MEDICAID 82570 Creatinine; other source No MEDICAID 82575 Creatinine; clearance No MEDICAID 82585 Cryofibrinogen No MEDICAID Cryoglobulin, qualitative or semi- 82595 quantitative (eg, cryocrit) No MEDICAID 82600 Cyanide No MEDICAID 82607 Cyanocobalamin (Vitamin B-12); No MEDICAID Cyanocobalamin (Vitamin B-12); 82608 unsaturated binding capacity No MEDICAID 82610 CYSTATIN C No MEDICAID Cystine and homocystine, urine, 82615 qualitative No MEDICAID 82626 Dehydroepiandrosterone (DHEA) No * MEDICAID Dehydroepiandrosterone-sulfate (DHEA- 82627 S) No * MEDICAID 82633 Desoxycorticosterone, 11- No MEDICAID 82634 Deoxycortisol, 11- No MEDICAID 82638 Dibucaine number No MEDICAID 82652 Dihydroxyvitamin D, 1,25- No MEDICAID Elastase, pancreatic (EL-1), fecal, 82656 qualitative or semi-quantitative No MEDICAID Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere 82657 No MEDICAID Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere 82658 No MEDICAID Electrophoretic technique, not elsewhere 82664 specified Yes MEDICAID 82668 Erythropoietin No MEDICAID 82670 Estradiol No * MEDICAID 82671 Estrogens; fractionated No * MEDICAID 82672 Estrogens; total No * MEDICAID 82677 Estriol No MEDICAID 82679 Estrone No * MEDICAID 82693 Ethylene glycol No MEDICAID 82696 Etiocholanolone No MEDICAID 82705 Fat or lipids, feces; qualitative No * MEDICAID 82710 Fat or lipids, feces; quantitative No MEDICAID 82715 Fat differential, feces, quantitative No MEDICAID 82725 Fatty acids, nonesterified No MEDICAID 82726 Very long chain fatty acids No MEDICAID 82728 Ferritin No MEDICAID Fetal fibronectin, cervicovaginal 82731 secretions, semi-quantitative No MEDICAID 82735 Fluoride No MEDICAID 82746 Folic acid; serum No MEDICAID 82747 Folic acid; RBC No MEDICAID 82757 Fructose, semen No * MEDICAID 82759 Galactokinase, RBC No MEDICAID 82760 Galactose No MEDICAID Galactose-1-phosphate uridyl transferase; 82775 quantitative No MEDICAID Galactose-1-phosphate uridyl transferase; 82776 screen No MEDICAID 82777 Galectin-3 Yes MEDICAID 82777 Galectin-3 No MEDICAID 82777 Galectin-3 No MEDICAID Gammaglobulin; IgA, IgD, IgG, IgM, each 82784 No MEDICAID 82785 Gammaglobulin; IgE No MEDICAID

274 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Gammaglobulin; immunoglobulin 82787 subclasses, (IgG1, 2, 3, or 4), each No MEDICAID 82800 Gases, blood, pH only No MEDICAID Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including 82803 No MEDICAID Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including 82805 No MEDICAID Gases, blood, O2 saturation only, by 82810 direct measurement, except pulse No MEDICAID Hemoglobin-oxygen affinity (pO2 for 50% 82820 hemoglobin saturation with No MEDICAID 82930 Gastric acid analysis, includes pH if performed, each specimen No MEDICAID 82938 Gastrin after secretin stimulation No MEDICAID 82941 Gastrin No MEDICAID 82943 Glucagon No MEDICAID 82945 Glucose, body fluid, other than blood No MEDICAID 82946 Glucagon tolerance test No MEDICAID Glucose; quantitative, blood (except 82947 reagent strip) No * MEDICAID 82948 Glucose; blood, reagent strip No MEDICAID Glucose; post glucose dose (includes 82950 glucose) No MEDICAID Glucose; tolerance test (GTT), three 82951 specimens (includes glucose) No * MEDICAID Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82952 No * MEDICAID Glucose-6-phosphate dehydrogenase 82955 (G6PD); quantitative No MEDICAID Glucose-6-phosphate dehydrogenase 82960 (G6PD); screen No MEDICAID Glucose, blood by glucose monitoring device(s) cleared by the FDA 82962 No MEDICAID 82963 Glucosidase, beta No MEDICAID 82965 Glutamate dehydrogenase No MEDICAID 82977 Glutamyltransferase, gamma (GGT) No MEDICAID 82978 Glutathione No MEDICAID 82979 Glutathione reductase, RBC No MEDICAID 82985 Glycated protein No MEDICAID Gonadotropin; follicle stimulating hormone 83001 (FSH) No * MEDICAID Gonadotropin; luteinizing hormone (LH) 83002 No * MEDICAID Growth hormone, human (HGH) 83003 (somatotropin) No MEDICAID Growth stimulation expressed gene 2 83006 (ST2, Interleukin 1 receptor like-1) No MEDICAID Helicobacter pylori, blood test analysis for 83009 urease activity, No MEDICAID 83010 Haptoglobin; quantitative No MEDICAID 83012 Haptoglobin; phenotypes No MEDICAID Helicobacter pylori; breath test analysis 83013 for urease activity, No MEDICAID Helicobacter pylori; drug administration 83014 No MEDICAID Heavy metal (eg, arsenic, barium, 83015 beryllium, bismuth, antimony, No MEDICAID Heavy metal (eg, arsenic, barium, 83018 beryllium, bismuth, antimony, No * MEDICAID Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, 83020 No MEDICAID Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, 83021 No MEDICAID

275 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Hemoglobin; by copper sulfate method, 83026 non-automated No MEDICAID 83030 Hemoglobin; F (fetal), chemical No MEDICAID 83033 Hemoglobin; F (fetal), qualitative No MEDICAID 83036 Hemoglobin; glycated No MEDICAID 83037 Glycosylated hb, home device No MEDICAID Hemoglobin; methemoglobin, qualitative 83045 No MEDICAID Hemoglobin; methemoglobin, quantitative 83050 No MEDICAID 83051 Hemoglobin; plasma No MEDICAID Hemoglobin; sulfhemoglobin, quantitative 83060 No MEDICAID 83065 Hemoglobin; thermolabile No MEDICAID 83068 Hemoglobin; unstable, screen No MEDICAID 83069 Hemoglobin; urine No MEDICAID 83070 Hemosiderin; qualitative No MEDICAID 83080 b-Hexosaminidase, each assay No MEDICAID 83088 Histamine No MEDICAID 83090 Homocystine No MEDICAID 83150 Homovanillic acid (HVA) No MEDICAID Hydroxycorticosteroids, 17- (17-OHCS) 83491 No MEDICAID HYDROXYINDOLACETIC ACID, 5- 83497 (HIAA) No MEDICAID 83498 Hydroxyprogesterone, 17-d No * MEDICAID 83500 Hydroxyproline; free No MEDICAID 83505 Hydroxyproline; total No MEDICAID Immunoassay for analyte other than 83516 infectious agent antibody or No * MEDICAID Immunoassay for analyte other than 83518 infectious agent antibody or No MEDICAID Immunoassay, analyte, quantitative; by 83519 radiopharmaceutical technique No MEDICAID Immunoassay, analyte, quantitative; not 83520 otherwise specified No MEDICAID 83525 Insulin; total No MEDICAID 83527 Insulin; free No MEDICAID 83528 Intrinsic factor No MEDICAID 83540 Iron No MEDICAID 83550 Iron binding capacity No MEDICAID 83570 Isocitric dehydrogenase (IDH) No MEDICAID 83582 Ketogenic steroids, fractionation No MEDICAID 83586 Ketosteroids, 17- (17-KS); total No MEDICAID Ketosteroids, 17- (17-KS); fractionation 83593 No MEDICAID 83605 Lactate (lactic acid) No MEDICAID 83615 Lactate dehydrogenase (LD), (LDH); No MEDICAID Lactate dehydrogenase (LD), (LDH); 83625 isoenzymes, separation and No MEDICAID 83630 Lactoferrin, fecal, qualitative No MEDICAID 83631 Lactoferrin, fecal (quant) No MEDICAID Lactogen, human placental (HPL) human chorionic somatomammotropin 83632 No MEDICAID 83633 Lactose, urine; qualitative No MEDICAID 83655 Assay blood for Lead No MEDICAID Fetal lung maturity assessment; lecithin 83661 sphingomyelin (L/S) ratio No MEDICAID Fetal lung maturity assessment; foam 83662 stability test No MEDICAID Fetal lung maturity assessment; 83663 fluorescence polarization No MEDICAID Fetal lung maturity assessment; lamellar 83664 body density No MEDICAID 83670 Leucine aminopeptidase (LAP) No MEDICAID 83690 Lipase No MEDICAID 83695 Assay of lipoprotein(a) No MEDICAID

276 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LIPO-PROTEIN-ASSOCIATED 83698 PHOSPHOLIPASE A2, (LP-PLA2) No MEDICAID 83700 Lipopro bld, electrophoretic No MEDICAID 83701 Lipoprotein bld, hr fraction No MEDICAID 83704 Lipoprotein, bld, by nmr No MEDICAID Lipoprotein, direct measurement; high 83718 density cholesterol (HDL No MEDICAID Lipoprotein, direct measurement; direct measurement, VLDL cholesterol 83719 No MEDICAID Lipoprotein, direct measurement; direct 83721 measurement, LDL cholesterol No MEDICAID 83727 Luteinizing releasing factor (LRH) No MEDICAID 83735 Magnesium No MEDICAID 83775 Malate dehydrogenase No MEDICAID 83785 Manganese No MEDICAID Mass spectrometry and tandem mass 83789 spectrometry (MS, MS/MS), No MEDICAID 83825 Mercury, quantitative No MEDICAID 83835 Metanephrines No MEDICAID 83857 Methemalbumin No MEDICAID Microfluidic analysis utilizing an integrated 83861 collection and analysis device, tear No osmolarity MEDICAID Mucopolysaccharides, acid; quantitative 83864 No MEDICAID 83872 Mucin, synovial fluid (Ropes test) No MEDICAID Myelin basic protein, cerebrospinal fluid 83873 No MEDICAID 83874 Myoglobin No MEDICAID 83876 Myeloperoxidase (MPO) No MEDICAID 83880 Natriuretic peptide No MEDICAID Nephelometry, each analyte not 83883 elsewhere specified No MEDICAID 83885 Nickel No MEDICAID 83915 Nucleotidase 5- No MEDICAID Oligoclonal immune (oligoclonal bands) 83916 No MEDICAID Organic acids; total, quantitative, each 83918 specimen No MEDICAID Organic acids; qualitative, each specimen 83919 No MEDICAID 83921 Organic acid, single, quantitative No MEDICAID 83930 Osmolality; blood No MEDICAID 83935 Osmolality; urine No MEDICAID 83937 Osteocalcin (bone g1a protein) No MEDICAID 83945 Oxalate No MEDICAID 83950 Oncoprotein, HER-2/neu No MEDICAID Oncoprotein; des-gamma-carboxy- 83951 prothrombin (DCP) No MEDICAID Oncoprotein; des-gamma-carboxy- 83951 No prothrombin (DCP) MEDICAID 83970 Parathormone (parathyroid hormone) No MEDICAID 83986 pH, body fluid, except blood No MEDICAID ASSAY PH; EXHALED BREATH 83987 CONDENSATE No MEDICAID 83992 Phencyclidine (PCP) No MEDICAID 83993 CALPROTECTIN, FECAL No MEDICAID 84030 Phenylalanine (PKU), blood No MEDICAID 84035 Phenylketones, qualitative No MEDICAID 84060 Phosphatase, acid; total No MEDICAID 84066 Phosphatase, acid; prostatic No MEDICAID 84075 Phosphatase, alkaline; No MEDICAID Phosphatase, alkaline; heat stable (total 84078 not included) No MEDICAID 84080 Phosphatase, alkaline; isoenzymes No MEDICAID 84081 Phosphatidylglycerol No MEDICAID Phosphogluconate, 6-, dehydrogenase, 84085 RBC No MEDICAID

277 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 84087 Phosphohexose isomerase No MEDICAID 84100 Phosphorus inorganic (phosphate); No MEDICAID Phosphorus inorganic (phosphate); urine 84105 No MEDICAID 84106 Porphobilinogen, urine; qualitative No MEDICAID 84110 Porphobilinogen, urine; quantitative No MEDICAID Placental alpha microglobulin-1 (PAMG- 1), cervicovaginal secretion, qualitative 84112 No MEDICAID 84119 Porphyrins, urine; qualitative No MEDICAID Porphyrins, urine; quantitation and 84120 fractionation No MEDICAID 84126 Porphyrins, feces; quantitative No MEDICAID 84132 Potassium; serum No MEDICAID 84133 Potassium; urine No MEDICAID 84134 Prealbumin No MEDICAID 84135 Pregnanediol No * MEDICAID 84138 Pregnanetriol No MEDICAID 84140 Pregnenolone No MEDICAID 84143 17-hydroxypregnenolone No * MEDICAID 84144 Progesterone No * MEDICAID 84145 ASSAY PROCALCITONIN (PCT) No MEDICAID 84146 Prolactin No * MEDICAID 84150 Prostaglandin, each No MEDICAID Prostate specific antigen (PSA); 84152 complexed (direct measurement) No MEDICAID 84153 Prostate specific antigen (PSA); total No MEDICAID 84154 Prostate specific antigen (PSA); free No MEDICAID Protein, total, except by refractometry; 84155 serum No MEDICAID Protein, total, except by refractometry; 84156 urine No MEDICAID Protein, total, except by refractometry; 84157 other source (eg, synovial No MEDICAID Protein, total, by refractometry, any 84160 source No MEDICAID Pregnancy-associated plasma protein-A 84163 (PAPP-A) No MEDICAID Protein; electrophoretic fractionation and 84165 quantitation, serum No MEDICAID Protein; electrophoretic fractionation and 84166 quantitation, other fluids No MEDICAID Protein; Western Blot, with interpretation and report, blood or other 84181 No MEDICAID Protein; Western Blot, with interpretation and report, blood or other 84182 No MEDICAID 84202 Protoporphyrin, RBC; quantitative No MEDICAID 84203 Protoporphyrin, RBC; screen No MEDICAID 84206 Proinsulin No MEDICAID 84207 Pyridoxal phosphate (Vitamin B-6) No MEDICAID 84210 Pyruvate No MEDICAID 84220 Pyruvate kinase No MEDICAID 84228 Quinine No MEDICAID 84233 Receptor assay; estrogen No MEDICAID 84234 Receptor assay; progesterone No MEDICAID Receptor assay; endocrine, other than estrogen or progesterone (specify 84235 No MEDICAID Receptor assay; non-endocrine (eg, 84238 acetylcholine) (specify receptor) No MEDICAID 84244 Renin No MEDICAID 84252 Riboflavin (Vitamin B-2) No MEDICAID 84255 Selenium No MEDICAID 84260 Serotonin No MEDICAID Sex hormone binding globulin (SHBG) 84270 No MEDICAID 84275 SIALIC ACID Not Covered MEDICAID

278 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 84285 SILICA No MEDICAID 84295 Sodium; serum No MEDICAID 84300 Sodium; urine No MEDICAID 84302 Sodium; other source No MEDICAID 84305 Somatomedin No MEDICAID 84307 Somatostatin No MEDICAID Spectrophotometry, analyte not elsewhere 84311 specified No MEDICAID 84315 Specific gravity (except urine) No MEDICAID Sugars, chromatographic, TLC or paper 84375 chromatography No MEDICAID Sugars (mono-, di-, and oligosaccharides); single qualitative, each 84376 No MEDICAID Sugars (mono-, di-, and oligosaccharides); multiple qualitative, 84377 each No MEDICAID Sugars (mono-, di-, and oligosaccharides); single quantitative, 84378 each No MEDICAID Sugars (mono-, di-, and oligosaccharides); multiple quantitative, 84379 each No MEDICAID 84392 Sulfate, urine No MEDICAID 84402 Testosterone; free No * MEDICAID 84403 Testosterone; total No * MEDICAID 84410 Testosterone; bioavailable, direct measurement (eg, differential precipitation) No MEDICAID 84425 Thiamine (Vitamin B-1) No MEDICAID 84430 Thiocyanate No MEDICAID ASSAY THROMBOXANE METABOLITE(S), INCLUDING THROMBOXANE IF PERFORMED, 84431 URINE No MEDICAID 84432 Thyroglobulin No MEDICAID 84436 Thyroxine; total No MEDICAID Thyroxine; requiring elution (eg, neonatal) 84437 No MEDICAID 84439 Thyroxine; free No MEDICAID 84442 Thyroxine binding globulin (TBG) No MEDICAID 84443 Thyroid stimulating hormone (TSH) No * MEDICAID Thyroid stimulating immune globulins 84445 (TSI) No MEDICAID 84446 Tocopherol alpha (Vitamin E) No MEDICAID 84449 Transcortin (cortisol binding globulin) No MEDICAID Transferase; aspartate amino (AST) 84450 (SGOT) No MEDICAID Transferase; alanine amino (ALT) (SGPT) 84460 No MEDICAID 84466 Transferrin No MEDICAID 84478 Triglycerides No MEDICAID Thyroid hormone (T3 or T4) uptake or 84479 thyroid hormone binding ratio No MEDICAID 84480 Triiodothyronine T3; total (TT-3) No MEDICAID 84481 Triiodothyronine T3; free No MEDICAID 84482 Triiodothyronine T3; reverse No MEDICAID 84484 Troponin, quantitative No MEDICAID 84485 Trypsin; duodenal fluid No MEDICAID 84488 Trypsin; feces, qualitative No MEDICAID Trypsin; feces, quantitative, 24-hour 84490 collection No MEDICAID 84510 Tyrosine No MEDICAID 84512 Troponin, qualitative No MEDICAID 84520 Urea nitrogen; quantitative No MEDICAID Urea nitrogen; semiquantitative (eg, 84525 reagent strip test) No MEDICAID 84540 Urea nitrogen, urine No MEDICAID 84545 Urea nitrogen, clearance No MEDICAID

279 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 84550 Uric acid; blood No MEDICAID 84560 Uric acid; other source No MEDICAID 84577 Urobilinogen, feces, quantitative No MEDICAID 84578 Urobilinogen, urine; qualitative No MEDICAID Urobilinogen, urine; quantitative, timed 84580 specimen No MEDICAID 84583 Urobilinogen, urine; semiquantitative No MEDICAID 84585 Vanillylmandelic acid (VMA), urine No MEDICAID 84586 Vasoactive intestinal peptide (VIP) No MEDICAID Vasopressin (antidiuretic hormone, ADH) 84588 No MEDICAID 84590 Vitamin A No MEDICAID 84591 Vitamin, not otherwise specified No MEDICAID 84597 Vitamin K No MEDICAID Volatiles (eg, acetic anhydride, carbon 84600 tetrachloride, dichloroethane, No MEDICAID Xylose absorption test, blood and/or urine 84620 No MEDICAID 84630 Zinc No MEDICAID 84681 C-peptide No MEDICAID Gonadotropin, chorionic (hCG); 84702 quantitative No * MEDICAID Gonadotropin, chorionic (hCG); qualitative 84703 No * MEDICAID GONADOTROPIN, CHORIONIC (hCG); 84704 FREE BETA CHAIN No MEDICAID Ovulation tests, by visual color 84830 comparison methods for human No * MEDICAID 84999 Unlisted chemistry procedure No MEDICAID 85002 Bleeding time No MEDICAID Blood count; automated differential WBC 85004 count No MEDICAID Blood count; blood smear, microscopic examination with manual 85007 No MEDICAID Blood count; blood smear, microscopic examination without manual 85008 No MEDICAID Blood count; manual differential WBC 85009 count, buffy coat No MEDICAID 85013 Blood count; spun microhematocrit No MEDICAID 85014 Blood count; hematocrit (Hct) No MEDICAID 85018 Blood count; hemoglobin (Hgb) No MEDICAID Blood count; complete (CBC), automated 85025 (Hgb, Hct, RBC, WBC and No MEDICAID Blood count; complete (CBC), automated 85027 (Hgb, Hct, RBC, WBC and No MEDICAID Blood count; manual cell count 85032 (erythrocyte, leukocyte, or platelet) No MEDICAID Blood count; red blood cell (RBC), 85041 automated No MEDICAID 85044 Blood count; reticulocyte, manual No MEDICAID 85045 Blood count; reticulocyte, automated No MEDICAID Blood count; reticulocytes, automated, including one or more cellular 85046 No MEDICAID Blood count; leukocyte (WBC), automated 85048 No * MEDICAID 85049 Blood count; platelet, automated No MEDICAID 85055 Reticulated platelet assay No MEDICAID Blood smear, peripheral, interpretation by physician with written report 85060 No MEDICAID 85097 Bone marrow, smear interpretation No MEDICAID 85130 Chromogenic substrate assay No MEDICAID 85170 Clot retraction No MEDICAID 85175 Clot lysis time, whole blood dilution No MEDICAID Clotting; factor II, prothrombin, specific 85210 No MEDICAID

280 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Clotting; factor V (AcG or proaccelerin), 85220 labile factor No MEDICAID Clotting; factor VII (proconvertin, stable 85230 factor) No MEDICAID 85240 Clotting; factor VIII (AHG), one stage No MEDICAID 85244 Clotting; factor VIII related antigen No MEDICAID Clotting; factor VIII, VW factor, ristocetin 85245 cofactor No MEDICAID 85246 Clotting; factor VIII, VW factor antigen No MEDICAID Clotting; factor VIII, von Willebrand factor, 85247 multimetric analysis No MEDICAID 85250 Clotting; factor IX (PTC or Christmas) No MEDICAID 85260 Clotting; factor X (Stuart-Prower) No MEDICAID 85270 Clotting; factor XI (PTA) No MEDICAID 85280 Clotting; factor XII (Hageman) No MEDICAID 85290 Clotting; factor XIII (fibrin stabilizing) No MEDICAID Clotting; factor XIII (fibrin stabilizing), 85291 screen solubility No MEDICAID Clotting; prekallikrein assay (Fletcher 85292 factor assay) No MEDICAID Clotting; high molecular weight kininogen 85293 assay (Fitzgerald factor No MEDICAID Clotting inhibitors or anticoagulants; 85300 antithrombin III, activity No MEDICAID Clotting inhibitors or anticoagulants; 85301 antithrombin III, antigen assay No MEDICAID Clotting inhibitors or anticoagulants; 85302 protein C, antigen No MEDICAID Clotting inhibitors or anticoagulants; 85303 protein C, activity No MEDICAID Clotting inhibitors or anticoagulants; 85305 protein S, total No MEDICAID Clotting inhibitors or anticoagulants; 85306 protein S, free No MEDICAID Activated Protein C (APC) resistance 85307 assay No MEDICAID 85335 Factor inhibitor test No MEDICAID 85337 Thrombomodulin No MEDICAID 85345 Coagulation time; Lee and White No MEDICAID 85347 Coagulation time; activated No MEDICAID 85348 Coagulation time; other methods No MEDICAID 85360 Euglobulin lysis No MEDICAID Fibrin(ogen) degradation (split) products 85362 (FDP)(FSP); agglutination No MEDICAID Fibrin(ogen) degradation (split) products (FDP)(FSP); paracoagulation 85366 No MEDICAID Fibrin(ogen) degradation (split) products 85370 (FDP)(FSP); quantitative No MEDICAID Fibrin degradation products, D-dimer; 85378 qualitative or semiquantitative No MEDICAID Fibrin degradation products, D-dimer; 85379 quantitative No MEDICAID Fibrin degradation products, D-dimer; ultrasensitive (eg, for evaluation 85380 No MEDICAID 85384 Fibrinogen; activity No MEDICAID 85385 Fibrinogen; antigen No MEDICAID Fibrinolysins or coagulopathy screen, 85390 interpretation and report No MEDICAID Coagulation/fibrinolysis assay, whole 85396 blood (eg, viscoelastic clot No MEDICAID Coagulation and fibrinolysis, functional activty, not otherwise specified (eg, ADAMTS-13), each analyte 85397 No MEDICAID Fibrinolytic factors and inhibitors; plasmin 85400 No MEDICAID Fibrinolytic factors and inhibitors; alpha-2 85410 antiplasmin No MEDICAID

281 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Fibrinolytic factors and inhibitors; 85415 plasminogen activator No MEDICAID Fibrinolytic factors and inhibitors; 85420 plasminogen, except antigenic assay No MEDICAID Fibrinolytic factors and inhibitors; 85421 plasminogen, antigenic assay No MEDICAID 85441 Heinz bodies; direct No MEDICAID Heinz bodies; induced, acetyl 85445 phenylhydrazine No MEDICAID Hemoglobin or RBCs, fetal, for 85460 fetomaternal hemorrhage; differential No MEDICAID Hemoglobin or RBCs, fetal, for 85461 fetomaternal hemorrhage; rosette No MEDICAID 85475 Hemolysin, acid No MEDICAID 85520 Heparin assay No MEDICAID 85525 Heparin neutralization No MEDICAID 85530 Heparin-protamine tolerance test No MEDICAID 85536 Iron stain, peripheral blood No MEDICAID Leukocyte alkaline phosphatase with 85540 count No MEDICAID 85547 Mechanical fragility, RBC No MEDICAID 85549 Muramidase No MEDICAID 85555 Osmotic fragility, RBC; unincubated No MEDICAID 85557 Osmotic fragility, RBC; incubated No MEDICAID Platelet, aggregation (in vitro), each agent 85576 No MEDICAID 85597 Phospholipid neutralization; platelet No MEDICAID Phospholipid neutralization; hexagonal 85598 phospholipid No MEDICAID 85610 Prothrombin time; No MEDICAID Prothrombin time; substitution, plasma 85611 fractions, each No MEDICAID Russell viper venom time (includes 85612 venom); undiluted No MEDICAID Russell viper venom time (includes 85613 venom); diluted No MEDICAID 85635 Reptilase test No MEDICAID Sedimentation rate, erythrocyte; non- 85651 automated No MEDICAID Sedimentation rate, erythrocyte; 85652 automated No MEDICAID 85660 Sickling of RBC, reduction No MEDICAID 85670 Thrombin time; plasma No MEDICAID 85675 Thrombin time; titer No MEDICAID 85705 Thromboplastin inhibition, tissue No MEDICAID Thromboplastin time, partial (PTT); 85730 plasma or whole blood No MEDICAID Thromboplastin time, partial (PTT); 85732 substitution, plasma fractions, each No MEDICAID 85810 Viscosity No MEDICAID UNLISTED HEMATOLOGY AND 85999 COAGULATION PROCEDURE No MEDICAID Agglutinins, febrile (eg, Brucella, 86000 Francisella, Murine typhus, Q fever, No MEDICAID ALLERGEN SPECIFIC IgG QUANTITATIVE OR SEMIQUANTITATIVE, EACH 86001 ALLERGEN No MEDICAID ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH 86003 ALLERGEN No * MEDICAID ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE OR DISK) 86005 No * MEDICAID Allergen specific IgE; quantitative or semiquantitative, recombinant or purified 86008 component, each No MEDICAID

282 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Antibody identification; leukocyte 86021 antibodies No MEDICAID Antibody identification; platelet antibodies 86022 No MEDICAID Antibody identification; platelet associated 86023 immunoglobulin assay No MEDICAID 86038 Antinuclear antibodies (ANA); No MEDICAID 86039 Antinuclear antibodies (ANA); titer No MEDICAID 86060 Antistreptolysin 0; titer No MEDICAID 86063 Antistreptolysin 0; screen No MEDICAID Blood bank physician services; difficult cross match and/or evaluation 86077 No MEDICAID Blood bank physician services; 86078 investigation of transfusion reaction No MEDICAID Blood bank physician services; authorization for deviation from standard 86079 No MEDICAID 86140 C-reactive protein; No MEDICAID C-reactive protein; high sensitivity 86141 (hsCRP) No MEDICAID 86146 Beta 2 Glycoprotein I antibody, each No MEDICAID Cardiolipin (phospholipid) antibody, each 86147 Ig class No MEDICAID Anti-phosphatidylserine (phospholipid) 86148 antibody No MEDICAID Cell enumeration using immunologic selection and identification in fluid 86152 No specimen (eg, circulating tumor cells in blood); MEDICAID Cell enumeration using immunologic selection and identification in fluid 86153 specimen (eg, circulating tumor cells in No blood); physician interpretation and report, when required MEDICAID 86155 Chemotaxis assay, specify method No MEDICAID 86156 Cold agglutinin; screen No MEDICAID 86157 Cold agglutinin; titer No MEDICAID Complement; antigen, each component 86160 No MEDICAID Complement; functional activity, each 86161 component No MEDICAID 86162 Complement; total hemolytic (CH50) No MEDICAID Complement fixation tests, each antigen 86171 No MEDICAID 86200 Ccp antibody No MEDICAID 86215 Deoxyribonuclease, antibody No MEDICAID Deoxyribonucleic acid (DNA) antibody; 86225 native or double stranded No MEDICAID Deoxyribonucleic acid (DNA) antibody; 86226 single stranded No MEDICAID Extractable nuclear antigen, antibody to, 86235 any method (eg, nRNP, SS-A, No MEDICAID Fluorescent noninfectious agent antibody; 86255 screen, each antibody No MEDICAID Fluorescent noninfectious agent antibody; 86256 titer, each antibody No MEDICAID Growth hormone, human (HGH), antibody 86277 No MEDICAID 86280 Hemagglutination inhibition test (HAI) No MEDICAID IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE IR 86294 SEMIQUANTITATIVE (eg, No MEDICAID IMMUNOASSAY FOR TUMOR ANTIGEN QUANTITATIVE; CA 15-3 (27.29) 86300 No MEDICAID IMMUNOASSAY FOR TUMOR 86301 ANTIGEN, QUANTITATIVE; CA 19-9 No MEDICAID IMMUNOASSAY FOR TUMOR 86304 ANTIGEN, QUANTITATIVE; CA 125 No MEDICAID

283 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IMMUNOLOGY: HUMAN EPIDIDYMIS 86305 PROTEIN (HE4). No MEDICAID 86308 Heterophile antibodies; screening No MEDICAID 86309 Heterophile antibodies; titer No MEDICAID Heterophile antibodies; titers after 86310 absorption with beef cells and No MEDICAID IMMUNOASSAY FOR TUMOR ANTIGEN (EG, CANCER ANTIGEN 125), EACH 86316 No MEDICAID Immunoassay for infectious agent 86317 antibody, quantitative, not otherwise No MEDICAID Immunoassay for infectious agent 86318 antibody, qualitative or No MEDICAID 86320 Immunoelectrophoresis; serum No MEDICAID Immunoelectrophoresis; other fluids (eg, 86325 urine, cerebrospinal fluid) No MEDICAID Immunoelectrophoresis; crossed (2- 86327 dimensional assay) No MEDICAID Immunodiffusion; not elsewhere specified 86329 No MEDICAID Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen 86331 No MEDICAID 86332 Immune complex assay No MEDICAID Immunofixation electrophoresis; serum 86334 No MEDICAID Immunofixation electrophoresis; other 86335 fluids with concentration No MEDICAID 86336 Inhibin A No MEDICAID 86337 Insulin antibodies No MEDICAID 86340 Intrinsic factor antibodies No MEDICAID 86341 Islet cell antibody No MEDICAID Leukocyte histamine release test (LHR) 86343 Not Covered MEDICAID 86344 Leukocyte phagocytosis No MEDICAID CELLULAR FUNCTION ASSAY INVOLVING STIMULATION (EG, MITOGEN OR ANTIGEN) AND DETECTION OF A BIOMARKER (EG, 86352 ATP) No MEDICAID Lymphocyte transformation, mitogen 86353 (phytomitogen) or antigen induced No MEDICAID 86355 B cells, total count No MEDICAID MONONUCLEAR CELL ANTIGEN, QUANTITATIVE (EG, FLOW CYTOMETRY), NOT OTHERWISE 86356 SPECIFIED, EACH ANTIGEN No MEDICAID 86357 Nk cells, total count No MEDICAID 86359 T cells; total count No MEDICAID T cells; absolute CD4 and CD8 count, 86360 including ratio No MEDICAID 86361 T cells; absolute CD4 count No MEDICAID 86367 Stem cells, total count No MEDICAID Microsomal antibodies (eg, thyroid or liver- 86376 kidney), each No MEDICAID 86382 Neutralization test, viral No MEDICAID 86384 Nitroblue tetrazolium dye test (NTD) No MEDICAID Nuclear Matrix Protein 22 (NMP22), 86386 qualitative No MEDICAID Particle agglutination; screen, each 86403 antibody No MEDICAID Particle agglutination; titer, each antibody 86406 No MEDICAID 86430 Rheumatoid factor; qualitative No MEDICAID 86431 Rheumatoid factor; quantitative No MEDICAID Tuberculosis test, cell mediated immunity antigen response measurement; gamma 86480 interferon No MEDICAID

284 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon- producing T-cells in cell suspension 86481 No MEDICAID 86485 Skin test; candida No MEDICAID SKIN TEST; UNLISTED ANTIGEN, 86486 EACH No MEDICAID 86490 Skin test; coccidioidomycosis No MEDICAID 86510 Skin test; histoplasmosis No MEDICAID 86580 Skin test; tuberculosis, intradermal No MEDICAID 86590 Streptokinase, antibody No MEDICAID Syphilis test; qualitative (eg, VDRL, RPR, 86592 ART) No MEDICAID 86593 Syphilis test; quantitative No MEDICAID 86602 Antibody; actinomyces No MEDICAID 86603 Antibody; adenovirus No MEDICAID 86606 Antibody; Aspergillus No MEDICAID Antibody; bacterium, not elsewhere 86609 specified No MEDICAID 86611 Antibody; Bartonella No MEDICAID 86612 Antibody; Blastomyces No MEDICAID 86615 Antibody; Bordetella No MEDICAID Antibody; Borrelia burgdorferi (Lyme 86617 disease) confirmatory test (eg, No MEDICAID Antibody; Borrelia burgdorferi (Lyme 86618 disease) No MEDICAID 86619 Antibody; Borrelia (relapsing fever) No MEDICAID 86622 Antibody; Brucella No MEDICAID 86625 Antibody; Campylobacter No MEDICAID 86628 Antibody; Candida No MEDICAID 86631 Antibody; Chlamydia No MEDICAID 86632 Antibody; Chlamydia, IgM No MEDICAID 86635 Antibody; Coccidioides No MEDICAID 86638 Antibody; Coxiella burnetii (Q fever) No MEDICAID 86641 Antibody; Cryptococcus No MEDICAID 86644 Antibody; cytomegalovirus (CMV) No MEDICAID 86645 Antibody; cytomegalovirus (CMV), IgM No MEDICAID 86648 Antibody; Diphtheria No MEDICAID Antibody; encephalitis, California (La 86651 Crosse) No MEDICAID Antibody; encephalitis, Eastern equine 86652 No MEDICAID 86653 Antibody; encephalitis, St. Louis No MEDICAID Antibody; encephalitis, Western equine 86654 No MEDICAID Antibody; enterovirus (eg, coxsackie, 86658 echo, polio) No MEDICAID Antibody; Epstein-Barr (EB) virus, early 86663 antigen (EA) No MEDICAID Antibody; Epstein-Barr (EB) virus, nuclear 86664 antigen (EBNA) No MEDICAID Antibody; Epstein-Barr (EB) virus, viral 86665 capsid (VCA) No MEDICAID 86666 Antibody; Ehrlichia No MEDICAID 86668 Antibody; Francisella tularensis No MEDICAID Antibody; fungus, not elsewhere specified 86671 No MEDICAID 86674 Antibody; Giardia lamblia No MEDICAID 86677 Antibody; Helicobacter pylori No MEDICAID Antibody; helminth, not elsewhere 86682 specified No MEDICAID 86684 Antibody; Haemophilus influenza No MEDICAID 86687 Antibody; HTLV-I No MEDICAID 86688 Antibody; HTLV-II No MEDICAID Antibody; HTLV or HIV antibody, 86689 confirmatory test (eg, Western Blot) No MEDICAID 86692 Antibody; hepatitis, delta agent No MEDICAID

285 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Antibody; herpes simplex, non-specific 86694 type test No MEDICAID 86695 Antibody; herpes simplex, type 1 No MEDICAID 86696 Antibody; herpes simplex, type 2 No MEDICAID 86698 Antibody; histoplasma No MEDICAID 86701 Antibody; HIV-1 No MEDICAID 86702 Antibody; HIV-2 No MEDICAID Antibody; HIV-1 and HIV-2, single assay 86703 No MEDICAID Hepatitis B core antibody (HBcAb); total 86704 No MEDICAID Hepatitis B core antibody (HBcAb); IgM 86705 antibody No MEDICAID 86706 Hepatitis B surface antibody (HBsAb) No MEDICAID 86707 Hepatitis Be antibody (HBeAb) No MEDICAID 86708 Hepatitis A antibody (HAAb); total No MEDICAID Hepatitis A antibody (HAAb); IgM antibody 86709 No MEDICAID 86710 Antibody; influenza virus No MEDICAID Antibody; JC (John Cunningham) virus 86711 No MEDICAID 86713 Antibody; Legionella No MEDICAID 86717 Antibody; Leishmania No MEDICAID 86720 Antibody; Leptospira No MEDICAID 86723 Antibody; Listeria monocytogenes No MEDICAID Antibody; lymphocytic choriomeningitis 86727 No MEDICAID 86732 Antibody; mucormycosis No MEDICAID 86735 Antibody; mumps No MEDICAID 86738 Antibody; mycoplasma No MEDICAID 86741 Antibody; Neisseria meningitidis No MEDICAID 86744 Antibody; Nocardia No MEDICAID 86747 Antibody; parvovirus No MEDICAID 86750 Antibody; Plasmodium (malaria) No MEDICAID Antibody; protozoa, not elsewhere 86753 specified No MEDICAID 86756 Antibody; respiratory syncytial virus No MEDICAID 86757 Antibody; Rickettsia No MEDICAID 86759 Antibody; rotavirus No MEDICAID 86762 Antibody; rubella No MEDICAID 86765 Antibody; rubeola No MEDICAID 86768 Antibody; Salmonella No MEDICAID 86771 Antibody; Shigella No MEDICAID 86774 Antibody; tetanus No MEDICAID 86777 Antibody; Toxoplasma No MEDICAID 86778 Antibody; Toxoplasma, IgM No MEDICAID IMMUNOASSAY: TREPONEMA 86780 PALLIDUM No MEDICAID 86784 Antibody; Trichinella No MEDICAID 86787 Antibody; varicella-zoster No MEDICAID 86788 ANTIBODY; WEST NILE VIRUS, IGM No MEDICAID 86789 ANTIBODY; WEST NILE VIRUS No MEDICAID Antibody; virus, not elsewhere specified 86790 No MEDICAID 86793 Antibody; Yersinia No MEDICAID 86794 Antibody; Zika virus, IgM No MEDICAID 86800 Thyroglobulin antibody No MEDICAID 86803 Hepatitis C antibody; No MEDICAID Hepatitis C antibody; confirmatory test 86804 (eg, immunoblot) No MEDICAID Lymphocytotoxicity assay, visual 86805 crossmatch; with titration No MEDICAID Lymphocytotoxicity assay, visual 86806 crossmatch; without titration No MEDICAID Serum screening for cytotoxic percent 86807 reactive antibody (PRA); standard No MEDICAID Serum screening for cytotoxic percent 86808 reactive antibody (PRA); quick No MEDICAID

286 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HLA typing; A, B, or C (eg, A10, B7, B27), 86812 single antigen No MEDICAID HLA typing; A, B, or C, multiple antigens 86813 No MEDICAID 86816 HLA typing; DR/DQ, single antigen No MEDICAID 86817 HLA typing; DR/DQ, multiple antigens No MEDICAID HLA typing; lymphocyte culture, mixed 86821 (MLC) No MEDICAID HUMAN LEUKOCYTE ANTIGEN (HLA) CROSSMATCH, NON-CYTOTOXIC (EG, USING FLOW CYTOMETRY); FIRST SERUM SAMPLE OR DILUTION 86825 No MEDICAID HUMAN LEUKOCYTE ANTIGEN (HLA) CROSSMATCH, NON-CYTOTOXIC (EG, USING FLOW CYTOMETRY); EACH ADDL SERUM SAMPLE OR DILUTION 86826 (LIST SEPAR No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, flow 86828 cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I and Class II HLA antigens No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow 86829 cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I or Class II HLA antigens No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow 86830 cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class I No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow 86831 cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class II No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative 86832 panel for identification of antibody specificities (eg, individual antigen per bead methodology), HLA Class I No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative 86833 panel for identification of antibody specificities (eg, individual antigen per bead methodology), HLA Class II No MEDICAID Antibody to human leukocyte antigens (HLA), solid phase assays (eg, 86834 microspheres or beads, ELISA, Flow cytometry); semi-quantitative panel (eg, titer), HLA Class I No MEDICAID

287 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Antibody to human leukocyte antigens (HLA), solid phase assays (eg, 86835 microspheres or beads, ELISA, Flow cytometry); semi-quantitative panel (eg, titer), HLA Class II No MEDICAID UNLISTED IMMUNOLOGY 86849 PROCEDURE No MEDICAID Antibody screen, RBC, each serum 86850 technique No MEDICAID 86860 Antibody elution (RBC), each elution No MEDICAID Antibody identification, RBC antibodies, each panel for each serum 86870 No MEDICAID Antihuman globulin test (Coombs test); 86880 direct, each antiserum No MEDICAID Antihuman globulin test (Coombs test); 86885 indirect, qualitative, each No MEDICAID Antihuman globulin test (Coombs test); 86886 indirect, titer, each antiserum No MEDICAID AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND STORAGE; 86890 PREDEPOSITED No MEDICAID Autologous blood or component, collection processing and storage; intra- 86891 No MEDICAID 86900 Blood typing; ABO No MEDICAID 86901 Blood typing; Rh (D) No MEDICAID Blood typing; antigen testing of donor blood using reagent serum, each antigen 86902 test No MEDICAID Blood typing; antigen screening for 86904 compatible unit using patient serum, No MEDICAID Blood typing; RBC antigens, other than 86905 ABO or Rh (D), each No MEDICAID Blood typing; Rh phenotyping, complete 86906 No MEDICAID BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH 86910 AND MN Not Covered MEDICAID BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH 86911 ADDITIONAL ANTIGEN SYSTEM Not Covered MEDICAID Compatibility test each unit; immediate 86920 spin technique No MEDICAID Compatibility test each unit; incubation 86921 technique No MEDICAID Compatibility test each unit; antiglobulin 86922 technique No MEDICAID 86923 Compatibility test, electric No MEDICAID Fresh frozen plasma, thawing, each unit 86927 No MEDICAID Frozen blood, each unit; freezing 86930 (includes preparation) No MEDICAID 86931 Frozen blood, each unit; thawing No MEDICAID Frozen blood, each unit; freezing 86932 (includes preparation) and thawing No MEDICAID Hemolysins and agglutinins; auto, screen, 86940 each No MEDICAID Hemolysins and agglutinins; incubated 86941 No MEDICAID 86945 Irradiation of blood product, each unit No MEDICAID 86950 Leukocyte transfusion No MEDICAID 86960 Vol reduction of blood/prod No MEDICAID Pooling of platelets or other blood 86965 products No MEDICAID Pretreatment of RBCs for use in RBC 86970 antibody detection, identification, No MEDICAID Pretreatment of RBCs for use in RBC 86971 antibody detection, identification, No MEDICAID

288 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Pretreatment of RBCs for use in RBC 86972 antibody detection, identification, No MEDICAID Pretreatment of serum for use in RBC antibody identification; incubation 86975 No MEDICAID Pretreatment of serum for use in RBC 86976 antibody identification; by No MEDICAID Pretreatment of serum for use in RBC antibody identification; incubation 86977 No MEDICAID Pretreatment of serum for use in RBC 86978 antibody identification; by No MEDICAID Splitting of blood or blood products, each 86985 unit No MEDICAID UNLISTED TRANSFUSION MEDICINE 86999 PROCEDURE No MEDICAID Animal inoculation, small animal; with 87003 observation and dissection No MEDICAID Concentration (any type), for infectious 87015 agents No MEDICAID Culture, bacterial; blood, aerobic, with 87040 isolation and presumptive No MEDICAID Culture, bacterial; stool, aerobic, with 87045 isolation and preliminary No MEDICAID Culture, bacterial; stool, aerobic, 87046 additional pathogens, isolation and No MEDICAID Culture, bacterial; any other source 87070 except urine, blood or stool, No * MEDICAID Culture, bacterial; quantitative, aerobic with isolation and presumptive 87071 No MEDICAID Culture, bacterial; quantitative, anaerobic 87073 with isolation and No MEDICAID Culture, bacterial; any source, except 87075 blood, anaerobic with isolation No MEDICAID Culture, bacterial; anaerobic isolate, 87076 additional methods required for No MEDICAID Culture, bacterial; aerobic isolate, 87077 additional methods required for No MEDICAID Culture, presumptive, pathogenic 87081 organisms, screening only; No MEDICAID Culture, presumptive, pathogenic organisms, screening only; with colony 87084 No MEDICAID Culture, bacterial; quantitative colony 87086 count, urine No MEDICAID Culture, bacterial; with isolation and 87088 presumptive identification of No MEDICAID Culture, fungi (mold or yeast) isolation, 87101 with presumptive No MEDICAID Culture, fungi (mold or yeast) isolation, 87102 with presumptive No MEDICAID Culture, fungi (mold or yeast) isolation, 87103 with presumptive No MEDICAID Culture, fungi, definitive identification, 87106 each organism; yeast No MEDICAID Culture, fungi, definitive identification, 87107 each organism; mold No MEDICAID 87109 Culture, mycoplasma, any source No * MEDICAID 87110 Culture, chlamydia, any source No * MEDICAID Culture, tubercle or other acid-fast bacilli 87116 (eg, TB, AFB, mycobacteria) No MEDICAID Culture, mycobacterial, definitive 87118 identification, each isolate No MEDICAID Culture, typing; immunofluorescent 87140 method, each antiserum No MEDICAID Culture, typing; gas liquid chromatography (GLC) or high pressure liquid 87143 No MEDICAID Culture, typing; immunologic method, 87147 other than immunofluoresence (eg, No MEDICAID

289 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Culture, typing; identification by nucleic 87149 acid probe No MEDICAID CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID (DNA OR RNA) PROBE, AMPLIFIED PROBE TECHNIQUE, PER CULTURE OR ISOLATE, EA ORGANISM 87150 No MEDICAID Culture, typing; identification by pulse field 87152 gel typing No MEDICAID CULTURE TYPING: IDENTIFICATION BY NUCLEIC ACID SEQUENCING METHOD, EACH ISOLATE (EG, SEQUENCING OF THE 16S RRNA 87153 GENE) No MEDICAID 87158 Culture, typing; other methods No MEDICAID Dark field examination, any source (eg, 87164 penile, vaginal, oral, skin); No MEDICAID Dark field examination, any source (eg, 87166 penile, vaginal, oral, skin); No MEDICAID 87168 Macroscopic examination; arthropod No MEDICAID 87169 Macroscopic examination; parasite No MEDICAID Pinworm exam (eg, cellophane tape prep) 87172 No MEDICAID 87176 Homogenization, tissue, for culture No MEDICAID Ova and parasites, direct smears, 87177 concentration and identification No MEDICAID Susceptibility studies, antimicrobial agent; 87181 agar dilution method, per No MEDICAID Susceptibility studies, antimicrobial agent; 87184 disk method, per plate (12 No MEDICAID Susceptibility studies, antimicrobial agent; 87185 enzyme detection (eg, beta No MEDICAID Susceptibility studies, antimicrobial agent; 87186 microdilution or agar No MEDICAID Susceptibility studies, antimicrobial agent; 87187 microdilution or agar No MEDICAID Susceptibility studies, antimicrobial agent; 87188 macrobroth dilution method, No MEDICAID Susceptibility studies, antimicrobial agent; 87190 mycobacteria, proportion No MEDICAID Serum bactericidal titer (Schlicter test) 87197 No MEDICAID Smear, primary source with interpretation; Gram or Giemsa stain for 87205 No MEDICAID Smear, primary source with interpretation; fluorescent and/or acid fast 87206 No MEDICAID Smear, primary source with interpretation; special stain for inclusion 87207 No MEDICAID 87209 Smear, complex stain No MEDICAID Smear, primary source with interpretation; wet mount for infectious 87210 No MEDICAID Tissue examination by KOH slide of 87220 samples from skin, hair, or nails for No MEDICAID Toxin or antitoxin assay, tissue culture 87230 (eg, Clostridium difficile No MEDICAID TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM 87230 DIFFICILE TOXIN) No MEDICAID Virus isolation; inoculation of embryonated 87250 eggs, or small animal, No MEDICAID Virus isolation; tissue culture inoculation, 87252 observation, and No MEDICAID Virus isolation; tissue culture, additional 87253 studies or definitive No MEDICAID Virus isolation; centrifuge enhanced (shell 87254 vial) technique, includes No MEDICAID

290 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Virus isolation; including identification by non-immunologic method, 87255 No MEDICAID Infectious agent antigen detection by 87260 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87265 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87267 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87269 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87270 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87271 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87272 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87273 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87274 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87275 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87276 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87278 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87279 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87280 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87281 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87283 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87285 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87290 immunofluorescent technique; No MEDICAID Infectious agent antigen detection by 87299 immunofluorescent technique; not No MEDICAID Infectious agent antigen detection by 87300 immunofluorescent technique, No MEDICAID Infectious agent antigen detection by 87301 enzyme immunoassay technique, No MEDICAID 87305 INF AGT ANTIGEN; ASPERGILLUS No MEDICAID Infectious agent antigen detection by 87320 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87324 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87327 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87328 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87329 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87332 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87335 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87336 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87337 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87338 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87339 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87340 enzyme immunoassay technique, No MEDICAID

291 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent antigen detection by 87341 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87350 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87380 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87385 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple- step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result 87389 No MEDICAID Infectious agent antigen detection by 87390 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87391 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87400 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87420 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87425 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87427 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87430 enzyme immunoassay technique, No MEDICAID Infectious agent antigen detection by 87449 enzyme immunoassay technique No MEDICAID Infectious agent antigen detection by 87450 enzyme immunoassay technique No MEDICAID Infectious agent antigen detection by 87451 enzyme immunoassay technique No MEDICAID Infectious agent detection by nucleic acid 87471 (DNA or RNA); Bartonella No MEDICAID Infectious agent detection by nucleic acid 87472 (DNA or RNA); Bartonella No MEDICAID Infectious agent detection by nucleic acid 87475 (DNA or RNA); Borrelia No MEDICAID Infectious agent detection by nucleic acid 87476 (DNA or RNA); Borrelia No MEDICAID Infectious agent detection by nucleic acid 87480 (DNA or RNA); Candida No MEDICAID Infectious agent detection by nucleic acid 87481 (DNA or RNA); Candida No MEDICAID Infectious agent detection by nucleic acid 87482 (DNA or RNA); Candida No MEDICAID 87483 Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus agalactiae, enterovirus, human parechovirus, herpes simplex virus type 1 and 2, human herpesvirus 6, cytomegalovirus, varicella zoster virus, Cryptococcus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets

No MEDICAID Infectious agent detection by nucleic acid 87485 (DNA or RNA); Chlamydia No MEDICAID Infectious agent detection by nucleic acid 87486 (DNA or RNA); Chlamydia No MEDICAID Infectious agent detection by nucleic acid 87487 (DNA or RNA); Chlamydia No MEDICAID Infectious agent detection by nucleic acid 87490 (DNA or RNA); Chlamydia No MEDICAID

292 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent detection by nucleic acid 87491 (DNA or RNA); Chlamydia No MEDICAID Infectious agent detection by nucleic acid 87492 (DNA or RNA); Chlamydia No MEDICAID INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CLOSTRIDIUIM DIFFICILE, TOXIN GENE(S), AMPLIED PROBE 87493 TECHNIQUE No MEDICAID Infectious agent detection by nucleic acid 87495 (DNA or RNA); No MEDICAID Infectious agent detection by nucleic acid 87496 (DNA or RNA); No MEDICAID Infectious agent detection by nucleic acid 87497 (DNA or RNA); No MEDICAID INFECTION AGENT DETECTION BY 87498 NUCLEIC ACID; ENTEROVIRUS No MEDICAID INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); VANCOMYCIN RESISTANCE (EG, ENTEROCOCCUS SPECIES VAN A, VAN B), AMPLIFIED PROBE 87500 TECHNIQUE No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, reverse transcription and amplified probe technique, each type or subtype 87501 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types 87502 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure)

87503 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87505 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87506 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 87507 No MEDICAID

293 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent detection by nucleic acid 87510 (DNA or RNA); Gardnerella No MEDICAID Infectious agent detection by nucleic acid 87511 (DNA or RNA); Gardnerella No MEDICAID Infectious agent detection by nucleic acid 87512 (DNA or RNA); Gardnerella No MEDICAID Infectious agent detection by nucleic acid 87516 (DNA or RNA); hepatitis B No MEDICAID Infectious agent detection by nucleic acid 87517 (DNA or RNA); hepatitis B No MEDICAID INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, DIRECT PROBE 87520 TECHNIQUE No MEDICAID INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, AMPLIFIED PROBE 87521 TECHNIQUE No MEDICAID INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87522 HEPATITIS C, QUANTIFICATION No MEDICAID Infectious agent detection by nucleic acid 87525 (DNA or RNA); hepatitis G, No MEDICAID Infectious agent detection by nucleic acid 87526 (DNA or RNA); hepatitis G, No MEDICAID Infectious agent detection by nucleic acid 87527 (DNA or RNA); hepatitis G, No MEDICAID Infectious agent detection by nucleic acid 87528 (DNA or RNA); Herpes simplex No MEDICAID Infectious agent detection by nucleic acid 87529 (DNA or RNA); Herpes simplex No MEDICAID Infectious agent detection by nucleic acid 87530 (DNA or RNA); Herpes simplex No MEDICAID Infectious agent detection by nucleic acid 87531 (DNA or RNA); Herpes virus-6, No MEDICAID Infectious agent detection by nucleic acid 87532 (DNA or RNA); Herpes virus-6, No MEDICAID Infectious agent detection by nucleic acid 87533 (DNA or RNA); Herpes virus-6, No MEDICAID Infectious agent detection by nucleic acid 87534 (DNA or RNA); HIV-1, direct No MEDICAID Infectious agent detection by nucleic acid 87535 (DNA or RNA); HIV-1, No MEDICAID Infectious agent detection by nucleic acid 87536 (DNA or RNA); HIV-1, No MEDICAID Infectious agent detection by nucleic acid 87537 (DNA or RNA); HIV-2, direct No MEDICAID Infectious agent detection by nucleic acid 87538 (DNA or RNA); HIV-2, No MEDICAID Infectious agent detection by nucleic acid 87539 (DNA or RNA); HIV-2, No MEDICAID Infectious agent detection by nucleic acid 87540 (DNA or RNA); Legionella No MEDICAID Infectious agent detection by nucleic acid 87541 (DNA or RNA); Legionella No MEDICAID Infectious agent detection by nucleic acid 87542 (DNA or RNA); Legionella No MEDICAID Infectious agent detection by nucleic acid 87550 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87551 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87552 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87555 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87556 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87557 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87560 (DNA or RNA); Mycobacteria No MEDICAID

294 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent detection by nucleic acid 87561 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87562 (DNA or RNA); Mycobacteria No MEDICAID Infectious agent detection by nucleic acid 87580 (DNA or RNA); Mycoplasma No MEDICAID Infectious agent detection by nucleic acid 87581 (DNA or RNA); Mycoplasma No MEDICAID Infectious agent detection by nucleic acid 87582 (DNA or RNA); Mycoplasma No MEDICAID Infectious agent detection by nucleic acid 87590 (DNA or RNA); Neisseria No MEDICAID Infectious agent detection by nucleic acid 87591 (DNA or RNA); Neisseria No MEDICAID Infectious agent detection by nucleic acid 87592 (DNA or RNA); Neisseria No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 87623 44) No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87624 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed 87625 No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 87631 respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 3-5 targets No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 87632 respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 6-11 targets No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 87633 respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 12-25 targets No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique 87634 No MEDICAID INFECTION AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87640 STAPHYLOCOCCUS No MEDICAID INFECTION AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87641 STAPHYLOCOCCUS No MEDICAID Infectious agent detection by nucleic acid 87650 (DNA or RNA); Streptococcus, No MEDICAID Infectious agent detection by nucleic acid 87651 (DNA or RNA); Streptococcus, No MEDICAID

295 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent detection by nucleic acid 87652 (DNA or RNA); Streptococcus, No MEDICAID DETECT INF AGT STREPTOCOCCUS 87653 No MEDICAID Infectious agent detection by nucleic acid 87660 (DNA or RNA); Trichomonas No MEDICAID 87661 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe 87662 technique No MEDICAID Infectious agent detection by nucleic acid 87797 (DNA or RNA), not otherwise No MEDICAID Infectious agent detection by nucleic acid 87798 (DNA or RNA), not otherwise No MEDICAID Infectious agent detection by nucleic acid 87799 (DNA or RNA), not otherwise No MEDICAID Infectious agent detection by nucleic acid 87800 (DNA or RNA), multiple No MEDICAID Infectious agent detection by nucleic acid 87801 (DNA or RNA), multiple No MEDICAID Infectious agent antigen detection by 87802 immunoassay with direct optical No MEDICAID Infectious agent antigen detection by 87803 immunoassay with direct optical No MEDICAID Infectious agent antigen detection by 87804 immunoassay with direct optical No MEDICAID Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1 antigen(s), with HIV-1 87806 and HIV-2 antibodies No MEDICAID Infectious agent antigen detection by 87807 immunoassay with direct optical No MEDICAID INFECTION AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87808 TRICHOMONAS No MEDICAID INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; 87809 ADENOVIRUS No MEDICAID Infectious agent detection by 87810 immunoassay with direct optical No MEDICAID Infectious agent detection by 87850 immunoassay with direct optical No MEDICAID Infectious agent detection by 87880 immunoassay with direct optical No MEDICAID Infectious agent detection by 87899 immunoassay with direct optical No MEDICAID INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION USING REGULARLY UPDATED GENOTYPIC 87900 BIOINFORMATICS No MEDICAID Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease 87901 regions No MEDICAID Infectious agent genotype analysis by 87902 nucleic acid (DNA or RNA); No MEDICAID INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; 87903 UP TO 10 DRU No MEDICAID INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) W/DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; EA ADDL 87904 DRUG TE No MEDICAID

296 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal 87905 fluid) No MEDICAID Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other 87906 region (eg, integrase, fusion) No MEDICAID Infectious agent genotype analysis by 87910 nucleic acid (DNA or RNA); cytomegalovirus No MEDICAID Infectious agent genotype analysis by 87912 nucleic acid (DNA or RNA); Hepatitis B virus No MEDICAID UNLISTED MICROBIOLOGY 87999 PROCEDURE No MEDICAID NECROPSY (AUTOPSY), GROSS 88000 EXAMINATION ONLY; WITHOUT CNS Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS 88005 EXAMINATION ONLY; WITH BRAIN Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITH BRAIN 88007 AND SPINAL CORD Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; INFANT WITH 88012 BRAIN Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; STILLBORN OR 88014 NEWBORN WITH BRAIN Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; MACERATED 88016 STILLBORN Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS AND 88020 MICROSCOPIC; WITHOUT CNS Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS AND 88025 MICROSCOPIC; WITH BRAIN Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITH BRAIN AND 88027 SPINAL CORD Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; INFANT WITH BRAIN 88028 Not Covered MEDICAID NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; STILLBORN OR 88029 NEWBORN WITH BRAIN Not Covered MEDICAID NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; 88036 REGIONAL Not Covered MEDICAID NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; 88037 SINGLE ORGAN Not Covered MEDICAID NECROPSY (AUTOPSY); FORENSIC 88040 EXAMINATION Not Covered MEDICAID NECROPSY (AUTOPSY); CORONER'S 88045 CALL Not Covered MEDICAID UNLISTED NECROPSY (AUTOPSY) 88099 PROCEDURE Not Covered MEDICAID CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SMEARS 88104 WITH INTERPRETATION No MEDICAID Cytopathology, fluids, washings or 88106 brushings, except cervical or No MEDICAID Cytopathology, concentration technique, smears and interpretation (eg, 88108 No MEDICAID Cytopathology, selective cellular 88112 enhancement technique with No MEDICAID Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual 88120 No MEDICAID

297 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer- 88121 assisted technology No MEDICAID 88125 Cytopathology, forensic (eg, sperm) No MEDICAID Sex chromatin identification; Barr bodies 88130 No MEDICAID Sex chromatin identification; peripheral blood smear, polymorphonuclear 88140 No MEDICAID Cytopathology, cervical or vaginal (any 88141 reporting system), requiring No MEDICAID Cytopathology, cervical or vaginal (any 88142 reporting system), collected in No MEDICAID Cytopathology, cervical or vaginal (any 88143 reporting system), collected in No MEDICAID Cytopathology smears, cervical or 88147 vaginal; screening by automated No MEDICAID Cytopathology smears, cervical or 88148 vaginal; screening by automated No MEDICAID Cytopathology, slides, cervical or vaginal; 88150 manual screening under No MEDICAID Cytopathology, slides, cervical or vaginal; 88152 with manual screening and No MEDICAID Cytopathology, slides, cervical or vaginal; 88153 with manual screening and No MEDICAID Cytopathology, slides, cervical or vaginal, 88155 definitive hormonal No MEDICAID Cytopathology, smears, any other source; 88160 screening and interpretation No MEDICAID Cytopathology, smears, any other source; 88161 preparation, screening and No MEDICAID Cytopathology, smears, any other source; 88162 extended study involving over No MEDICAID Cytopathology, slides, cervical or vaginal (the Bethesda System); manual 88164 No MEDICAID Cytopathology, slides, cervical or vaginal 88165 (the Bethesda System); with No MEDICAID Cytopathology, slides, cervical or vaginal 88166 (the Bethesda System); with No MEDICAID Cytopathology, slides, cervical or vaginal 88167 (the Bethesda System); with No MEDICAID Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site 88172 No MEDICAID Cytopathology, evaluation of fine needle 88173 aspirate; interpretation and No MEDICAID Cytopathology, cervical or vaginal (any 88174 reporting system), collected in No MEDICAID Cytopathology, cervical or vaginal (any 88175 reporting system), collected in No MEDICAID Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)

88177 No MEDICAID FLOW CYTOMETRY; CELL CYCLE OR 88182 DNA ANALYSIS No MEDICAID Flow cytometry, cell surface, cytoplasmic, 88184 or nuclear marker, No MEDICAID Flow cytometry, cell surface, cytoplasmic, 88185 or nuclear marker, No MEDICAID Flow cytometry, interpretation; 2 to 8 88187 markers No MEDICAID

298 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Flow cytometry, interpretation; 9 to 15 88188 markers No MEDICAID Flow cytometry, interpretation; 16 or more 88189 markers No MEDICAID UNLISTED CYTOPATHOLOGY 88199 PROCEDURE No MEDICAID Tissue culture for non-neoplastic 88230 disorders; lymphocyte No MEDICAID Tissue culture for non-neoplastic 88233 disorders; skin or other solid tissue No MEDICAID Tissue culture for non-neoplastic 88235 disorders; amniotic fluid or chorionic No MEDICAID Tissue culture for neoplastic disorders; 88237 bone marrow, blood cells No MEDICAID Tissue culture for neoplastic disorders; 88239 solid tumor No MEDICAID CRYOPRESERVATION, FREEZING 88240 AND STORAGE OF CELLS, EACH CELL No LINE MEDICAID THAWING AND EXPANSION OF 88241 No FROZEN CELLS, EACH ALIQUOT MEDICAID Chromosome analysis for breakage 88245 syndromes; baseline Sister No MEDICAID Chromosome analysis for breakage 88248 syndromes; baseline breakage, No MEDICAID Chromosome analysis for breakage 88249 syndromes; score 100 cells, No MEDICAID Chromosome analysis; count 5 cells, 1 88261 karyotype, with banding No MEDICAID Chromosome analysis; count 15-20 cells, 88262 2 karyotypes, with banding No MEDICAID Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with 88263 No MEDICAID Chromosome analysis; analyze 20-25 88264 cells No MEDICAID Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 88267 No MEDICAID Chromosome analysis, in situ for amniotic 88269 fluid cells, count cells from No MEDICAID MOLECULAR CYTOGENETICS; DNA 88271 PROBE, EACH (EG, FISH) No MEDICAID Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 88272 No MEDICAID Molecular cytogenetics; chromosomal in situ hybridization, analyze 88273 No MEDICAID MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 25-99 CELLS 88274 No MEDICAID Molecular cytogenetics; interphase in situ 88275 hybridization, analyze No MEDICAID Chromosome analysis; additional 88280 karyotypes, each study No MEDICAID Chromosome analysis; additional 88283 specialized banding technique (eg, No MEDICAID Chromosome analysis; additional cells 88285 counted, each study No MEDICAID Chromosome analysis; additional high 88289 resolution study No MEDICAID CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION 88291 AND REPORT No MEDICAID 88299 UNLISTED CYTOGENETIC STUDY No MEDICAID Level I - Surgical pathology, gross 88300 examination only No MEDICAID Level II - Surgical pathology, gross and 88302 microscopic examination No MEDICAID

299 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Level III - Surgical pathology, gross and 88304 microscopic examination No MEDICAID LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC 88305 EXAMINATION No MEDICAID Level V - Surgical pathology, gross and 88307 microscopic examination No MEDICAID Level VI - Surgical pathology, gross and 88309 microscopic examination No MEDICAID Decalcification procedure (List separately in addition to code for surgical 88311 No MEDICAID Special stains (List separately in addition 88312 to code for primary No MEDICAID SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR SURGICAL PATHOLOGY EXAMINATION); GROUP II, ALL OTHER, 88313 (EG, IRON, TRICHROME No MEDICAID Special stains (List separately in addition 88314 to code for primary No MEDICAID Determinative histochemistry or 88319 cytochemistry to identify enzyme No MEDICAID Consultation and report on referred slides 88321 prepared elsewhere No MEDICAID Consultation and report on referred 88323 material requiring preparation of No MEDICAID Consultation, comprehensive, with review of records and specimens, with 88325 No MEDICAID Pathology consultation during surgery; 88329 No MEDICAID Pathology consultation during surgery; 88331 first tissue block, with frozen No MEDICAID Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) 88332 No MEDICAID 88333 Intraop cyto path consult, 1 No MEDICAID Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure) 88334 No MEDICAID Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) 88341 No MEDICAID IMMUNOCYTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), EACH 88342 ANTIBODY No MEDICAID Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure 88344 No MEDICAID Immunofluorescent study, each antibody; 88346 direct method No MEDICAID 88348 Electron microscopy; diagnostic No MEDICAID Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary 88350 procedure) No MEDICAID Morphometric analysis; skeletal muscle 88355 No MEDICAID 88356 Morphometric analysis; nerve No MEDICAID 88358 TUMOR (EG, DNA PLOIDY) No MEDICAID

300 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (eg, Her- 88360 No MEDICAID MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (eg, Her- 88361 2/neu, No MEDICAID 88362 Nerve teasing preparations No MEDICAID Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) 88363 No MEDICAID In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) 88364 No MEDICAID TISSUE IN SITU HYBRIDIZATION (EG 88365 FISH), EACH PROBE No MEDICAID In situ hybridization (eg, FISH), per specimen; each multiplex probe stain 88366 procedure No MEDICAID MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (quantitative or 88367 No MEDICAID MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (quantitative or 88368 No MEDICAID Morphometric analysis, in situ hybridization (quantitative or semiquantitative), manual, per specimen; each additional single probe stain procedure (List separately in addition to code for 88369 primary procedure) No MEDICAID Protein analysis of tissue by Western Blot, 88371 with interpretation and No MEDICAID Protein analysis of tissue by Western Blot, 88372 with interpretation and No MEDICAID Morphometric analysis, in situ hybridization (quantitative or semiquantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary 88373 procedure) No MEDICAID Morphometric analysis, in situ hybridization (quantitative or semiquantitative), using computer-assisted technology, per specimen; each multiplex 88374 probe stain procedure No MEDICAID Optical endomicroscopic image(s), 88375 interpretation and report, real-time or referred, each endoscopic session No MEDICAID Morphometric analysis, in situ hybridization (quantitative or semiquantitative), manual, per specimen; each 88377 multiplex probe stain procedure No MEDICAID Microdissection (eg, mechanical, laser 88380 capture) No MEDICAID MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY IDENTIFIED 88381 TARGET); MANUAL No MEDICAID MACROSCOPIC EXAM, DISSECTION, & PREPARATION OF TISSUE FOR NON- MICROSCOPIC ANALYTICAL STUDIES; EACH TISSUE PREPARATION 88387 No MEDICAID

301 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MACROSCOPIC EXAM, DISSECTION, & PREP OF TISSUE FOR NON- MICROSCOPIC ANALYTICAL STUDIES; IN CONJUNCTION W/TOUCH IMPRINT, INTRAOP CON 88388 No MEDICAID UNLISTED SURGICAL PATHOLOGY 88399 Yes PROCEDURE MEDICAID 88400 BILRUBIN, TOTAL, TRANSCUTANEOUS No MEDICAID 88720 Bilirubin, total, transcutaneous No MEDICAID HEMOGLOBIN (HGB), QUANTITATIVE, 88738 TRANSCUTANEOUS No MEDICAID Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin 88740 No MEDICAID Hemoglobin, quantitative, transcutaneous, per day; methemoglobin 88741 No MEDICAID Unlisted in vivo (eg, transcutaneous) 88749 laboratory service No MEDICAID 89049 Chct for mal hyperthermia No MEDICAID CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CSF, JOINT FLUID), 89050 EXCEPT BLOOD; No MEDICAID Cell count, miscellaneous body fluids (eg, 89051 cerebrospinal fluid, joint No MEDICAID Leukocyte assessment, fecal, qualitative 89055 or semiquantitative No MEDICAID Crystal identification by light microscopy 89060 with or without polarizing No MEDICAID Fat stain, feces, urine, or respiratory 89125 secretions No MEDICAID 89160 Meat fibers, feces No MEDICAID 89190 Nasal smear for eosinophils No MEDICAID Sputum, obtaining specimen, aerosol 89220 induced technique (separate No MEDICAID 89230 Sweat collection by iontophoresis No MEDICAID UNLISTED MISCELLANEOUS 89240 PATHOLOGY TEST No MEDICAID CULTURE OF OOCYTE(S);/EMBRYO(S), LESS THAN 89250 4 DAYS; Not Covered MEDICAID CULTURE AND FERTILIZATION OF OOCYTE(S); WITH CO-CULTURE OF 89251 EMBRYOS Not Covered MEDICAID ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) 89253 Not Covered MEDICAID OOCYTE IDENTIFICATION FROM 89254 FOLLICULAR FLUID Not Covered MEDICAID PREPARATION OF EMBRYO FOR 89255 TRANSFER (ANY METHOD) Not Covered MEDICAID SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL 89257 FLUID) No MEDICAID 89258 CRYOPRESERVATION; EMBRYO Not Covered MEDICAID 89259 CRYOPRESERVATION, SPERM Not Covered MEDICAID SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS 89260 WITH SEMEN ANALYSIS No MEDICAID SPERM ISOLATION; COMPLEX PREP (EG, PER COL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS 89261 No MEDICAID SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR 89264 CRYOPRESERVED Not Covered MEDICAID 89268 INSEMINATION OF OOCYTES Not Covered MEDICAID

302 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EXTENDED CULTURE OF 89272 OOCYTE(S)/EMPRYO(S), 4-7 DAYS Not Covered MEDICAID ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; LESS THAN OR 89280 EQUAL TO 10 OOCYTES Not Covered MEDICAID ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; GREATER THAN 89281 10 OOCYTES Not Covered MEDICAID BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE- IMPLANTATION GENETIC DIAG); LESS THAN OR EQUAL TO 5 EMBROY 89290 Not Covered MEDICAID BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE- IMPLANTATION GENETIC DIAG); 89291 GREATER THAN 5 EMBRYOS Not Covered MEDICAID Semen analysis; presence and/or motility of sperm including Huhner test 89300 No MEDICAID Semen analysis; motility and count (not 89310 including Huhner test) No MEDICAID Semen analysis; complete (volume, 89320 count, motility, and differential) No MEDICAID SEMEN ANALYSIS, PRESENCE 89321 AND/OR MOTILITY OF SPERM No MEDICAID SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY AND DIFFERENTIAL USING STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) 89322 No MEDICAID 89325 Sperm antibodies No MEDICAID SPERM EVALUATION; HAMSTER 89329 PENETRATION TEST Not Covered MEDICAID Sperm evaluation; cervical mucus 89330 penetration test, with or without No MEDICAID SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE (SPERM CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS INDICATED) 89331 No MEDICAID CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR 89335 Not Covered MEDICAID 89337 Cryopreservation, mature oocyte(s) Not Covered MEDICAID 89342 STORAGE/YEAR; EMBRYO(S) Not Covered MEDICAID STORAGE, (PER YEAR); 89343 SPERM/SEMEN Not Covered MEDICAID STORAGE, (PER YEAR); REPRODUCTIVE TISSUE, 89344 TESTICULAR/OVARIAN Not Covered MEDICAID 89346 STORAGE, (PER YEAR); OOCYTE Not Covered MEDICAID THAWING OF CRYOPRESERVED; 89352 EMBRYO(S) Not Covered MEDICAID THAWING OF CRYOPRESERVED; 89353 SPERM/SEMEN, EACH ALIQUOT Not Covered MEDICAID THAWING OF CRYOPRESERVED; REPRODUCTIVE TISSUE, 89354 TESTICULAR/OVARIAN Not Covered MEDICAID THAWING OF CRYOPRESERVED; 89356 OOCYTES, EACH ALIQUOT Not Covered MEDICAID UNLISTED REPRODUCTIVE MEDICINE LABORATORY PROCEDURE 89398 Yes MEDICAID IMMUNE GLOBULIN (IG), HUMAN, FOR 90281 INTRAMUSCULAR USE Yes ExGEN MEDICAID IMMUNE GLOBULIN (IGIV), HUMAN, 90283 FOR INTRAVENOUS USE Yes ExGEN MEDICAID

303 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IMMUNE GLOBULIN (SCIg), HUMAN, 90284 FOR USE IN SUBCUTANEOUS Yes INFUSIONS, 100 MG, EACH MEDICAID 90287 Botulinum antitoxin, equine, any route No MEDICAID Botulism immune globulin, human, for 90288 intravenous use No MEDICAID Cytomegalovirus immune globulin (CMV- IgIV), human, for intravenous use 90291 No MEDICAID Diphtheria antitoxin, equine, any route 90296 Yes MEDICAID Hepatitis B immune globulin (HBIg), 90371 human, for intramuscular use No MEDICAID RABIES IMMUNE GLOBULIN (RIG), HUMAN, FOR INTRAMUSCULAR 90375 AND/OR SUBCUTANEOUS USE No MEDICAID RABIES IMMUNE GLOBULIN (RIG-HT), HUMAN, FOR INTRAMUSCULAR AND/OR SUBCUTANEOUS USE 90376 No MEDICAID RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, FOR INTRAMUSCULAR USE (RSV-IgM) 50 90378 mg (SYNAGIS) Yes ExGEN MEDICAID Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use 90384 No MEDICAID Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use 90385 No MEDICAID Rho(D) immune globulin (RhIgIV), human, 90386 for intravenous use No MEDICAID Tetanus immune globulin (TIg), human, 90389 for intramuscular use No MEDICAID Vaccinia immune globulin, human, for 90393 intramuscular use No MEDICAID Varicella-zoster immune globulin, human, 90396 Yes for intramuscular use MEDICAID 90399 UNLISTED IMMUNE GLOBULIN Yes MEDICAID Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid 90460 component No MEDICAID Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) 90461 No MEDICAID H1N1 IMMUNIZATION ADMINISTRATION (intramuscular, intranasal), INCLUDING COUNSELING 90470 WHEN PERFORMED No MEDICAID Immunization administration (includes 90471 percutaneous, intradermal, No MEDICAID Immunization administration (includes 90472 percutaneous, intradermal, No MEDICAID Immunization administration by intranasal 90473 or oral route; one vaccine No MEDICAID Immunization administration by intranasal or oral route; each additional 90474 No MEDICAID Adenovirus vaccine, type 4, live, for oral 90476 use No MEDICAID Adenovirus vaccine, type 7, live, for oral 90477 use No MEDICAID

304 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Anthrax vaccine, for subcutaneous use 90581 No MEDICAID Bacillus Calmette-Guerin vaccine (BCG) 90585 for tuberculosis, live, for No MEDICAID Bacillus Calmette-Guerin vaccine (BCG) 90586 for bladder cancer, live, for No MEDICAID Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use 90587 Not Covered MEDICAID Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intramuscular use 90620 No MEDICAID Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for 90621 intramuscular use No MEDICAID Cholera vaccine, live, adult dosage, 1 dose 90625 schedule, for oral use Yes MEDICAID Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for 90630 intradermal use No MEDICAID Hepatitis A vaccine, adult dosage, for 90632 intramuscular use No MEDICAID Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for 90633 No MEDICAID Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for 90634 No MEDICAID Hepatitis A and hepatitis B vaccine (HepA- 90636 HepB), adult dosage, for No MEDICAID Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4 dose schedule, when administered to children 2- 15 months of age, for intramuscular use 90644 No MEDICAID Hemophilus influenza b vaccine (Hib), 90647 PRP-OMP conjugate (3 dose No MEDICAID Hemophilus influenza b vaccine (Hib), 90648 PRP-T conjugate (4 dose No MEDICAID HUMAN PAPILLOMA VIRUS (HPV) 90649 VACCINE, TYPES 6, 11, 16, 18 Yes (QUADRIVALENT), 3 DOSE MEDICAID HUMAN PAPILLOMAVIRUS (HPV) VACCINE, TYPE 16 AND 18, BIVALENT, 90650 3 DOSE SCHEDULE, FOR Yes INTRAMUSCULAR USE (FDA APPROVAL PENDING) MEDICAID Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular 90651 use No MEDICAID Influenza vaccine, inactivated, subunit, 90653 adjuvanted, for intramuscular use No MEDICAID Influenza virus vaccine, split virus, 90654 preservative-free, for intradermal use No MEDICAID Influenza virus vaccine, split virus, 90655 preservative free, for children No MEDICAID Influenza virus vaccine, split virus, 90656 preservative free, for use in No MEDICAID Influenza virus vaccine, split virus, for 90657 children 6-35 months of age, No MEDICAID Influenza virus vaccine, split virus, for use 90658 in individuals 3 years of No MEDICAID INFLUENZA VIRUS VACCINE, LIVE, 90660 FOR INTRANASAL USE No MEDICAID

305 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INFLUENZA VIRUS VACCINE, DERIVED FROM CELL CULTURES, SUBUNIT, PRESERVATIVE AND ANTIBIOTIC FREE, FOR INTRAMUSCULAR USE 90661 No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE (FDA 90662 APPROVAL PENDING) No MEDICAID Influenza virus vaccine, pandemic 90664 formulation, live for intranasal use Not Covered MEDICAID Influenza virus vaccine, pandemic formulation, split virus, preservative free, 90666 for intramuscular use Not Covered MEDICAID Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for 90667 intramuscular use Not Covered MEDICAID Influenza virus vaccine, pandemic formulation, split virus, for intramuscular 90668 use Not Covered MEDICAID PNEUMOCCAL CONJUGATE VACCINE, 13 VALENT, FOR INTRAMUSCULAR 90670 USE No MEDICAID Influenza virus vaccine, quadrivalent, live, 90672 for intranasal use No MEDICAID 90673 Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use No MEDICAID 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use No MEDICAID Rabies vaccine, for intramuscular use 90675 No MEDICAID 90676 Rabies vaccine, for intradermal use No MEDICAID Rotavirus vaccine, tetravalent, live, for 90680 oral use No MEDICAID ROTAVIRUS VACCINE, HUMAN, ATTENUATED, 2 DOSE SCHEDULE, LIVE, FOR ORAL USE (FDA APPROVAL 90681 PENDING) No MEDICAID 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use No MEDICAID Influenza virus vaccine, quadrivalent, split virus, preservative free, when 90685 administered to children 6-35 months of age, for intramuscular use No MEDICAID Influenza virus vaccine, quadrivalent, split virus, preservative free, when 90686 administered to individuals 3 years of age and older, for intramuscular use No MEDICAID Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 90687 months of age, for intramuscular use No MEDICAID Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 90688 years of age and older, for intramuscular use No MEDICAID 90690 TYPHOID VACCINE, LIVE, ORAL Not Covered MEDICAID TYPHOID VACCINE, VI CAPSULAR 90691 POLYSACCHARIDE (VICPS), FOR No INTRAMUSCULAR USE MEDICAID

306 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND POLIOVIRUS VACCINE, INACTIVATED (DTaP-IPV), WHEN ADMINISTERED TO CHILDREN 4 YEARS THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE (FDA 90696 APPROVAL PENDING) No MEDICAID Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-HibHepB), for intramuscular use 90697 Not Covered MEDICAID DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS FLU TYPE B, & POLIOVIRUS VACCINE INACTVTD 90698 (DTaP-Hib-IPV) FOR IM USE No MEDICAID Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for 90700 No MEDICAID Diphtheria and tetanus toxoids (DT) 90702 adsorbed for use in individuals No MEDICAID Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous 90707 No MEDICAID Measles, mumps, rubella, and varicella 90710 vaccine (MMRV), live, for No MEDICAID Poliovirus vaccine, inactivated, (IPV), for 90713 subcutaneous use No MEDICAID 90714 Td vaccine no prsrv >/= 7 im No MEDICAID Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for 90715 No MEDICAID Varicella virus vaccine, live, for 90716 subcutaneous use No MEDICAID YELLOW FEVER VACCINE, LIVE, FOR 90717 No SUBCUTANEOUS USE MEDICAID Diphtheria, tetanus toxoids, acellular 90723 pertussis vaccine, Hepatitis B, No MEDICAID Pneumococcal polysaccharide vaccine, 90732 23-valent, adult or No MEDICAID Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous 90733 No MEDICAID Meningococcal conjugate vaccine, 90734 serogroups A, C, Y and W-135 No MEDICAID ZOSTER (SHINGLES) VACCINE, LIVE, FOR SUBCUTANEOUS INJECTION 90736 No * MEDICAID JAPANESE ENCEPHALITIS VIRUS VACCINE, INACTIVATED, FOR 90738 INTRAMUSCULAR USE Not Covered MEDICAID Hepatitis B vaccine, adult dosage (2 dose 90739 schedule), for intramuscular use No MEDICAID Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 90740 No MEDICAID Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use 90743 No MEDICAID Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for 90744 No MEDICAID Hepatitis B vaccine, adult dosage, for 90746 intramuscular use No MEDICAID

307 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 90747 No MEDICAID Hepatitis B and Hemophilus influenza b 90748 vaccine (HepB-Hib), for No MEDICAID 90749 UNLISTED VACCINE/TOXOID Yes MEDICAID 90750 Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular use No MEDICAID Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for 90756 intramuscular use No MEDICAID Psychiatric diagnostic interview 90801 examination Yes * MEDICAID Pharmacologic management, including prescription, use, and review of 90862 Yes * MEDICAID Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure) 90863 Not Covered MEDICAID Therapeutic repetitive transcranial magnetic stimulation treatment; planning 90867 Yes MEDICAID Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session 90868 Yes MEDICAID Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re- determination with delivery and 90869 management Yes MEDICAID ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY 90870 MONITORING) Yes MEDICAID Interpretation or explanation of results of 90887 psychiatric, other medical Yes * MEDICAID UNLISTED PSYCHIATRIC SERVICE OR 90899 Yes PROCEDURE MEDICAID Hemodialysis procedure with single 90935 physician evaluation No MEDICAID Hemodialysis procedure requiring 90937 repeated evaluation(s) with or without No MEDICAID Hemodialysis access flow study to 90940 Yes determine blood flow in grafts and MEDICAID Dialysis procedure other than 90945 hemodialysis (eg, peritoneal dialysis, No MEDICAID Dialysis procedure other than 90947 hemodialysis (eg, peritoneal dialysis, No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face- to-face physician v 90951 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to- face physician visits 90952 No MEDICAID

308 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per 90953 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per 90954 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month 90955 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month 90956 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per 90957 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month 90958 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1physician visit per month

90959 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face physician visits per month 90960 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face physician visits per month 90961 No MEDICAID End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face 90962 physician visit per month No MEDICAID

309 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90963 No MEDICAID End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents 90964 No MEDICAID End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90965 No MEDICAID End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older 90966 No MEDICAID End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger 90967 than 2 years of age No MEDICAID End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years 90968 of age No MEDICAID End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 90969 years of age No MEDICAID End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years 90970 of age and older No MEDICAID Dialysis training, patient, including helper 90989 where applicable, any mode, No MEDICAID Dialysis training, patient, including helper 90993 where applicable, any mode, No MEDICAID Hemoperfusion (eg, with activated 90997 charcoal or resin) No MEDICAID UNLISTED DIALYSIS PROCEDURE, 90999 Yes INPATIENT OR OUTPATIENT MEDICAID Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; 2-dimensional data 91010 No MEDICAID Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion during 2-dimensional data study (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)

91013 No MEDICAID 91020 Gastric motility (manometric) studies No MEDICAID 91022 Duodenal motility study No MEDICAID Esophagus, acid perfusion (Bernstein) 91030 test for esophagitis No MEDICAID Esophagus, gastroesophageal reflux test; 91034 with nasal catheter pH No MEDICAID

310 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ESPOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; W/MUCOSAL ATTACHED TELEMETRY ELECTRODE(S) PLACEMENT; RECORDING, 91035 ANALYSIS/INTERPRETATION No MEDICAID Esophageal function test, gastroesophageal reflux test with nasal 91037 No MEDICAID Esophageal function test, gastroesophageal reflux test with nasal 91038 No MEDICAID Esophageal balloon distension 91040 provocation study No MEDICAID Breath hydrogen test (eg, for detection of lactase deficiency), fructose 91065 No MEDICAID GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY) ESOPHAGUS THRU ILEUM, W PHYS INTERPRETATION & 91110 REPORT No MEDICAID GASTROINTESTINAL TRACT IMAGING, INTRLUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERP AND REPORT 91111 No MEDICAID Gastrointestinal transit and pressure measurement, stomach through colon, 91112 wireless capsule, with interpretation and report No MEDICAID Colon motility (manometric) study, minimum 6 hours continuous recording (including provocation tests, eg, meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report 91117 No MEDICAID Rectal sensation, tone, and compliance 91120 test (ie, response to No MEDICAID 91122 Anorectal manometry No MEDICAID Electrogastrography, diagnostic, 91132 transcutaneous; No MEDICAID Electrogastrography, diagnostic, 91133 transcutaneous; with provocative No MEDICAID Liver elastography, mechanically induced shear wave (eg, vibration), without imaging, with interpretation and report 91200 No MEDICAID UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE 91299 Yes MEDICAID Ophthalmological services: medical 92002 examination and evaluation with No MEDICAID Ophthalmological services: medical 92004 examination and evaluation with No MEDICAID Ophthalmological services: medical 92012 examination and evaluation, with No MEDICAID Ophthalmological services: medical 92014 examination and evaluation, with No MEDICAID 92015 Determination of refractive state No MEDICAID Ophthalmological examination and evaluation, under general anesthesia, 92018 No MEDICAID Ophthalmological examination and evaluation, under general anesthesia, 92019 No MEDICAID 92020 Gonioscopy (separate procedure) No MEDICAID COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR 92025 BILATERAL, No MEDICAID

311 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Sensorimotor examination with multiple measurements of ocular deviation 92060 No MEDICAID ORTHOPTIC AND/OR PLEOPTIC 92065 TRAINING, W/CONTINUING MEDICAL Yes DIRECTION & EVAL MEDICAID Fitting of contact lens for treatment of 92071 ocular surface disease No * MEDICAID Fitting of contact lens for management of keratoconus, initial fitting 92072 No * MEDICAID Visual field examination, unilateral or 92081 bilateral, with interpretation No MEDICAID Visual field examination, unilateral or 92082 bilateral, with interpretation No MEDICAID Visual field examination, unilateral or 92083 bilateral, with interpretation No MEDICAID Serial tonometry (separate procedure) with multiple measurements of 92100 No MEDICAID Scanning computerized ophthalmic diagnostic imaging, anterior segment, with 92132 No interpretation and report, unilateral or bilateral MEDICAID Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve 92133 No MEDICAID Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or 92134 bilateral; retina No MEDICAID Ophthalmic biometry by partial coherence interferometry with intraocular 92136 No MEDICAID Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, 92145 No with interpretation and report MEDICAID Ophthalmoscopy, extended, with retinal 92225 drawing (eg, for retinal No MEDICAID Ophthalmoscopy, extended, with retinal 92226 drawing (eg, for retinal No MEDICAID Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or 92227 bilateral No MEDICAID Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral 92228 or bilateral No MEDICAID Fluorescein angioscopy with interpretation 92230 and report No MEDICAID Fluorescein angiography (includes multiframe imaging) with interpretation 92235 No MEDICAID Indocyanine-green angiography (includes 92240 multiframe imaging) with No MEDICAID 92242 Fluorescein angiography and indocyanine- green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral No MEDICAID Fundus photography with interpretation 92250 and report No MEDICAID 92260 Ophthalmodynamometry No MEDICAID

312 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Needle oculoelectromyography, one or 92265 more extraocular muscles, one or No MEDICAID Electro-oculography with interpretation 92270 and report No MEDICAID Electroretinography with interpretation 92275 and report No MEDICAID Color vision examination, extended, eg, 92283 anomaloscope or equivalent No MEDICAID Dark adaptation examination with 92284 interpretation and report No MEDICAID External ocular photography with 92285 interpretation and report for No MEDICAID SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY W/ INTERPRETATION 92286 AND REPORT No MEDICAID SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY W/ INTERPRETATION AND REPORT W/FLUORESCEIN 92287 ANGIOGRAPHY No MEDICAID Prescription of optical and physical 92310 No characteristics of and fitting of MEDICAID Prescription of optical and physical 92311 characteristics of and fitting of No * MEDICAID Prescription of optical and physical 92312 characteristics of and fitting of No * MEDICAID Prescription of optical and physical 92313 characteristics of and fitting of No * MEDICAID Prescription of optical and physical 92314 characteristics of contact lens, Not Covered * MEDICAID Prescription of optical and physical 92315 characteristics of contact lens, No * MEDICAID Prescription of optical and physical 92316 characteristics of contact lens, No * MEDICAID Prescription of optical and physical 92317 characteristics of contact lens, No * MEDICAID MODIFICATION OF CONTACT LENS (SEPARATE PROCEDURE), WITH MEDICAL SUPERVISION OF 92325 ADAPTATION No MEDICAID 92326 REPLACEMENT OF CONTACT LENS No MEDICAID Fitting of spectacles, except for aphakia; 92340 No monofocal MEDICAID Fitting of spectacles, except for aphakia; 92341 No bifocal MEDICAID Fitting of spectacles, except for aphakia; 92342 No multifocal, other than MEDICAID Fitting of spectacle prosthesis for aphakia; 92352 No monofocal MEDICAID Fitting of spectacle prosthesis for aphakia; 92353 No multifocal MEDICAID FITTING OF SPECTACLE MOUNTED LOW VISION AID; SINGLE ELEMENT 92354 SYSTEM Not Covered MEDICAID FITTING OF SPECTACLE MOUNTED LOW VISION AID; TELESCOPIC OR 92355 OTHER COMPOUND LENS SYSTEM Not Covered MEDICAID PROSTHESIS SERVICE FOR APHAKIA, TEMPORARY (DISPOSABLE OR LOAN, INCLUDING MATERIALS) 92358 No MEDICAID REPAIR AND REFITTING 92370 SPECTACLES; EXCEPT FOR APHAKIA No MEDICAID REPAIR AND REFITTING 92371 SPECTACLES; SPECTACLE No PROSTHESIS FOR APHAKIA MEDICAID UNLISTED OPHTHALMOLOGICAL 92499 SERVICE OR PROCEDURE Yes MEDICAID Otolaryngologic examination under 92502 general anesthesia No MEDICAID

313 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Binocular microscopy (separate diagnostic 92504 procedure) No MEDICAID TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER

92507 Yes * MEDICAID TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER 92508 (INCLUDES AURAL REHABILITATION); Yes GROUP, T MEDICAID Nasopharyngoscopy with endoscope 92511 (separate procedure) No MEDICAID Nasal function studies (eg, 92512 rhinomanometry) Not Covered MEDICAID Facial nerve function studies (eg, 92516 electroneuronography) No MEDICAID 92520 Laryngeal function studies No MEDICAID Evaluation of speech fluency (eg, 92521 Yes stuttering, cluttering) MEDICAID Evaluation of speech sound production (eg, articulation, phonological process, 92522 Yes apraxia, dysarthria); MEDICAID Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of 92523 language comprehension and expression Yes (eg, receptive and expressive language)

MEDICAID Behavioral and qualitative analysis of 92524 Yes voice and resonance MEDICAID Treatment of swallowing dysfunction 92526 Yes and/or oral function for feeding MEDICAID Spontaneous nystagmus, including gaze 92531 No MEDICAID 92532 Positional nystagmus test No MEDICAID Caloric vestibular test, each irrigation 92533 (binaural, bithermal No MEDICAID 92534 Optokinetic nystagmus test No MEDICAID Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations) 92537 No MEDICAID Caloric vestibular test with recording, bilateral; monothermal (i.e., one irrigation in each ear for 92538 a total of two irrigations) No MEDICAID BASIC VESTIBULAR EVAL, INCL SPONTANEOUS NYSTAGMUS TEST W/ECCENTRIC GAZE FIXATION NYSTAGMUS, W/REC, POSITIONAL 92540 NYST. TEST, MIN 4 PO No MEDICAID SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION 92541 NYSTAGMUS, WITH RECORDING No MEDICAID POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH 92542 RECORDING No MEDICAID OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR PERIPHERAL STIMULATION, WITH 92544 RECORDING No MEDICAID OSCILLATING TRACKING TEST, WITH 92545 RECORDING No MEDICAID SINUSOIDAL VERTICAL AXIS 92546 ROTATIONAL TESTING No MEDICAID USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN ADDITION TO 92547 CODE FOR PRIMARY PROCEDURE) No MEDICAID

314 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPUTERIZED DYNAMIC 92548 No POSTUROGRAPHY MEDICAID TYMPANOMETRY AND REFLEX 92550 THRESHOLD MEASUREMENTS No MEDICAID 92551 Screening test, pure tone, air only No MEDICAID Pure tone audiometry (threshold); air only 92552 No MEDICAID Pure tone audiometry (threshold); air and 92553 bone No MEDICAID 92555 Speech audiometry threshold; No MEDICAID Speech audiometry threshold; with 92556 speech recognition No MEDICAID Comprehensive audiometry threshold evaluation and speech recognition 92557 No MEDICAID Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis 92558 No MEDICAID AUDIOMETRIC TESTING OF GROUPS 92559 Not Covered MEDICAID 92560 Bekesy audiometry; screening No MEDICAID 92561 Bekesy audiometry; diagnostic No MEDICAID Loudness balance test, alternate binaural 92562 or monaural No MEDICAID 92563 Tone decay test No MEDICAID Short increment sensitivity index (SISI) 92564 No MEDICAID 92565 Stenger test, pure tone No MEDICAID 92567 Tympanometry (impedance testing) No MEDICAID 92568 Acoustic reflex testing No MEDICAID ACOUSTIC IMMITTANCE TESTING, INCL TYMPANOMETRY (IMPENDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, & ACOUSTIC REFLEX DELAY TE 92570 No MEDICAID 92571 Filtered speech test No MEDICAID 92572 Staggered spondaic word test No MEDICAID 92575 Sensorineural acuity level test No MEDICAID 92576 Synthetic sentence identification test No MEDICAID 92577 Stenger test, speech No MEDICAID Visual reinforcement audiometry (VRA) 92579 No MEDICAID 92582 Conditioning play audiometry No MEDICAID 92583 Select picture audiometry No MEDICAID 92584 Electrocochleography No MEDICAID AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL 92585 NERVOUS SYSTEM No MEDICAID 92586 AUDITOR EVOKE POTENT, LIMIT No MEDICAID Evoked otoacoustic emissions; limited 92587 (single stimulus level, either No MEDICAID Evoked otoacoustic emissions; comprehensive or diagnostic evaluation 92588 No MEDICAID Hearing aid examination and selection; 92590 Yes monaural MEDICAID Hearing aid examination and selection; 92591 Yes binaural MEDICAID 92592 Hearing aid check; monaural Yes MEDICAID 92593 Hearing aid check; binaural Yes MEDICAID Electroacoustic evaluation for hearing aid; 92594 No monaural MEDICAID Electroacoustic evaluation for hearing aid; 92595 No binaural MEDICAID Ear protector attenuation measurements 92596 No MEDICAID

315 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Evaluation for use and/or fitting of voice 92597 Yes prosthetic device to MEDICAID DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLAT, PATIENT UNDER 92601 Yes 7 YEARS OF AGE; WITH PROGRAMMING MEDICAID 92602 SUBSEQUENT REPROGRAMMING Yes MEDICAID DIAGNOSTIC ANALYSIS OF 92603 COCHLEAR IMPLANT, AGE 7 YEARS Yes OR OLDER; WITH PROGRAMMING MEDICAID DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 OR 92604 Yes OLDER; SUBSEQUENT REPROGRAMMING MEDICAID EVALUATION FOR PRESCRIPTION OF NON-SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE 92605 COMMUNICATION DEVICE Not Covered MEDICAID THERAPEUTIC SERVICE(S) FOR THE USE OF NON-SPEECH- GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION 92606 Not Covered MEDICAID EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO- 92607 FACE W/ THE PT;1ST HR No MEDICAID EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 92608 No MEDICAID THERAPEUTIC SERVICES FOR THE USE OF SPEECH- GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION 92609 No MEDICAID EVALUATION OF ORAL AND 92610 PHARYNGEAL SWALLOWING Yes FUNCTION MEDICAID Motion fluoroscopic evaluation of 92611 Yes swallowing function by cine or video MEDICAID Flexible fiberoptic endoscopic evaluation of swallowing by cine or video 92612 No MEDICAID Flexible fiberoptic endoscopic evaluation of swallowing by cine or video 92613 No MEDICAID Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by 92614 No MEDICAID Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by 92615 No MEDICAID Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal 92616 No MEDICAID Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal 92617 No MEDICAID Evaluation for prescription of non-speech- generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) 92618 No MEDICAID Evaluation of central auditory function, 92620 with report; initial 60 No MEDICAID Evaluation of central auditory function, 92621 with report; each No MEDICAID

316 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Assessment of tinnitus (includes pitch, 92625 Yes loudness matching, and MEDICAID EVALUATION OF AUDITORY 92626 REHABILITATION STATUS, FIRST Yes HOUR MEDICAID EVALUATION OF AUDITORY REHABILITATION STATUS; EACH 92627 ADDITIONAL 15 MINUTES (LIST Yes SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDUR MEDICAID AUDITORY REHABILITATION; PRE- 92630 Yes LINGUAL HEARING LOSS MEDICAID AUDITORY REHABILITATION; POST- 92633 Yes LINGUAL HEARING LOSS MEDICAID DIAGNOSTIC ANALYSIS WITH PROGRAMMING OF AUDITORY 92640 BRAINSTEM IMPLANT, PER HOUR No MEDICAID UNLISTED OTORHINOLARYNGOLOGICAL 92700 SERVICE OR PROCEDURE Yes MEDICAID Percutaneous transluminal coronary 92920 angioplasty; single major coronary artery or branch No MEDICAID Percutaneous transluminal coronary angioplasty; each additional branch of a 92921 major coronary artery (List separately in addition to code for primary procedure) No MEDICAID Percutaneous transluminal coronary atherectomy, with coronary angioplasty 92924 when performed; single major coronary artery or branch No MEDICAID Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch 92925 of a major coronary artery (List separately in addition to code for primary procedure) No MEDICAID Percutaneous transcatheter placement of intracoronary stent(s), with coronary 92928 angioplasty when performed; single major coronary artery or branch No MEDICAID Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each 92929 additional branch of a major coronary artery (List separately in addition to code for primary procedure) No MEDICAID Percutaneous transluminal coronary atherectomy, with intracoronary stent, with 92933 coronary angioplasty when performed; single major coronary artery or branch No MEDICAID Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; 92934 each additional branch of a major coronary artery (List separately in addition to code for primary procedure) No MEDICAID Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of 92937 intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel No MEDICAID

317 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and 92938 angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure) No MEDICAID Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary 92941 artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel No MEDICAID Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery 92943 branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel No MEDICAID Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, 92944 atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)

No MEDICAID Cardiopulmonary resuscitation (eg, in 92950 cardiac arrest) No MEDICAID 92953 Temporary transcutaneous pacing No MEDICAID Cardioversion, elective, electrical 92960 conversion of arrhythmia; external No MEDICAID Cardioversion, elective, electrical 92961 conversion of arrhythmia; internal No MEDICAID Cardioassist-method of circulatory assist; 92970 internal No MEDICAID CARDIOASSIST-METHOD OF 92971 CIRCULATORY ASSIST; EXTERNAL No MEDICAID Percutaneous transluminal coronary 92973 thrombectomy (List separately in No MEDICAID PLACEMENT OF RADIATION DELIVERY DEVICE FOR CORONARY 92974 BRACHYTHERAPY No MEDICAID Thrombolysis, coronary; by intracoronary infusion, including selective 92975 No MEDICAID Thrombolysis, coronary; by intravenous 92977 infusion No MEDICAID Intravascular ultrasound (coronary vessel 92978 or graft) during diagnostic No MEDICAID Intravascular ultrasound (coronary vessel 92979 or graft) during diagnostic No MEDICAID Percutaneous balloon valvuloplasty; aortic 92986 valve No MEDICAID Percutaneous balloon valvuloplasty; mitral 92987 valve No MEDICAID Percutaneous balloon valvuloplasty; 92990 pulmonary valve No MEDICAID Atrial septectomy or septostomy; 92992 transvenous method, balloon (eg, No MEDICAID

318 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Atrial septectomy or septostomy; blade 92993 method (Park septostomy) No MEDICAID Percutaneous transluminal pulmonary artery balloon angioplasty; single 92997 No MEDICAID Percutaneous transluminal pulmonary artery balloon angioplasty; each 92998 No MEDICAID Electrocardiogram, routine ECG with at 93000 least 12 leads; with No MEDICAID Electrocardiogram, routine ECG with at 93005 least 12 leads; tracing only, No MEDICAID Electrocardiogram, routine ECG with at 93010 least 12 leads; interpretation No MEDICAID CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; WITH PHYSICIAN SUPERVISION, WITH INTERPRETATION AND REPORT 93015 No MEDICAID Cardiovascular stress test using maximal 93016 or submaximal treadmill or No MEDICAID Cardiovascular stress test using maximal 93017 or submaximal treadmill or No MEDICAID Cardiovascular stress test using maximal 93018 or submaximal treadmill or No MEDICAID 93024 Ergonovine provocation test No MEDICAID 93025 MICROVOLT T-WAVE ASSESSMENT No MEDICAID Rhythm ECG, one to three leads; with 93040 interpretation and report No MEDICAID Rhythm ECG, one to three leads; tracing 93041 only without interpretation and No MEDICAID Rhythm ECG, one to three leads; 93042 interpretation and report only No MEDICAID Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive

93050 No MEDICAID External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation 93224 No MEDICAID External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)

93225 No MEDICAID External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report 93226 No MEDICAID External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; physician review and interpretation 93227 No MEDICAID

319 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report 93228 No MEDICAID External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

93229 No MEDICAID Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review 93260 and report by a physician or other Yes qualified health care professional; implantable subcutaneous lead defibrillator system MEDICAID Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system 93261 No MEDICAID External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation 93268 No MEDICAID External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection) 93270 No MEDICAID External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; transmission download and analysis 93271 No MEDICAID

320 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; physician review and interpretation 93272 No MEDICAID Signal-averaged electrocardiography 93278 No (SAECG), with or without ECG MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93279 programmed values with physician Yes analysis, review and report; single lead pacemaker system MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93280 programmed values with physician Yes analysis, review and report; dual lead pacemaker system MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93281 programmed values with physician Yes analysis, review and report; multiple lead pacemaker system MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93282 programmed values with physician Yes analysis, review and report; single lead implantable cardioverter-defibrilla MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93283 programmed values with physician Yes analysis, review and report; dual lead implantable cardioverter-defibrillato MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93284 programmed values with physician Yes analysis, review and report; multiple lead implantable cardioverter-defibril MEDICAID Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent 93285 programmed values with physician Yes analysis, review and report; implantable loop recorder system MEDICAID

321 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Peri-procedural device evaluation and programming of device system parameters before and after a surgery, 93286 procedure, or test with physician analysis, Yes review and report; single, dual, or multiple lead pacemaker system MEDICAID Peri-procedural device evaluation and programming of device system parameters before and after a surgery, procedure, or test with physician analysis, 93287 review and report; single, dual, or multiple Yes lead implantable cardioverter-defibrillator system MEDICAID Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system 93288 No MEDICAID Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead cardioverter- defibrillator system, including analysis of heart r 93289 No MEDICAID Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic 93290 No MEDICAID Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis 93291 No MEDICAID Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; wearable defibrillator system 93292 No MEDICAID Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with physician analysis, review and report(s), up to 90 days 93293 No MEDICAID Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead apcemaker system with interim physician analysis, review(s) and 93294 report(s) No MEDICAID Interrogation device evaluation(s) (remote), up to 90 days; single, dual or multiple lead implantable cardioverter- defibrillator system with interim physician analysis, review(s) and report(s) 93295 No MEDICAID

322 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interrogation device evaluation(s) (remote), up to 90 days; single, dual or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquistion(s), receipt of transmissions and technician review, technical support and 93296 No MEDICAID Interrogation device evaluation(s), (remote), up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiological cardiovascular data elements from all internal and external sensors, physician analysis, review( 93297 No MEDICAID Interrogation device evaluation(s), (remote), up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, physician analysis, review(s) and report(s) 93298 No MEDICAID Interrogation device evaluation(s), (remote), up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquistion(s), receipt of transmissions and technician review, technical support and distribution of re 93299 No MEDICAID Transthoracic echocardiography for 93303 congenital cardiac anomalies; No MEDICAID Transthoracic echocardiography for 93304 congenital cardiac anomalies; No MEDICAID Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color 93306 flow Doppler echocardiography No MEDICAID Echocardiography, transthoracic, real- 93307 time with image documentation No MEDICAID Echocardiography, transthoracic, real- 93308 time with image documentation No MEDICAID Echocardiography, transesophageal, real 93312 time with image documentation No MEDICAID Echocardiography, transesophageal, real 93313 time with image documentation No MEDICAID Echocardiography, transesophageal, real 93314 time with image documentation No MEDICAID Transesophageal echocardiography for 93315 congenital cardiac anomalies; No MEDICAID Transesophageal echocardiography for 93316 congenital cardiac anomalies; No MEDICAID Transesophageal echocardiography for 93317 congenital cardiac anomalies; No MEDICAID Echocardiography, transesophageal 93318 (TEE) for monitoring purposes, No MEDICAID Doppler echocardiography, pulsed wave 93320 and/or continuous wave with No MEDICAID Doppler echocardiography, pulsed wave 93321 and/or continuous wave with No MEDICAID Doppler echocardiography color flow 93325 velocity mapping (List separately in No MEDICAID Echocardiography, transthoracic, real- 93350 time with image documentation No MEDICAID

323 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Echocardiography, transthoracic, real- time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation 93351 No MEDICAID Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) 93352 No MEDICAID Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D

93355 No MEDICAID Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed 93451 No MEDICAID Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93452 No MEDICAID Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93453 No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 93454 interpretation; No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography 93455 No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart 93456 catheterization No MEDICAID

324 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization 93457 No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when 93458 performed No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 93459 No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 93460 No MEDICAID Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 93461 No MEDICAID Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) 93462 No MEDICAID Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)

93463 No MEDICAID

325 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure) 93464 No MEDICAID INSERTION AND PLACEMENT OF FLOW DIRECTED CATHETER (EG, SWAN- GANZ) FOR MONITORING 93503 PURPOSES No MEDICAID 93505 ENDOMYOCARDIAL BIOPSY No MEDICAID RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC 93530 ANOMALIES No MEDICAID Combined right heart catheterization and 93531 retrograde left heart No MEDICAID COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH INTACT SEPTUM WITH OR WITHOUT 93532 RETROGRADE L No MEDICAID Combined right heart catheterization and 93533 transseptal left heart No MEDICAID INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; WITH CARDIAC OUTPUT 93561 No MEDICAID INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; SUBSEQUENT MEASUREME 93562 No MEDICAID 93563 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately in addition to code for primary procedure) No MEDICAID 93564 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure)

No MEDICAID 93565 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for primary procedure) No MEDICAID

326 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 93566 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure) No MEDICAID 93567 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure) No MEDICAID 93568 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure) No MEDICAID Intravascular Doppler velocity and/or 93571 pressure derived coronary flow No MEDICAID Intravascular Doppler velocity and/or 93572 pressure derived coronary flow No MEDICAID PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL COMMUNICATION (IE, FONTAN FENESTRATION, ATRAIL SEPTAL DEFECT) W/ PATI 93580 No MEDICAID PERCUTANEOUS TRANSCATHETER CLOSURE OF A CONGENITAL VENTRICULAR SEPTA DEFECT WITH 93581 IMPLANT No MEDICAID 93582 Percutaneous transcatheter closure of patent ductus arteriosus No MEDICAID 93583 Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including temporary pacemaker insertion when performed No MEDICAID 93590 Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve No MEDICAID 93591 Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve No MEDICAID 93592 Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure) No MEDICAID 93600 Bundle of His recording No MEDICAID 93602 Intra-atrial recording No MEDICAID 93603 Right ventricular recording No MEDICAID Intraventricular and/or intra-atrial mapping 93609 of tachycardia site(s) with No MEDICAID 93610 Intra-atrial pacing No MEDICAID 93612 Intraventricular pacing No MEDICAID Intracardiac electrophysiologic 3- dimensional mapping (List separately 93613 No MEDICAID Esophageal recording of atrial electrogram with or without ventricular 93615 No MEDICAID Esophageal recording of atrial electrogram with or without ventricular 93616 No MEDICAID Induction of arrhythmia by electrical 93618 pacing No MEDICAID Comprehensive electrophysiologic 93619 evaluation with right atrial pacing and No MEDICAID

327 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Comprehensive electrophysiologic 93620 evaluation including insertion and No MEDICAID Comprehensive electrophysiologic 93621 Yes evaluation including insertion and MEDICAID Comprehensive electrophysiologic 93622 evaluation including insertion and No MEDICAID Programmed stimulation and pacing after 93623 intravenous drug infusion (List No MEDICAID Electrophysiologic follow-up study with 93624 pacing and recording to test No MEDICAID Intra-operative epicardial and endocardial 93631 pacing and mapping to No MEDICAID Electrophysiologic evaluation of single or 93640 dual chamber pacing No MEDICAID Electrophysiologic evaluation of single or 93641 dual chamber pacing No MEDICAID Electrophysiologic evaluation of single or 93642 dual chamber pacing No MEDICAID Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic 93644 parameters) No MEDICAID Intracardiac catheter ablation of 93650 atrioventricular node function, No MEDICAID Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with 93653 intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry No MEDICAID Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of 93654 arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed

No MEDICAID Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to 93655 treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) No MEDICAID

328 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial 93656 recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation No MEDICAID Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining 93657 after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) No MEDICAID EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE M 93660 No MEDICAID Intracardiac echocardiography during 93662 therapeutic/diagnostic No MEDICAID Peripheral arterial disease (PAD) 93668 rehabilitation, per session No MEDICAID 93701 Bioimpedance, thoracic, electrical No MEDICAID Bioimpedance spectroscopy (BIS), 93702 extracellular fluid analysis for No lymphedema assessment(s) MEDICAID Electronic analysis of antitachycardia 93724 pacemaker system (includes No MEDICAID 93740 Temperature gradient studies Not Covered MEDICAID INITIAL SET-UP/PROGRAMMING BY DR OF WEARABLE CARDIOVERTER- DEFRIBRILLATOR, INCL INITIAL PROGRAM, BASE LINE ECG, DATA 93745 TRANSMISSION Yes MEDICAID INTERROGATION OF VENTRICULAR ASSIST DEVICE (VAD), IN PERSON, W/PHYS ANALYSIS OF DVC PARAMETERS, RVW OF DEVICE 93750 FUNCTION, W/PROGRAM No MEDICAID 93770 Determination of venous pressure No MEDICAID AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR 93784 LONGER; INCLU No MEDICAID AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR 93786 LONGER; RECOR No MEDICAID AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR 93788 LONGER; SCANN No MEDICAID AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR 93790 LONGER; PHYSI No MEDICAID

329 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results

93792 No MEDICAID Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed

93793 No MEDICAID 93797 CARDIAC REHABILITATION Yes MEDICAID PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC 93798 REHABILITATION; WITH CONTINUOUS Yes ECG MONITORING (PER SESSION) MEDICAID UNLISTED CARDIOVASCULAR 93799 SERVICE OR PROCEDURE Yes MEDICAID Duplex scan of extracranial arteries; 93880 complete bilateral study No MEDICAID Duplex scan of extracranial arteries; 93882 unilateral or limited study No MEDICAID Transcranial Doppler study of the 93886 intracranial arteries; complete study No MEDICAID Transcranial Doppler study of the 93888 intracranial arteries; limited study No MEDICAID Transcranial Doppler study of the 93890 intracranial arteries; No MEDICAID Transcranial Doppler study of the 93892 intracranial arteries; emboli No MEDICAID Transcranial Doppler study of the 93893 intracranial arteries; emboli No MEDICAID Quantitative carotid intima media 93895 thickness and carotid atheroma Yes evaluation, bilateral MEDICAID Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)

93922 No MEDICAID

330 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more level(s), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia)

93923 No MEDICAID Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study 93924 No MEDICAID Duplex scan of lower extremity arteries or arterial bypass grafts; bilateral 93925 No MEDICAID Duplex scan of lower extremity arteries or 93926 arterial bypass grafts; No MEDICAID Duplex scan of upper extremity arteries or 93930 arterial bypass grafts; No MEDICAID Duplex scan of upper extremity arteries or 93931 arterial bypass grafts; No MEDICAID Duplex scan of extremity veins including responses to compression and 93970 No MEDICAID Duplex scan of extremity veins including responses to compression and 93971 No MEDICAID Duplex scan of arterial inflow and venous 93975 outflow of abdominal, pelvic, No MEDICAID Duplex scan of arterial inflow and venous 93976 outflow of abdominal, pelvic, No MEDICAID Duplex scan of aorta, inferior vena cava, 93978 iliac vasculature, or bypass No MEDICAID Duplex scan of aorta, inferior vena cava, 93979 iliac vasculature, or bypass No MEDICAID Duplex scan of arterial inflow and venous 93980 outflow of penile vessels; No MEDICAID Duplex scan of arterial inflow and venous outflow of penile vessels; follow- 93981 No MEDICAID Duplex scan of hemodialysis access 93990 (including arterial inflow, body of No MEDICAID

331 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Unlisted noninvasive vascular diagnostic 93998 study Yes MEDICAID VENTILATION ASSIST & MGMT, INITIATION OF PRESSURE OR VOLUME PRESET VENTS FOR ASSISTED OR CONTROLLED 94002 BREATHING; HOSP INPT/OBS, INIT No MEDICAID VENTILATION ASSIST & MGMT, INITIAL PRESSURE OR VOLUME PRESET VENTS FOR ASSISTED OR CNTRLD BREATHING; HOSP INPT/OBS, EA 94003 SUBSEQ DAY No MEDICAID VENTILATION ASSIST & MGMT, INITIATION OF PRESSURE OR VOLUME PRESET VENTS FOR ASSISTED OR CONTROLLED BREATHING; NURSING FAC PER DAY 94004 No MEDICAID HOME VENTILATOR MGMT CARE PLAN OVERSIGHT IN HOME/DOMICILIARY/REST HOME, REQ STATUS/LAB/STUDIES RVW, & 94005 ORDER REV, 30 MIN> PER MONTH No MEDICAID Spirometry, including graphic record, total 94010 and timed vital capacity, No MEDICAID MEASUREMENT OF SPIROMETRIC FORCED EXPIRATORY FLOWS IN AN INFANT OR CHILD THROUGH 2 YEARS 94011 OF AGE No MEDICAID MEASUREMENT OF SPIROMETRIC FORCED EXPIRATORY FLOWS, BEFORE AND AFTER BRONCHODILATOR, IN AN INFANT OR CHILD THROUGH 2 YEARS OF AGE 94012 No MEDICAID MEASUREMENT OF LUNG VOLUMES (IE, (FRC), (FVP), & (ERV)) IN INFANT OR CHILD THROUGH 2 YEARS OF 94013 AGE No MEDICAID Patient-initiated spirometric recording per 94014 30-day period of time; No MEDICAID Patient-initiated spirometric recording per 94015 30-day period of time; No MEDICAID Patient-initiated spirometric recording per 94016 30-day period of time; No MEDICAID Bronchodilation responsiveness, 94060 spirometry as in 94010, pre- and No MEDICAID Bronchospasm provocation evaluation, 94070 multiple spirometric No MEDICAID Vital capacity, total (separate procedure) 94150 No MEDICAID Maximum breathing capacity, maximal 94200 voluntary ventilation No MEDICAID Expired gas collection, quantitative, single 94250 procedure (separate No MEDICAID 94375 Respiratory flow volume loop No MEDICAID Breathing response to CO2 (CO2 94400 response curve) No MEDICAID Breathing response to hypoxia (hypoxia 94450 response curve) No MEDICAID HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN 94452 INTERPRETATION AND REPORT No MEDICAID HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN INTERPRETATION AND REPORT; WITH SUPPLEMENTAL OXYGEN 94453 TITRATION No MEDICAID INTRAPULMONARY SUFACTANT ADMINISTRATION BY A PHYSICIAN 94610 THROUGH ENDOTRACHEAL TUBE No MEDICAID

332 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and 94617 pulse oximetry No MEDICAID Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, 94618 when performed No MEDICAID Pulmonary stress testing; complex 94621 (including measurements of CO2 No MEDICAID Pressurized or nonpressurized inhalation 94640 treatment for acute airway No MEDICAID Aerosol inhalation of pentamidine for 94642 pneumocystis carinii pneumonia No MEDICAID CONTINUOUS INHALATION TREATMENT W/AEROSOL 94644 MEDICATION; FIRST HOUR No MEDICAID CONTINUOUS INHALATION TREATMENT W/AEROSOL 94645 MEDICATION; EACH ADD No MEDICAID Continuous positive airway pressure 94660 ventilation (CPAP), initiation and No MEDICAID Continuous negative pressure ventilation 94662 (CNP), initiation and No MEDICAID DEMONSTRATION &/OR EVAL OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR IPPB 94664 DEVICE No MEDICAID MANIPULATION CHEST WALL, INITIAL DEMONSTRATION AND/OR EVAL 94667 No MEDICAID MANIPULATION CHEST WALL, 94668 SUBSEQUENT No MEDICAID 94669 Mechanical chest wall oscillation to facilitate lung function, per session No MEDICAID Oxygen uptake, expired gas analysis; rest 94680 and exercise, direct, simple No MEDICAID Oxygen uptake, expired gas analysis; 94681 including CO2 output, percentage No MEDICAID Oxygen uptake, expired gas analysis; 94690 rest, indirect (separate procedure) No MEDICAID Plethysmography for determination of lung volumes and, when performed, airway 94726 resistance No MEDICAID Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing 94727 volumes No MEDICAID Airway resistance by impulse oscillometry 94728 No MEDICAID Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure) 94729 No MEDICAID Pulmonary compliance study (eg, plethysmography, volume and pressure 94750 No MEDICAID Noninvasive ear or pulse oximetry for 94760 oxygen saturation; single No MEDICAID Noninvasive ear or pulse oximetry for 94761 oxygen saturation; multiple No MEDICAID Noninvasive ear or pulse oximetry for 94762 oxygen saturation; by continuous No MEDICAID Carbon dioxide, expired gas determination 94770 by infrared analyzer No MEDICAID Circadian respiratory pattern recording 94772 (pediatric pneumogram), 12 to 24 Yes MEDICAID

333 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCL RESP RATE/PATTERN&HEART RATE PER 30-DAY PERIOD; INCL 94774 MONITOR ATTACH, DOWNLOAD No MEDICAID PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCL RESP RATE, PATTERN & HEART RATE PER 30-DAY PERIOD; MONITOR 94775 ATTACHMENT ONLY No MEDICAID PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCL RESP RATE, PATTERN & HEART RATE PER 30-DAY PERIOD; 94776 MONITORING, DOWNLOAD INFO, No MEDICAID PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCL RESP RATE, PATTERN & HEART RATE PER 30-DAY PERIOD; PHYS 94777 REVIEW/INTERP/REPORT No MEDICAID Car seat/bed testing for airway integrity, neonate, with continual nursing observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; 60 94780 minutes No MEDICAID Car seat/bed testing for airway integrity, neonate, with continual nursing observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; each additional full 30 minutes (List separately in addition to code for primary procedure)

94781 No MEDICAID UNLISTED PULMONARY SERVICE OR 94799 PROCEDURE Yes MEDICAID Percutaneous tests (scratch, puncture, prick) with allergenic extracts, 95004 No MEDICAID NITRIC OXIDE EXPIRED GAS 95012 DETERMINATION No MEDICAID Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, 95017 immediate type reaction, including test interpretation and report, specify number of tests No MEDICAID Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or 95018 biologicals, immediate type reaction, including test interpretation and report, specify number of tests No MEDICAID Intracutaneous (intradermal) tests with 95024 allergenic extracts, immediate No MEDICAID Intracutaneous (intradermal) tests, 95027 sequential and incremental, with No MEDICAID INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, DELAYED TYPE REACTION, INCLUDING READING, SPECIFY NUMBER OF TESTS 95028 No MEDICAID Patch or application test(s) (specify 95044 number of tests) No MEDICAID

334 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Photo patch test(s) (specify number of 95052 tests) No MEDICAID 95056 Photo tests No MEDICAID OPHTHALMIC MUCOUS MEMBRANE 95060 No TESTS MEDICAID DIRECT NASAL MUCOUS MEMBRANE 95065 No TEST MEDICAID Inhalation bronchial challenge testing (not 95070 including necessary No MEDICAID Inhalation bronchial challenge testing (not 95071 including necessary No MEDICAID Ingestion challenge test (sequential and incremental ingestion of test items, eg, 95076 food, drug or other substance); initial 120 minutes of testing No MEDICAID Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); each 95079 additional 60 minutes of testing (List separately in addition to code for primary procedure) No MEDICAID Professional services for allergen immunotherapy not including provision 95115 No MEDICAID Professional services for allergen immunotherapy not including provision 95117 No MEDICAID Professional services for allergen 95120 immunotherapy in prescribing No MEDICAID Professional services for allergen 95125 immunotherapy in prescribing No MEDICAID Professional services for allergen 95130 immunotherapy in prescribing No MEDICAID Professional services for allergen 95131 immunotherapy in prescribing No MEDICAID Professional services for allergen 95132 immunotherapy in prescribing No MEDICAID Professional services for allergen 95133 immunotherapy in prescribing No MEDICAID Professional services for allergen 95134 immunotherapy in prescribing No MEDICAID Professional services for the supervision of preparation and provision 95144 No MEDICAID Professional services for the supervision of preparation and provision 95145 No MEDICAID Professional services for the supervision of preparation and provision 95146 No MEDICAID Professional services for the supervision of preparation and provision 95147 No MEDICAID Professional services for the supervision of preparation and provision 95148 No MEDICAID Professional services for the supervision of preparation and provision 95149 No MEDICAID Professional services for the supervision of preparation and provision 95165 No MEDICAID Professional services for the supervision of preparation and provision 95170 No MEDICAID RAPID DESENSITIZATION 95180 PROCEDURE, EACH HOUR No MEDICAID

335 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNLISTED ALLERGY/CLINICAL IMMUNOLOGIC SERVICE OR 95199 PROCEDURE Yes MEDICAID Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording 95249 No MEDICAID AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TISSURE FLUID VIA A SUBCUTANEOUS SENSOR FOR UP TO 95250 72 HOURS; SENSOR PLACEM No MEDICAID AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TISSUE FLUID VIA A SUBCUTANEOUS SENSOR FOR UP TO 95251 72 HOURS; PHYSICIAN INTE No MEDICAID Polysomnography; younger than 6 years, sleep staging with 4 or more additional 95782 parameters of sleep, attended by a technologist No MEDICAID Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of 95783 continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist No MEDICAID Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time 95800 No MEDICAID Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) 95801 No MEDICAID Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 95803 No hours to 14 consecutive days of recording) MEDICAID MULTIPLE SLEEP LATENCY OR MAINTENANCE OF WAKEFULNESS TESTING, RECORDING, ANALYSIS AND INTERPRETATION OF 95805 PHYSIOLOGICAL MEASUREMENTS No MEDICAID SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN 95806 SATURATION, UNATTENDED BY A No MEDICAID SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN 95807 SATURATION, ATTENDED BY A TE No MEDICAID POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL PARAMETERS OF SLEEP, ATTENDED 95808 BY A TECHNOLOGIST No MEDICAID POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST 95810 No MEDICAID

336 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSU 95811 No MEDICAID Electroencephalogram (EEG) extended 95812 monitoring; 41-60 minutes No MEDICAID Electroencephalogram (EEG) extended monitoring; greater than one hour 95813 No MEDICAID Electroencephalogram (EEG); including recording awake and drowsy 95816 No MEDICAID Electroencephalogram (EEG); including recording awake and asleep 95819 No MEDICAID Electroencephalogram (EEG); recording 95822 in coma or sleep only No MEDICAID Electroencephalogram (EEG); cerebral 95824 death evaluation only No MEDICAID Electroencephalogram (EEG); all night 95827 recording No MEDICAID Electrocorticogram at surgery (separate 95829 procedure) No MEDICAID INSERTION BY PHYSICIAN OF SPHENOIDAL ELECTRODES FOR ELECTROENCEPHALOGRAPHIC (EEG) 95830 RECORDING No MEDICAID Muscle testing, manual (separate 95831 procedure) with report; extremity No MEDICAID Muscle testing, manual (separate 95832 procedure) with report; hand, with or No MEDICAID Muscle testing, manual (separate 95833 procedure) with report; total No MEDICAID Muscle testing, manual (separate 95834 procedure) with report; total No MEDICAID Range of motion measurements and 95851 Yes report (separate procedure); each MEDICAID Range of motion measurements and 95852 Yes report (separate procedure); hand, MEDICAID Cholinesterase inhibitor challenge test for 95857 myasthenia gravis No MEDICAID Needle electromyography; one extremity 95860 with or without related No MEDICAID Needle electromyography; two extremities 95861 with or without related No MEDICAID Needle electromyography; three 95863 extremities with or without related No MEDICAID Needle electromyography; four extremities 95864 with or without related No MEDICAID 95865 Muscle test, larynx No MEDICAID 95866 Muscle test, hemidiaphragm No MEDICAID Needle electromyography; cranial nerve 95867 supplied muscle(s), unilateral No MEDICAID NEEDLE ELECTROMYOGRAPHY, CRANIAL NERVE SUPPLIED MUSCLES, 95868 BILATERAL No * MEDICAID Needle electromyography; thoracic 95869 paraspinal muscles (excluding T1 or No MEDICAID Needle electromyography; limited study of 95870 muscles in one extremity or No MEDICAID Needle electromyography using single fiber electrode, with quantitative 95872 No MEDICAID ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE 95873 FOR PRIMARY PROCEDURE No MEDICAID

337 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODEVERVATION (LIST SEPARATELY IN ADDITION TO CODE 95874 FOR PRIMARY PROCEDU No MEDICAID Ischemic limb exercise test with serial 95875 specimen(s) acquisition for No MEDICAID Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) 95885 No MEDICAID Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, 5 or more muscles studied, innervated by 3 or more nerves or 4 or more spinal levels (List separately in addition to code for primary procedure) 95886 No MEDICAID Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure)

95887 No MEDICAID MOTOR &/OR SENSORY NERVE CONDUCTION, USING PRECONFIG ELECTRODE ARRAY(S), AMPLITUDE & LATENCY/VELOCITY STUDY, EA LIMB, 95905 INCL F-WAVE No MEDICAID Nerve conduction studies; 1-2 studies 95907 No MEDICAID Nerve conduction studies; 3-4 studies 95908 No MEDICAID Nerve conduction studies; 5-6 studies 95909 No MEDICAID Nerve conduction studies; 7-8 studies 95910 No MEDICAID Nerve conduction studies; 9-10 studies 95911 No MEDICAID Nerve conduction studies; 11-12 studies 95912 No MEDICAID Nerve conduction studies; 13 or more 95913 studies No MEDICAID Testing of autonomic nervous system function; cardiovagal innervation 95921 No MEDICAID Testing of autonomic nervous system function; vasomotor adrenergic 95922 No MEDICAID Testing of autonomic nervous system function; sudomotor, including one 95923 No MEDICAID Testing of autonomic nervous system function; combined parasympathetic and 95924 sympathetic adrenergic function testing with at least 5 minutes of passive tilt No MEDICAID Short-latency somatosensory evoked 95925 potential study, stimulation of No MEDICAID Short-latency somatosensory evoked 95926 potential study, stimulation of No MEDICAID SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 95927 No MEDICAID

338 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Central motor evoked potential study 95928 (transcranial motor No MEDICAID Central motor evoked potential study 95929 (transcranial motor No MEDICAID VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS 95930 SYSTEM, No MEDICAID Orbicularis oculi (blink) reflex, by 95933 electrodiagnostic testing No MEDICAID H-reflex, amplitude and latency study; 95936 record muscle other than No MEDICAID Neuromuscular junction testing (repetitive stimulation, paired stimuli), 95937 No MEDICAID Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper 95938 and lower limbs No MEDICAID Central motor evoked potential study (transcranial motor stimulation); in upper 95939 and lower limbs No MEDICAID Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring 95940 requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) No MEDICAID Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case 95941 while in the operating room, per hour (List separately in addition to code for primary procedure) No MEDICAID Simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, 95943 with mean heart rate and blood pressure Yes measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head- up postural change

MEDICAID Monitoring for identification and 95950 lateralization of cerebral seizure No MEDICAID Monitoring for localization of cerebral 95951 seizure focus by cable or radio, No MEDICAID Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, 95953 unattended No MEDICAID Pharmacological or physical activation requiring physician attendance 95954 No MEDICAID Electroencephalogram (EEG) during 95955 nonintracranial surgery (eg, carotid No MEDICAID Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse 95956 No MEDICAID

339 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike 95957 No MEDICAID WADA ACTIVATION TEST FOR HEMISPHERIC FUNCTION, INCLUDING ELECTROENCEPHALOGRAPHIC (EEG) MONITORING 95958 No MEDICAID FUNCTIONAL CORTICAL OR SUBCORTICAL MAPPING BY STIMULATION AND/OR RECORDING OF ELECTRODES ON BRAIN SURFACE, OR OF DEPTH 95961 ELECTRODES No MEDICAID FUNCTIONAL CORTICAL MAPPING BY STIMULATION OF ELECTRODES ON BRAIN SURFACE, OR OF DEPTH ELECTRODES, TO PROVOKE 95962 SEIZURES OR IDENTIFY No MEDICAID 95965 MAGNETOENCEPHALOGRAPHY No MEDICAID 95966 MAGNETOENCEPHALOGRAPHY No MEDICAID 95967 MAGNETOENCEPHALOGRAPHY No * MEDICAID ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND 95970 DURATION, CONFIGURATION OF No MEDICAID SIMPLE BRIAN, SPINAL CORD, OR PERPHERAL NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, W/ INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING 95971 No MEDICAID COMPLEX SPINAL CORD, OR PERPHERAL NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, W/ INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING 95972 No MEDICAID ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND 95974 DURATION, CONFIGURATION OF No MEDICAID ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG., RATE, PULSE AMPLITUDE AND 95975 DURATION, CONFIGURATION OF No MEDICAID ELECTRONIC ANALYSIS IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG., RATE, PULSE AMPLITUDE/ DURATION...) COMPLEX DEEP BRAIN 95978 No MEDICAID ELECTRONIC ANALYSIS IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG., RATE, PULSE AMPLITUDE/ DURATION...) COMPLEX DEEP BRAIN 95979 No MEDICAID

340 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; INTRAOPERATIVE, WITH PROGRAMMING 95980 No MEDICAID ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUENT, WITHOUT REPROGRAMMING 95981 No MEDICAID ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUENT, WITH REPROGRAMMING 95982 No MEDICAID REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR 95990 FOR DRUG No MEDICAID REFILLING & MAINTANCE OF IMPLANTABLE PUMP OR RESERVOIR 95991 FOR DRUG DELIVERY, No MEDICAID Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per 95992 day No MEDICAID UNLISTED NEUROLOGICAL OR NEUROMUSCULAR DIAGNOSTIC 95999 PROCEDURE Yes * MEDICAID 96000 MOTION ANALYSIS No MEDICAID 96001 MOTION ANALYSIS No MEDICAID 96002 MOTION ANALYSIS No MEDICAID 96003 MOTION ANALYSIS No MEDICAID 96004 MOTION ANALYSIS No MEDICAID NEUROFUNCTIONAL TESTING SELECTION & ADMIN DURING NONINVASIVE IMAGING FUNCTIONAL BRAIN MAPPING, ADMIN ENTIRELY BY PHYS OR PSYCHOLOG 96020 No MEDICAID MEDICAL GENETICS AND GENETIC COUNSELING SERIVCES, EACH 30 MINUTES FACE-TO-FACE WITH 96040 PATIENT/FAMILY No MEDICAID

341 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, 96105 SPEECH No MEDICAID DEVELOPMENTAL TESTING; LIMITED (EG, DEVELOPMENTAL SCREENING 96110 TEST II, EARLY LANGUAGE Yes MILESTONE SCREEN), WITH INTERPRETATION AND REP MEDICAID Developmental testing; extended 96111 Yes (includes assessment of motor, MEDICAID NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGMENT, EG, ACQUIRED KNOWLEDGE, ATTENTION, 96116 LANGUAGE, Yes MEDICAID NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND 96118 WISCONSIN CAR SORTING TEST) Yes MEDICAID NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WHECHLSER MEMORY SCALES AND WISCONSIN CARD SORTING TES 96119 Yes MEDICAID NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST) ADMINISTERED BY A COMPUTER, WITH QUALIFIED 96120 HEALTH CARE PROFESSIONAL I Yes MEDICAID STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUIALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE- TO FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT 96125 Yes MEDICAID Brief emotional/behavioral assessment (eg, depression inventory, attention- deficit/hyperactivity disorder [ADHD] 96127 scale), with scoring and documentation, Yes per standardized instrument

MEDICAID Health and behavior assessment (eg, 96150 health-focused clinical interview, No MEDICAID Health and behavior assessment (eg, 96151 health-focused clinical interview, No MEDICAID Health and behavior intervention, each 15 96152 minutes, face-to-face; No MEDICAID Health and behavior intervention, each 15 96153 minutes, face-to-face; group No MEDICAID Health and behavior intervention, each 15 minutes, face-to-face; family (with patient 96154 present) No MEDICAID Health and behavior intervention, each 15 minutes, face-to-face; family (w/out 96155 patient present) No MEDICAID

342 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 96160 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument No MEDICAID 96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument No MEDICAID Intravenous infusion, hydration; initial, 31 96360 minutes to 1 hour No MEDICAID Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) 96361 No MEDICAID Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial up to 1 hour 96365 No MEDICAID Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for 96366 primary procedure) No MEDICAID Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional sequential infusion, up to 1 hour (List separately in addition to code for primary 96367 procedure) No MEDICAID Intravenous infusion, hydration; concurrent infusion (List separately in addition to code for primary procedure) 96368 No MEDICAID Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial up to 1 hour, including pump set-up and establishment of subcutaneous 96369 infusion site(s) No MEDICAID Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96370 No MEDICAID Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) 96371 No MEDICAID Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96372 No MEDICAID Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra- 96373 arterial No MEDICAID Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial 96374 substance/drug No MEDICAID Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

96375 No MEDICAID

343 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) 96376 No MEDICAID 96377 Application of on-body injector (includes cannula insertion) for timed subcutaneous injection No MEDICAID Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial 96379 injection or infusion Yes MEDICAID 96401 Chemo, anti-neopl, sq/im No MEDICAID 96402 Chemo hormon antineopl sq/im No MEDICAID Chemotherapy administration, 96405 intralesional; up to and including 7 No MEDICAID Chemotherapy administration, 96406 intralesional; more than 7 lesions No MEDICAID 96409 Chemo, iv push, sngl drug No MEDICAID 96411 Chemo, iv push, addl drug No MEDICAID 96413 Chemo, iv infusion, 1 hr No MEDICAID 96415 Chemo, iv infusion, addl hr No MEDICAID 96416 Chemo prolong infuse w/pump No MEDICAID 96417 Chemo iv infus each addl seq No MEDICAID Chemotherapy administration, intra- 96420 arterial; push technique No MEDICAID Chemotherapy administration, intra- 96422 arterial; infusion technique, up to No MEDICAID Chemotherapy administration, intra- 96423 arterial; infusion technique, one to No MEDICAID Chemotherapy administration, intra- 96425 arterial; infusion technique, No MEDICAID Chemotherapy administration into pleural 96440 cavity, requiring and including No MEDICAID Chemotherapy administration into the peritoneal cavity via indwelling port or 96446 catheter No MEDICAID Chemotherapy administration, into CNS 96450 (eg, intrathecal), requiring and No MEDICAID 96521 Refill/maint, portable pump No MEDICAID 96522 Refill/maint pump/resvr syst No MEDICAID 96523 Irrig drug delivery device No MEDICAID Chemotherapy injection, subarachnoid or 96542 intraventricular via No MEDICAID UNLISTED CHEMOTHERAPY 96549 PROCEDURE Yes MEDICAID 96567 PHOTODYNAMIC THERAPY OF SKIN No MEDICAID Photodynamic therapy by endoscopic 96570 Yes application of light to ablate MEDICAID Photodynamic therapy by endoscopic 96571 Yes application of light to ablate MEDICAID Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day 96573 No MEDICAID Debridement of premalignant hyperkeratotic lesion(s) (ie, targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day 96574 No MEDICAID

344 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ACTINOTHERAPY (ULTRAVIOLET 96900 LIGHT) No MEDICAID Microscopic examination of hairs plucked 96902 or clipped by the examiner No MEDICAID WHOLE BODY INTEGUMENTARY PHOTOGRAPY, TO MONITOR HIGH RISK PATIENTS W/DYSPLASTIC NEVUS SYNDRM OR HX OF IT OR 96904 PERSONAL/FAMILY MELANO Not Covered MEDICAID PHOTOCHEMOTHERAPY; TAR AND ULTRAVIOLET B (GOECKERMAN 96910 Yes TREATMENT) OR PETROLATUM AND ULTRAVIOLET B MEDICAID PHOTOCHEMOTHERAPY; 96912 PSORALENS AND ULTRAVIOLET A Yes (PUVA) MEDICAID PHOTOCHEMOTHERAPY (GOECKERMAN AND/OR PUVA) FOR SEVERE PHOTORESPONSIVE DERMATOSES REQUIRING AT LEAST FOUR TO EIGHT HOURS OF CARE UN 96913 No MEDICAID LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE 96920 Yes (PSORIASIS); TOTAL AREA LESS THAN 250 SQ CM MEDICAID LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE 96921 Yes (PSORIASIS); 250 SQ CM TO 500 SQ CM MEDICAID LASER TREATMENT FOR 96922 INFLAMMATORY SKIN DISEASE Yes (PSORIASIS); OVER 500 SQ CM MEDICAID Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image 96931 acquisition and interpretation and report, first No lesion MEDICAID Reflectance confocal microscopy (RCM) for 96932 cellular and sub-cellular imaging of skin; image No acquisition only, first lesion MEDICAID Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; 96933 interpretation and report only, first lesion No MEDICAID Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each 96934 additional lesion (List separately in addition to No code for primary procedure) MEDICAID Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image 96935 acquisition only, each additional lesion (List No separately in addition to code for primary procedure) MEDICAID Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; 96936 interpretation and report only, each additional No lesion (List separately in addition to code for primary procedure) MEDICAID UNLISTED SPECIAL DERMATOLOGICAL SERVICE OR 96999 PROCEDURE Yes MEDICAID APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD 97010 PACKS Not Covered MEDICAID APPLICATION OF A MODALITY TO 97012 ONE OR MORE AREAS; TRACTION, Yes MECHANICAL MEDICAID APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL 97014 Yes STIMULATION (UNATTENDED) MEDICAID

345 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines APPLICATION OF A MODALITY TO 97016 ONE OR MORE AREAS; Yes VASOPNEUMATIC DEVICES MEDICAID APPLICATION OF A MODALITY TO 97018 ONE OR MORE AREAS; PARAFFIN Yes BATH MEDICAID APPLICATION OF A MODALITY TO 97022 ONE OR MORE AREAS; WHIRLPOOL Yes MEDICAID APPLICATION OF A MODALITY TO 97024 ONE OR MORE AREAS; DIATHERMY Yes (EG, MICROWAVE) MEDICAID APPLICATION OF A MODALITY TO 97026 Yes ONE OR MORE AREAS; INFRARED MEDICAID APPLICATION OF A MODALITY TO 97028 ONE OR MORE AREAS; ULTRAVIOLET Yes MEDICAID APPLICATION OF A MODALITY TO 97032 ONE OR MORE AREAS; ULTRAVIOLET Yes MEDICAID APPLICATION OF A MODALITY TO ONE OR MORE AREAS; 97033 Yes IONTOPHORESIS, EACH 15 MINUTES MEDICAID APPLICATION OF A MODALITY TO 97034 ONE OR MORE AREAS; CONTRAST Yes BATHS, EACH 15 MINUTES MEDICAID APPLICATION OF A MODALITY TO 97035 ONE OR MORE AREAS; ULTRASOUND, Yes EACH 15 MINUTES MEDICAID APPLICATION OF A MODALITY TO 97036 ONE OR MORE AREAS; HUBBARD Yes TANK, EACH 15 MINUTES MEDICAID UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT 97039 ATTENDANCE) Yes MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO 97110 DEVELOP STRENGTH AND Yes ENDURANCE, RANGE OF MOTIO MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF 97112 MOVEMENT, BALANCE, Yes COORDINATION, KINESTHET MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH 97113 THERAPEUTIC EXERCISES No MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 97116 Yes GAIT TRAINING (INCLUDES STAIR CLIMBING) MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 97124 MASSAGE, INCLUDING EFFLEURAGE, Yes PETRISSAGE AND/OR TAPOTEMENT (STROKING, MEDICAID

346 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on- one) patient contact termed code 97532

97127 Not Covered MEDICAID THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) 97139 Yes MEDICAID MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/MANIPULATION, 97140 MANUAL LYMPATHIC DRAINAGE, Yes MANUAL TRACTION), ONE OR MORE REGIONS, EACH 1 MEDICAID THERAPEUTIC PROCEDURE(S), 97150 GROUP (2 OR MORE INDIVIDUALS) No MEDICAID Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with 97161 stable and/or uncomplicated Yes characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to- face with the patient and/or family.

MEDICAID Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation 97162 restrictions; An evolving clinical Yes presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to- face with the patient and/or family.

MEDICAID

347 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical 97163 Yes presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to- face with the patient and/or family.

MEDICAID Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized 97164 patient assessment instrument and/or Yes measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.

MEDICAID Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem- focused assessment(s), and consideration 97165 of a limited number of treatment options. Yes Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.

MEDICAID

348 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an 97166 analysis of the occupational profile, Yes analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.

MEDICAID Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of 97167 the patient profile, analysis of data from Yes comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.

MEDICAID

349 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; 97168 and A revised plan of care. A formal Yes reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.

MEDICAID 97169 Athletic training evaluation, low complexity, requiring these components: A history and physical activity profile with no comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 15 minutes are spent face-to-face with the patient and/or family.

Not Covered MEDICAID 97170 Athletic training evaluation, moderate complexity, requiring these components: A medical history and physical activity profile with 1-2 comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing a total of 3 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.

Not Covered MEDICAID

350 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 97171 Athletic training evaluation, high complexity, requiring these components: A medical history and physical activity profile, with 3 or more comorbidities that affect physical activity; A comprehensive examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; Clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to- face with the patient and/or family.

Not Covered MEDICAID 97172 Re-evaluation of athletic training established plan of care requiring these components: An assessment of patient's current functional status when there is a documented change; and A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome with an update in management options, goals, and interventions. Typically, 20 minutes are spent face-to- face with the patient and/or family. Not Covered MEDICAID THERAPEUTIC ACTIVITIES, DIRECT (ONE ON ONE) PATIENT CONTACT BY 97530 THE PROVIDER (USE OF DYNAMIC Yes ACTIVITIES TO IMPROVE FUNCTIONAL PERFO MEDICAID SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE 97533 ADAPTIVE RESPONSES TO Yes ENVIORNMENTAL DEMANDS, DIRECT MEDICAID SELF CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY 97535 LIVING (ADL) AND COMPENSATORY Yes TRAINING, MEAL PREPARATION, SAFETY PROCE MEDICAID WHEELCHAIR MANAGEMENT (EG. 97542 ASSESSMENT, FITTING, TRAINING), Yes EACH 15 MINUTES MEDICAID WORK HARDENING/CONDITIONING; INITIAL 2 HOURS 97545 Not Covered MEDICAID WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 97546 Not Covered MEDICAID

351 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less 97597 No MEDICAID Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

97598 No MEDICAID Removal of devitalized tissue from wound(s), non-selective debridement, 97602 No MEDICAID NEGATIVE PRESSURE WOUND THERAPY, INCL TOPICAL 97605 APPLICATION(S), ASSESSMENT AND Yes INSTRUCTION FOR ONGOING CARE, PER SESSION, < 50 SQ CM MEDICAID NEGATIVE PRESSURE WOUND THERAPY, INCL TOPICAL APPLICATION(S), ASSESSMENT AND INSTRUCTION FOR ONGOING CARE, 97606 PER SESSION, > 50 SQ CM Yes MEDICAID Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical 97607 application(s), wound assessment, and Yes instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

MEDICAID Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical 97608 application(s), wound assessment, and Yes instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters MEDICAID 97610 Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day No MEDICAID

352 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, 97750 EACH 15 MINUTES No MEDICAID ASSISTIVE TECHNOLOGY ASSESSMENT (EG TO RESTORE, AUGMENT OR COMPENSATE FOR EXIST FNCT, OPTIMIZE FUNCT TASKS 97755 AND/OR MAX ENVRNMTL 15 No MEDICAID ORTHOTIC(S) MGMT & TRAINING (INCL ASSESSING & FITTING WHEN 97760 NOT OTHERWISE REPORTED), Yes UPPER/LOWER EXTREMITY(S) &/OR TRUNK, EA 15 MIN MEDICAID PROSTHETIC TRAINING, UPPER 97761 AND/OR LOWER EXTEMITY(S), EACH Yes 15 MINUTES MEDICAID Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent 97763 orthotic(s)/prosthetic(s) encounter, each Yes 15 minutes termed code 97762 MEDICAID UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE 97799 OR PROCEDURE Yes MEDICAID Medical nutrition therapy; initial 97802 assessment and intervention, No MEDICAID MEDICAL NUTRITION THERAPY, RE- ASSESSMENT AND INTERVENTION, 97803 INDIVIDUAL, No MEDICAID MEDICAL NUTRITION THERAPY, GROUP (2 OR MORE INDIVIDUAL(S)), 97804 EACH 30 MINUTES No MEDICAID ACUPUNCTURE, ONE OR MORE NEEDLES, WITHOUT ELECTRICAL STIMULATION; INTIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT 97810 WITH PATIENT Not Covered MEDICAID ACUPUNCTURE, 1OR MORE NEEDLES, W/O ELECTRICAL STIM; EACH ADDL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT W/PATIENT, W/RE-INSERTION 97811 Not Covered MEDICAID ACUPUNCTURE, ONE OR MORE NEEDLES, WITH ELECTRICAL STIMULATION; INTIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT 97813 WITH PATIENT Not Covered MEDICAID ACUPUNCTURE, 1OR MORE NEEDLES, W/ELECTRICAL STIM; EA ADD'L 15 MINS OF PERSONAL 1-ON-1 CONTACT W/PATIENT, W/RE- 97814 INSERTION OF NEEDLES Not Covered MEDICAID Osteopathic manipulative treatment 98925 Yes (OMT); one to two body regions MEDICAID Osteopathic manipulative treatment 98926 Yes (OMT); three to four body regions MEDICAID Osteopathic manipulative treatment 98927 Yes (OMT); five to six body regions MEDICAID Osteopathic manipulative treatment 98928 Yes (OMT); seven to eight body regions MEDICAID Osteopathic manipulative treatment 98929 Yes (OMT); nine to ten body regions MEDICAID CHIROPRACTIC MANIPULATIVE 98940 TREATMENT (CMT); SPINAL, ONE TO Yes TWO REGIONS MEDICAID

353 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CHIROPRACTIC MANIPULATIVE 98941 TREATMENT (CMT); SPINAL, THREE Yes TO FOUR REGIONS MEDICAID CHIROPRACTIC MANIPULATIVE 98942 TREATMENT (CMT); SPINAL, FIVE Yes REGIONS MEDICAID CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, 98943 ONE OR MORE REGIONS Not Covered MEDICAID EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A 98960 QUALIFIED No MEDICAID EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A 98961 QUALIFIED No MEDICAID EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A 98962 QUALIFIED No MEDICAID TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSIION

98966 No MEDICAID TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSIION

98967 No MEDICAID TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION

98968 No MEDICAID

354 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ON-LINE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS, USING THE INTERNET OR SIMILAR ELECTRONIC COMMUNICATION NETWORK 98969 No MEDICAID HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PHYSICIAN'S OFFICE TO A 99000 LABORATORY Not Covered MEDICAID HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN A PHYSICIAN'S OFFICE TO A 99001 LABORATORY (DISTANCE Not Covered MEDICAID HANDLING, CONVEYANCE, AND/OR ANY OTHER SERVICE IN CONNECTION WITH THE IMPLEMENTATION OF AN ORDER INVOLVING DEVICES (EG, DESIGNING, 99002 Not Covered MEDICAID Postoperative follow-up visit, normally 99024 included in the surgical No MEDICAID HOSPITAL MANDATED ON CALL SERVICE; IN-HOSPITAL, EACH HOUR 99026 Not Covered MEDICAID 99027 OUT-OF-HOSPITAL, EACH HOUR Not Covered MEDICAID Services requested after posted office 99050 hours in addition to basic Not Covered MEDICAID 99051 Med serv, eve/wkend/holiday No MEDICAID SERVICES(S) PROVIDED BETWEEN 10:00PM AND 8:00 AM AT 24-HOUR FACILITY, IN ADDITION TO BASIC 99053 SERVICE Not Covered MEDICAID SERVICES PROVIDED AT REQUEST OF PATIENT IN A LOCATION OTHER THAN PHYSICIAN'S OFFICE WHICH ARE NORMALLY PROVIDED IN THE 99056 OFFICE Not Covered MEDICAID Office services provided on an emergency 99058 basis No MEDICAID 99060 Out of office emerg med serv No MEDICAID SUPPLIES AND MATERIALS (EXCEPT SPECTACLES), PROVIDED BY THE PHYSICIAN OVER AND ABOVE THOSE USUALLY INCLUDED WITH THE 99070 OFFICE VISIT Not Covered MEDICAID EDUCATIONAL SUPPLIES, SUCH AS BOOKS, TAPES, AND PAMPHLETS, PROVIDED BY THE PHYSICIAN FOR THE PATIENT'S EDUCATION AT COST 99071 TO PHYSIC Not Covered MEDICAID 99075 MEDICAL TESTIMONY Not Covered MEDICAID Physician educational services rendered to patients in a group setting 99078 No MEDICAID Special reports such as insurance forms, 99080 more than the information Not Covered MEDICAID UNUSUAL TRAVEL (EG, TRANSPORTATION AND ESCORT OF 99082 PATIENT) Not Covered MEDICAID

355 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ANALYSIS OF INFORMATION DATA STORED IN COMPUTERS (EG, ECGS, BLOOD PRESSURES, HEMATOLOGIC 99090 DATA) No MEDICAID Collection and interpretation of physiologic 99091 data (eg, ECG, blood No MEDICAID Anesthesia for patient of extreme age, 99100 under 1 year and over 70 (List No MEDICAID Anesthesia complicated by utilization of 99116 total body hypothermia (List No MEDICAID Anesthesia complicated by utilization of 99135 controlled hypotension (List No MEDICAID Anesthesia complicated by emergency 99140 conditions (specify) (List No MEDICAID 99151 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

No MEDICAID 99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

No MEDICAID 99153 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)

No MEDICAID 99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age No MEDICAID 99156 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older No MEDICAID

356 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 99157 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service) No MEDICAID Anogenital examination with colposcopic magnification in childhood for 99170 No MEDICAID Visual function screening, automated or 99172 semi-automated bilateral No MEDICAID Screening test of visual acuity, 99173 quantitative, bilateral No MEDICAID OCULAR PHOTSCREENING WITH INTERPRETATION AND REPORT, 99174 BILATERAL No MEDICAID Ipecac or similar administration for 99175 individual emesis and continued No MEDICAID Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with remote analysis and report; with on-site 99177 analysis Not Covered MEDICAID PHYSICIAN ATTENDANCE AND 99183 SUPERVISION OF HYPERBARIC Yes OXYGEN THERAPY, PER SESSION MEDICAID Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling

99184 No MEDICAID Application of topical fluoride varnish by a physician or other qualified health care 99188 professional No MEDICAID Assembly and operation of pump with oxygenator or heat exchanger (with 99190 No MEDICAID Assembly and operation of pump with oxygenator or heat exchanger (with 99191 No MEDICAID Assembly and operation of pump with oxygenator or heat exchanger (with 99192 No MEDICAID Phlebotomy, therapeutic (separate 99195 procedure) No MEDICAID UNLISTED SPECIAL SERVICE OR 99199 REPORT Yes MEDICAID UNLISTED SPECIAL SERVICE OR 99199 Yes REPORT MEDICAID Office or other outpatient visit for the 99201 evaluation and management of a No MEDICAID Office or other outpatient visit for the 99202 evaluation and management of a No MEDICAID Office or other outpatient visit for the 99203 evaluation and management of a No MEDICAID Office or other outpatient visit for the 99204 evaluation and management of a No MEDICAID Office or other outpatient visit for the 99205 evaluation and management of a No MEDICAID Office or other outpatient visit for the 99211 evaluation and management of an No MEDICAID Office or other outpatient visit for the 99212 evaluation and management of an No MEDICAID

357 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Office or other outpatient visit for the 99213 evaluation and management of an No MEDICAID Office or other outpatient visit for the 99214 evaluation and management of an No MEDICAID Office or other outpatient visit for the 99215 evaluation and management of an No MEDICAID Observation care discharge day management (This code is to be utilized 99217 No MEDICAID Initial observation care, per day, for the 99218 evaluation and management of No MEDICAID Initial observation care, per day, for the 99219 evaluation and management of No MEDICAID Initial observation care, per day, for the 99220 evaluation and management of No MEDICAID Initial hospital care, per day, for the 99221 evaluation and management of a No MEDICAID Initial hospital care, per day, for the 99222 evaluation and management of a No MEDICAID Initial hospital care, per day, for the 99223 evaluation and management of a No MEDICAID Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.

99224 No MEDICAID Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.

99225 No MEDICAID

358 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

99226 No MEDICAID Subsequent hospital care, per day, for the evaluation and management of 99231 No MEDICAID Subsequent hospital care, per day, for the evaluation and management of 99232 No MEDICAID Subsequent hospital care, per day, for the evaluation and management of 99233 No MEDICAID Observation or inpatient hospital care, for 99234 the evaluation and No MEDICAID Observation or inpatient hospital care, for 99235 the evaluation and No MEDICAID Observation or inpatient hospital care, for 99236 the evaluation and No MEDICAID Hospital discharge day management; 30 99238 minutes or less No MEDICAID Hospital discharge day management; 99239 more than 30 minutes No MEDICAID Office consultation for a new or 99241 No established patient, which requires MEDICAID Office consultation for a new or 99242 No established patient, low severity MEDICAID Office consultation for a new or 99243 established patient, moderate severity No MEDICAID Office consultation for a new or 99244 No established patient, moderate to high MEDICAID Office consultation for a new or 99245 Yes established patient, high complexity MEDICAID Initial inpatient consultation for a new or 99251 No established patient, which MEDICAID Initial inpatient consultation for a new or 99252 No established patient, which MEDICAID Initial inpatient consultation for a new or 99253 No established patient, which MEDICAID Initial inpatient consultation for a new or 99254 No established patient, which MEDICAID Initial inpatient consultation for a new or 99255 No established patient, which MEDICAID Emergency department visit for the 99281 evaluation and management of a No MEDICAID Emergency department visit for the 99282 evaluation and management of a No MEDICAID Emergency department visit for the 99283 evaluation and management of a No MEDICAID Emergency department visit for the 99284 evaluation and management of a No MEDICAID Emergency department visit for the 99285 evaluation and management of a No MEDICAID Physician direction of emergency medical 99288 systems (EMS) emergency No MEDICAID

359 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Critical care, evaluation and management 99291 of the critically ill or No MEDICAID Critical care, evaluation and management 99292 of the critically ill or No MEDICAID 99304 Nursing facility care, init No MEDICAID 99305 Nursing facility care, init No MEDICAID 99306 Nursing facility care, init No MEDICAID 99307 Nursing fac care, subseq No MEDICAID 99308 Nursing fac care, subseq No MEDICAID 99309 Nursing fac care, subseq No MEDICAID 99310 Nursing fac care, subseq No MEDICAID Nursing facility discharge day 99315 management; 30 minutes or less No MEDICAID Nursing facility discharge day 99316 management; more than 30 minutes No MEDICAID 99318 Annual nursing fac assessmnt No MEDICAID 99324 Domicil/r-home visit new pat No ExGEN MEDICAID 99325 Domicil/r-home visit new pat No ExGEN MEDICAID 99326 Domicil/r-home visit new pat No ExGEN MEDICAID 99327 Domicil/r-home visit new pat No ExGEN MEDICAID 99328 Domicil/r-home visit new pat No ExGEN MEDICAID 99334 Domicil/r-home visit est pat No ExGEN MEDICAID 99335 Domicil/r-home visit est pat No ExGEN MEDICAID 99336 Domicil/r-home visit est pat No ExGEN MEDICAID 99337 Domicil/r-home visit est pat No ExGEN MEDICAID 99339 Domicil/r-home care supervis No ExGEN MEDICAID 99340 Domicil/r-home care supervis No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 99341 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 99342 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 99343 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 99344 THREE COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 99345 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE 99347 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE 99348 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE 99349 THREE KEY COMPONENTS: No ExGEN MEDICAID HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE 99350 THREE KEY COMPONENTS: No ExGEN MEDICAID Prolonged physician service in the office 99354 or other outpatient setting No MEDICAID

360 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prolonged physician service in the office 99355 or other outpatient setting No MEDICAID Prolonged physician service in the 99356 inpatient setting, requiring direct No MEDICAID Prolonged physician service in the 99357 inpatient setting, requiring direct No MEDICAID Prolonged evaluation and management service before and/or after direct 99358 No MEDICAID Prolonged evaluation and management service before and/or after direct 99359 No MEDICAID Physician standby service, requiring 99360 prolonged physician attendance, No MEDICAID MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH 99366 CARE PROFESSIONAL No MEDICAID MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, PATIENT AND/OR FAMILY NOT PRESENT, 30 MINUTES OR MORE; 99367 PARTICIPATION BY PHYSICIAN No MEDICAID MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, PATIENT AND/OR FAMILY NOT PRESENT, 30 MINUTES OR MORE; PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE 99368 PROFESSIONAL No MEDICAID Physician supervision of a patient under 99374 care of home health agency No MEDICAID Physician supervision of a patient under 99375 care of home health agency No MEDICAID Physician supervision of a hospice patient 99377 (patient not present) requiring No MEDICAID Physician supervision of a hospice patient 99378 (patient not present) requiring No MEDICAID Physician supervision of a nursing facility 99379 patient (patient not present) No MEDICAID Physician supervision of a nursing facility 99380 patient (patient not present) No MEDICAID SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTERMEDIATE, GREATER THAN 3 99406 MINUTES UP TO 10 MINUTES No MEDICAID SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTENSIVE, GREATER THAN 10 99407 MINUTES No MEDICAID ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED SCREENING (EG, AUDIT, DAST), AND BRIEF INTERVENTION (SBI) SERVICES; 15 99408 TO 30 MINUTES No MEDICAID ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED SCREENING (EG, AUDIT, DAST), AND BRIEF INTERVENTION (SBI) SERVICES; 99409 GREATER THAN 30 MINUTES No MEDICAID

361 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) 99415 No MEDICAID Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; Each additional 30 minutes (List separately in addition to code for prolonged service) 99416 No MEDICAID UNLISTED PREVENTIVE MEDICINE 99429 SERVICE Yes MEDICAID TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT OR GUARDIAN NOT ORGINATION FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION 99441 No MEDICAID TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT OR GUARDIAN NOT ORGINATION FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION 99442 No MEDICAID TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT OR GUARDIAN NOT ORGINATION FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION 99443 No MEDICAID ONLINE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT OR GUARDIAN, OR HEALTH CARE PROVIDER WITHIN THE PREVIOUS 7 DAYS, USING THE INTERNET OR SIMILAR ELECTRONIC COMMUNICATION NETWORK 99444 No MEDICAID

362 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5- 10 minutes of medical consultative discussion and review No MEDICAID 99447 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review No MEDICAID 99448 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review No MEDICAID 99449 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review No MEDICAID Basic life and/or disability examination that includes: measurement of . 99450 No MEDICAID Work related or medical disability 99455 examination by the treating physician No MEDICAID Work related or medical disability 99456 examination by other than the treating No MEDICAID Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant 99460 No MEDICAID Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing 99461 center No MEDICAID Subsequent hospital care, per day, for evaluation and management of normal 99462 newborn No MEDICAID Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date 99463 No MEDICAID Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn 99464 No MEDICAID Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output 99465 No MEDICAID

363 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport 99466 No MEDICAID Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; each additional 30 minutes (List separately in addition to code for prima 99467 No MEDICAID Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or 99468 less No MEDICAID Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less 99469 No MEDICAID Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age 99471 No MEDICAID Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months 99472 of age No MEDICAID Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 99475 through 5 years of age No MEDICAID Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age 99476 No MEDICAID INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF THE NEONATE, 28 DAYS OF AGE OR LESS, WHO REQUIRES INTENSIVE OBSERVATION, FREQUENT INTERVENTIONS, AND OTHER INTENSIVE CARE SERVICES 99477 No MEDICAID Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 99478 grams) No MEDICAID Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) 99479 No MEDICAID Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 99480 2501-5000 grams) No MEDICAID

364 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition- focused evaluation including a pertinent history and examination; Medical decision making of moderate or high complexity; Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity; Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]); Medication reconciliation and review for high-risk medications; Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s); Evaluation of safety (eg, home), including motor vehicle operation; Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks; Development, updating or revision, or review of an Advance Care Plan; Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with 99483 No MEDICAID the patient and/or caregiver with initial Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team.

99484 No MEDICAID Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two- way communication with transport team 99485 before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes

No MEDICAID

365 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two- way communication with transport team before transport, at the referring facility 99486 and during the transport, including data interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)

No MEDICAID Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified 99487 health care professional with no face-to- face visit, per calendar month No MEDICAID Complex chronic care coordination services; each additional 30 minutes of clinical staff time directed by a physician 99489 or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) No MEDICAID Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; review by the psychiatric consultant with modifications of the plan if recommended; entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.

99492 No MEDICAID

366 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation; participation in weekly caseload consultation with the psychiatric consultant; ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.

99493 No MEDICAID Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure)

99494 No MEDICAID Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of 99495 discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge No MEDICAID Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of 99496 discharge Medical decision making of high complexity during the service period Face- to-face visit, within 7 calendar days of discharge No MEDICAID

367 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 99497 No MEDICAID Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) 99498 No MEDICAID UNLISTED EVALUATION AND 99499 MANAGEMENT SERVICE Yes MEDICAID HOME VISIT FOR PRENATAL 99500 ASSESSMENT Not Covered ExGEN MEDICAID Home visit for postnatal assessment and 99501 follow-up care No ExGEN MEDICAID Home visit for newborn care and 99502 assessment No ExGEN MEDICAID Home visit for respiratory therapy care 99503 (eg, bronchodilator, oxygen No ExGEN MEDICAID Home visit for mechanical ventilation care 99504 No ExGEN MEDICAID 99505 HOME VISIT FOR STOMA CARE No ExGEN MEDICAID Home visit for intramuscular injections 99506 No ExGEN MEDICAID Home visit for care and maintenance of 99507 catheter(s) (eg, urinary, drainage, No ExGEN MEDICAID HOME VISIT FOR ASSISTANCE WITH 99509 ACTIVITIES OF DAILY LIVING Not Covered ExGEN MEDICAID HOME VISIT FOR INDIVIDUAL, FAMILY OR MARRIAGE COUNSELING 99510 Not Covered ExGEN MEDICAID 99511 HOME VISIT FOR FECAL IMPACTION No ExGEN MEDICAID 99512 Home visit for hemodialysis No ExGEN MEDICAID UNLISTED HOME VISIT SERVICE OR 99600 PROCEDURE Yes ExGEN MEDICAID HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 99601 HOURS) No ExGEN MEDICAID HOME INFUSION/SPECIALTY DRUG ADMIN, PER VISIT (UP TO 2 HRS); EACH ADDITIONAL HOUR LIST SEPARATELY IN ADDITION TO 99602 PRIMARY PROC No ExGEN MEDICAID MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE- TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; INITIAL 15 MINUTES, NEW 99605 PATIENT No MEDICAID MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE- TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; INITIAL 15 MINUTES, ESTABLISHED PATIENT 99606 No MEDICAID

368 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE- TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 99607 SERVICE) No MEDICAID HEART FAILURE ASSESSED: (INCL ASSESSMENT OF ALL THE FOLLOWING COMPONENTS): BLOOD PRESSURE MEASURED (2000F); 0001F LEVEL OF ACTIVITY ASSE Not Covered INFO MEDICAID Infectious disease, HCV, 6 biochemical assays, prognostic scores for fibrosis and 0001M necroinflammatory activity in liver No MEDICAID Liver disease, 10 biochemical assays, prognostic scores for fibrosis, steatosis 0002M and alcoholic steatohepatitis Yes MEDICAID oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps 0002U Not Covered MEDICAID Liver disease, 10 biochemical assays, prognostic scores for fibrosis, steatosis 0003M and nonalcoholic steatohepatitis Yes MEDICAID oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin ), utilizing serum, algorithm reported as a likelihood score 0003U Yes MEDICAID Scoliosis, DNG analysis of 53 single 0004M nucleotide polymorphisms, (SNPs), using saliva Yes MEDICAID Infectious disease (bacterial), DNA, 27 resistance genes, PCR amplification and probe hybridization in microarray format (molecular detection and identification of AmpC, carbapenemase and ESBL coding genes detected or not detected, per isolate (Gram-Negative Bacterial Resistance Gene PCR Panel 0004U Not Covered MEDICAID OSTEOARTHRITIS ASSESSED-INCLS COMPNTS: (1006F) SYMPT&FUNCT; (1007F) ANTI FLAM /OTC MED USE; (2004F) INIT EXAM OF INVOLVD 0005F JOINTS Not Covered INFO MEDICAID Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3 and SPDEF), urine, algorithm reported as risk score 0005U Not Covered MEDICAID Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, 0006M with alpha-fetoprotein level, algorithm reported as a risk classifer Yes MEDICAID

369 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service 0006U Not Covered MEDICAID Oncology (gastrointestional neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing 0007M whole peripheral blood, algorithm reported as a nomogram of tumor disease index Yes MEDICAID Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to 0007U buccal DNA, per date of service Not Covered MEDICAID Oncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalin- 0008M fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score Yes MEDICAID Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next generation sequencing, formalin-fixed paraffin embedded or fresh tissue, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, 0008U tetracycline and rifabutin Not Covered MEDICAID Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified 0009U or non-amplified Not Covered MEDICAID Oncology (High-Grade Prostate Cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA and human kallikrein 2 [hK2]) plus patient age, digital rectal examination status, and no history of positive prostate biopsy, utilizing plasma, prognostic algorithm reported as a probability score 0010M Not Covered MEDICAID Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per 0010U submitted isolate Not Covered MEDICAID Prescription drug monitoring, evaluation of drugs present by LCMS/ MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug 0011U compounds and metabolites Not Covered MEDICAID

370 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSESSMENT (INCLUDES ALL OF THE FOLLOWING COMPONENTS) (CAP): CO-MORBID CONDITIONS ASSESSED 0012F Not Covered INFO MEDICAID Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for having urothelial 0012M carcinoma Yes MEDICAID Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene 0012U rearrangement(s) Not Covered MEDICAID Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent 0013M urothelial carcinoma Yes MEDICAID Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific 0013U gene rearrangement(s) Not Covered MEDICAID Comprehensive preoperative assessment performed for cataract surgery with intraocular lens (IOL) placement (includes assessment of all of the following components) (EC): Dilated fundus evaluation performed within twelve months prior to cataract surgery (2020F), Pre-surgical (cataract) axial length, corneal power measurement and method of intraocular lens power calculation documented (must be performed within six twelve months prior to surgery) (3073F), Preoperative assessment of functional or medical indication(s) for surgery prior to the cataract surgery with intraocular lens placement (must be performed within twelve months prior to cataract surgery) (3325F)

0014F Not Covered INFO MEDICAID Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome nextgeneration sequencing, DNA, whole blood or bone marrow, report of 0014U specific gene rearrangement(s) Not Covered MEDICAID Melanoma follow up completed (includes assessment of all of the following components) (ML): History obtained regarding new or changing moles (1050F), Complete physical skin exam performed (2029F), Patient counseled to perform a monthly self skin examination (5005F) 0015F Not Covered INFO MEDICAID

371 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision 0015U support Not Covered MEDICAID Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with 0016U quantitation Not Covered MEDICAID Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 0017U mutation not detected or detected Not Covered MEDICAID Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance 0024U spectroscopy, quantitative Not Covered MEDICAID Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), 0025U urine, quantitative Yes MEDICAID Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quakinginduced conformational conversion, qualitative 0035U No MEDICAID Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence 0036U analyses Not Covered MEDICAID Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden 0037U Yes MEDICAID Vitamin D, 25 hydroxy D2 and D3, by LCMS/MS, serum microsample, 0038U quantitative No MEDICAID Deoxyribonucleic acid (DNA) antibody, double stranded, high avidity 0039U No MEDICAID BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative 0040U Yes MEDICAID Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by 0041U immunoblot, IgM No MEDICAID CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY W/CONTRAST ADMIN, INCLUDING POST-PROCESSING OF PARAMETRIC MAPS W/DETERMINATI 0042T No MEDICAID Borrelia burgdorferi, antibody detection of 12 recombinant protein groups, by 0042U immunoblot, IgG No MEDICAID Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgM 0043U No MEDICAID

372 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Tick-borne relapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG 0044U No MEDICAID Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by realtime RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as recurrence score

0045U Yes MEDICAID FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative 0046U Yes MEDICAID Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm 0047U reported as a risk score Yes MEDICAID IMPLANTATION OF VENTRICULAR ASSIST DEVICE, EXTRACORPORAL, PERCUTANEOUS TRANSSEPTAL ACCESS, SINGLE OR DUAL 0048T CANNULATION Yes MEDICAID Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) 0048U Yes MEDICAID NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, 0049U quantitative Yes MEDICAID Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements 0050U Yes MEDICAID Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, urine, 31 drug panel, reported as quantitative results, detected or not detected, per date of service 0051U No MEDICAID Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of HDL, LDL, and VLDL by vertical auto 0052U profile ultracentrifugation No MEDICAID Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as 0053U probability of higher tumor grade Yes MEDICAID Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on 0054T fluoroscopic images (List separately in No addition to code for primary procedure) MEDICAID

373 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prescription drug monitoring, 14 or more classes of drugs and substances, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report with therapeutic and toxic ranges, including steady-state range for the prescribed dose when detected, per date of service 0054U No MEDICAID Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on 0055T CT/MRI images (List separately in No addition to code for primary procedure) MEDICAID Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control 0055U targets), plasma Yes MEDICAID Hematology (acute myelogenous leukemia), DNA, whole genome nextgeneration sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s) 0056U Yes MEDICAID Oncology (solid organ neoplasia), mRNA, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffinembedded tissue, algorithm reported as a normalized percentile rank 0057U Yes MEDICAID Cryopreservation; Reproductive Tissue, 0058T Ovarian Not Covered MEDICAID Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma virus oncoprotein (small T 0058U antigen), serum, quantitative No MEDICAID Oncology (Merkel cell carcinoma), detection of antibodies to the Merkel cell polyoma virus capsid protein (VP1), serum, reported as positive or negative 0059U No MEDICAID Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in 0060U maternal blood Yes MEDICAID Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis 0061U Yes MEDICAID 0062U Autoimmune (systemic lupus erythema Yes MEDICAID 0063U Neurology (autism), 32 amines by LCM Yes MEDICAID 0064U Antibody, Treponema pallidum, total a No MEDICAID 0065U Syphilis test, non-treponemal antibody No MEDICAID 0066U Placental alpha-micro globulin-1 (PAM Yes MEDICAID 0067U Oncology (breast), immunohistochemi Yes MEDICAID 0068U Candida species panel (C. albicans, C No MEDICAID 0069U Oncology (colorectal), microRNA, RT-PCR Yes MEDICAID 0070U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0071U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0072U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0073U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0074U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID

374 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 0075U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0076U CYP2D6 (cytochrome P450, family 2, subfa Yes MEDICAID 0077U Immunoglobulin paraprotein (M-protein), qu Yes MEDICAID 0078U Pain management (opioid-use disorde Yes MEDICAID 0079U Comparative DNA analysis using mult Yes MEDICAID FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLD MR GUIDANCE; TOT LEIOMYOMATA VOLUME LESS THAN 200 CC OF ISSUE

0071T Not Covered MEDICAID FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLD MR GUIDANCE; TOT LEIOMYOMATA VOLUME < OR EQL TO 200 CC OF ISSUE 0072T Not Covered MEDICAID TRANSCATHETER PLACMNT OF EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID ARTERY STENT(S) INCLDG RADIOLOGIC 0075T SPRVSN & INTPRTN, PERCU No MEDICAID TRANSCATHETER PLACMNT OF EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID ARTERY STENT(S) INCLDG RADIOLOGIC 0076T SPRVSN & INTPRTN, PERCU No MEDICAID BREATH TEST FOR HEART 0085T TRANSPLANT REJECTION Not Covered MEDICAID REMOVAL OF TOTAL DISK ARTHROPLASTY, ANTERIOR APPROACH; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN 0095T ADDITION TO CODE FRO PRIMARY No MEDICAID REVISION OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN 0098T ADDITION TO CODE FOR PRIM P No MEDICAID PLACE A SUBCONJUNCTIVAL RETINAL PROSTHESIS RECEIVER & PULSE GENERATOR, & IMPLANT INTRA-OCULAR RETINAL ELECTRODE 0100T ARRAY, W/VITRECTOM Not Covered MEDICAID EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCULOSKELETAL SYSTEM, NOT OTHERWISE 0101T SPECIFIED; HIGH ENERGY Not Covered MEDICAID EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY PHYSICIAN, REQUIRING ANESTHESIA OTH THAN LOCAL, INVOLVING 0102T LATERAL HUMERAL EPI Not Covered MEDICAID QUANTITATIVE SENSORY TESTING (QST), TESTING & INTERP PER EXTREMITY; USE TOUCH PRESSURE STIMULI TO ASSESS LARGE 0106T DIAMETER SENSATION Not Covered MEDICAID QUANTITATIVE SENSORY TESTING (QST), TESTING & INTERP PER EXTREMITY; USE VIBRATION STIMULI TO ASSESS LARGE DIAMETER FIBER 0107T SENSATION Not Covered MEDICAID QUANTITATIVE SENSORY TESTING (QST), TEST & INTERP PER EXTREMITY; USE COOLING STIMULI TO ASSESS SMALL NERVE FIBER 0108T SENSATION & HYPER Not Covered MEDICAID

375 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines QUANTITATIVE SENSORY TESTING (QST), TEST & INTERP PER EXTREMITY; USING HEAT-PAIN STIMULI TO ASSESS SMALL NERVE 0109T FIBER SENSATION & H Not Covered MEDICAID QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERP PER EXTREMITY, USING OTHER STIMULI 0110T TO ASSESS SENSATION Not Covered MEDICAID LONG-CHAIN (C20-22) OMEGA-3 FATTY ACIDS IN RED BLOOD CELL 0111T (RBC) MEMBRANES No MEDICAID COMMON CAROTID INTIMA-MEDIA THICKNESS (IMT) STUDY FOR EVAL OF ATHEROSCLEROTIC BURDEN OF CORONARY HEART DISEASE RISK 0126T FACTOR ASSESSM Not Covered MEDICAID EXHALED BREATH CONDENSATE PH 0140T No MEDICAID PANCREATIC ISLET CELL TRANSPLANTATION THROUGH 0141T PORTAL VEIN, PERCUTANEOUS Not Covered MEDICAID PANCREATIC ISLET CELL TRANSPLANTATION THROUGH 0142T PORTAL VEIN, OPEN Not Covered MEDICAID COMPUTER AIDED DETECTION, INCL COMPUTER ALGORITHM ANALYSIS OF MRI IMAGE DATA FOR LESION DETECTION/CHARACTERIZATION, PHARMOCOKINETI 0159T Not Covered MEDICAID TOTAL DISC ARTHROPLASTY (ARTIF DISC), ANTERIOR APPROACH (NOT DECMPR), INCL DISCECTOMY TO PREP INTERSPACE, LUMBAR, EA ADD'L INT SP 0163T Not Covered MEDICAID REMOVAL OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH 0164T ADDITIONAL INTERSPACE No MEDICAID REVISION OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH 0165T ADDITIONAL INTERSPACE Not Covered MEDICAID COMPUTER AIDED DECTECTION (CAD) W/FURTHER PHYSICIAN REVIEW FOR INTERP/RPRT, W OR WO DIGITIZATION OF FILM X-RAY 0174T IMAGES, CHEST, CONC Not Covered MEDICAID COMPUTER AIDED DETECTION (CAD) W/FURTHER PHYSICIAN RVW FOR INTERP/RPT, W OR W/O DIGITIZATION OF FILM IMAGES, CHEST XRAYS, 0175T REMOTE Not Covered MEDICAID Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, 0184T full thickness) No MEDICAID REMOTE REAL-TIME INTERACTIVE VIDEOCONFERENCED CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; 0188T FIRST 30-74 MINUTES No MEDICAID

376 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REMOTE REAL-TIME INTERACTIVE VIDEOCONFERENCED CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES 0189T No MEDICAID PLACEMENT OF INTRAOCULAR 0190T Yes RADIATION SOURCE APPLICATOR MEDICAID Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork 0191T No MEDICAID Arthrodesis, pre-sacral interbody technique, including instrutmentation, imaging (when performed), and 0195T discectomy to prepare interspace, lumbar; Yes single interspace MEDICAID Arthrodesis, pre-sacral interbody technique, including instrutmentation, imaging (when performed), and discectomy to prepare interspace, lumbar; 0196T each additional interspace (List separately Yes in addition to code for primary procedure)

MEDICAID Measurement of ocular blood flow by repetitive intraocular pressure sampling, 0198T Yes with interpretation and report MEDICAID Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), 0200T including the use of a balloon or No mechanical device, when used, 1 or more needles MEDICAID Percutaneous sacral augmentation (sacroplasty), bilateral injections, including 0201T the use of a balloon or mechanical device, No when used, 2 or more needles MEDICAID POSTERIOR VERTEBRAL JOINT(s) ARTHROPLASTY (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine 0202T No MEDICAID INTRAVASCULAR CATHETER-BASED CORONARY VESSEL OR GRAFT SPECTROSCOPY DURING DX EVAL &/OR TX INTERVEN INCL IMAGING 0205T SUPV/INTRP/RPT, EA No MEDICAID ALGORITHMIC ANALYSIS, REMOTE, OF ELECTROCARDIOGRAPHIC 0206T DERIVED DATA WITH COMPUTER No PROBABILITY ASSESSMENT, INCL REPORT MEDICAID EVACUATION OF MEIBOMIAN GLANDS, AUTOMATED, USING HEAT 0207T Yes AND INTERMITTENT PRESSURE, UNILATERAL MEDICAID Pure tone audiometry (threshold), 0208T automated; air only No MEDICAID Pure tone audiometry (threshold), 0209T automated; air and bone No MEDICAID Speech audiometry threshold, automated 0210T (includes use of computer-assisted Yes device) MEDICAID

377 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Speech audiometry threshold, automated (includes use of computer-assisted 0211T Yes device); with speech recognition MEDICAID Comprehensive audiometry threshold evaluation and speech recognition 0212T (0209T, 0211T combined), automated Yes (includes use of computer-assisted device) MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0213T No MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) 0214T No MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 0215T No MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0216T No MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for 0217T primary procedure) No MEDICAID Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 0218T No MEDICAID Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical 0219T No MEDICAID Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic 0220T No MEDICAID Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar 0221T No MEDICAID

378 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary 0222T procedure) No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; 0228T single level No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (list separately in addition to code for primary procedure) 0229T No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; 0230T single level No MEDICAID Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (list separately in addition to code for primary procedure) 0231T Yes MEDICAID Injection(s), platelet rich plasma, any site, including image guidance, harvesting and 0232T Yes preparation when performed MEDICAID TRANSLUMINAL PERIPHERAL ATHERECTOMY, INCLUDING 0234T Yes RADIOLOGICAL SUPERVISION AND INTERPRETATION; RENAL ARTERY MEDICAID TRANSLUMINAL PERIPHERAL ATHERECTOMY, INCL RADIOLOGICAL SUPERVISION & INTERPRETATION; 0235T VISCERAL ARTERY (EXCEPT RENAL), Yes EA VESSEL MEDICAID TRANSLUMINAL PERIPHERAL ATHERECTOMY, INCLUDING 0236T RADIOLOGICAL SUPERVISION AND Yes INTERPRETATION; ABDOMINAL AORTA MEDICAID TRANSLUMINAL PERIPHERAL ATHERECTOMY, INCL RADIOLOGICAL SUPERVISION & INTERPRETATION; 0237T BRACHIOCEPHALIC TRUNK & Yes BRANCHES, EA VESSEL MEDICAID TRANSLUMINAL PERIPHERAL ATHERECTOMY, INCLUDING 0238T RADIOLOGICAL SUPERVISION AND Yes INTERPRETATION; ILIAC ARTERY, EACH VESSEL MEDICAID LIGATION, HEMORRHOIDAL VASCULAR BUNDLE(S), INCLUDING 0249T Yes ULTRASOUND GUIDANCE MEDICAID Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space 0253T Yes MEDICAID ENDOVASCULAR RPR ILIAC ARTERY BIFURCATION USING BIFURCATED 0254T ENDOPROSTHESIS FROM COMMON Yes ILIAC ARTERY INTO BOTH EXT/INT ILIAC, UNILAT MEDICAID

379 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest

0263T Not Covered MEDICAID 0264T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest Not Covered MEDICAID Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy 0265T Not Covered MEDICAID Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative interrogation, programming, and repositioning, when performed)

0266T Not Covered MEDICAID Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 0267T Not Covered MEDICAID Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) 0268T Not Covered MEDICAID Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) 0269T Not Covered MEDICAID Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and 0270T repositioning, when performed) Not Covered MEDICAID Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) 0271T Not Covered MEDICAID

380 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day)

0272T Not Covered MEDICAID Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming 0273T Not Covered MEDICAID Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

0274T No MEDICAID Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

0275T Not Covered MEDICAID Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes) 0278T Not Covered MEDICAID Corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar keratoplasty (List separately in addition to code for primary procedure) 0290T No MEDICAID External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation 0295T No MEDICAID

381 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording) 0296T No MEDICAID External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report 0297T No MEDICAID External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation 0298T No MEDICAID Insertion of ocular telescope prosthesis including removal of crystalline lens 0308T Yes MEDICAID Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, 0309T includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) Yes MEDICAID Non-invasive calculation and analysis of central arterial pressure waveforms with 0311T interpretation and report No MEDICAID Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to 0312T esophagogastric junction (EGJ), with implantation of pulse generator, includes programming Not Covered MEDICAID Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk 0313T neurostimulator electrode array, including connection to existing pulse generator Not Covered MEDICAID Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal 0314T trunk neurostimulator electrode array and pulse generator Not Covered MEDICAID Vagus nerve blocking therapy (morbid 0315T obesity); removal of pulse generator Not Covered MEDICAID Vagus nerve blocking therapy (morbid 0316T obesity); replacement of pulse generator Not Covered MEDICAID Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator 0317T electronic analysis, includes reprogramming when performed Not Covered MEDICAID Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with 0329T interpretation and report Not Covered MEDICAID Tear film imaging, unilateral or bilateral, 0330T with interpretation and report Not Covered MEDICAID Myocardial sympathetic innervation 0331T imaging, planar qualitative and quantitative assessment; Not Covered MEDICAID

382 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Myocardial sympathetic innervation imaging, planar qualitative and 0332T quantitative assessment; with tomographic SPECT Not Covered MEDICAID Visual evoked potential, screening of 0333T visual acuity, automated Not Covered MEDICAID 0335T Extra-osseous subtalar joint implant for talotarsal stabilization Not Covered MEDICAID 0337T Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral Not Covered MEDICAID 0338T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral Not Covered MEDICAID 0339T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral Not Covered MEDICAID 0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral Not Covered MEDICAID 0342T Therapeutic apheresis with selective HDL delipidation and plasma reinfusion Not Covered MEDICAID 0346T Ultrasound, elastography (List separately in addition to code for primary procedure) No MEDICAID Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) 0347T Not Covered INFO MEDICAID Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when 0348T performed) Not Covered INFO MEDICAID Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) 0349T Not Covered INFO MEDICAID Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) 0350T Not Covered INFO MEDICAID Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative 0351T Not Covered INFO MEDICAID

383 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, 0352T real time or referred Not Covered INFO MEDICAID Optical coherence tomography of breast, surgical cavity; real time intraoperative 0353T Not Covered INFO MEDICAID Optical coherence tomography of breast, surgical cavity; interpretation and report, 0354T real time or referred Not Covered INFO MEDICAID Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report 0355T Not Covered INFO MEDICAID Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each 0356T Not Covered INFO MEDICAID Cryopreservation; immature oocyte(s) 0357T Not Covered INFO MEDICAID Bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report 0358T Not Covered INFO MEDICAID Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

0375T No MEDICAID Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) 0376T No MEDICAID Anoscopy with directed submucosal injection of bulking agent for fecal 0377T incontinence Not Covered MEDICAID Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 0378T Not Covered MEDICAID Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional 0379T Not Covered MEDICAID Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation 0380T and report Not Covered MEDICAID

384 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 0381T Not Covered MEDICAID External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation 0382T only Not Covered MEDICAID External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 0383T Not Covered MEDICAID External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation 0384T only Not Covered MEDICAID External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 0385T Not Covered MEDICAID External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation 0386T only Not Covered MEDICAID Transcatheter insertion or replacement of permanent leadless pacemaker, 0387T ventricular Not Covered MEDICAID Transcatheter removal of permanent 0388T leadless pacemaker, ventricular Not Covered MEDICAID Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system 0389T Not Covered MEDICAID Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker 0390T system Not Covered MEDICAID

385 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system 0391T Not Covered MEDICAID High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed 0394T No MEDICAID High dose rate electronic brachytherapy, interstitial or intracavity, per fraction, includes basic dosimetry, when performed 0395T No MEDICAID Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure) 0396T Not Covered MEDICAID Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure) 0397T Not Covered MEDICAID Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed 0398T Not Covered MEDICAID Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics) (List separately in addition to code for primary procedure) 0399T No MEDICAID Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; one to five lesions 0400T Not Covered MEDICAID Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; six or more lesions 0401T Not Covered MEDICAID Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry 0402T when performed) Yes MEDICAID Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day 0403T No MEDICAID Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency 0404T No MEDICAID

386 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-to-face time

0405T Not Covered MEDICAID Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant 0406T No MEDICAID Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement 0407T No MEDICAID Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes

0408T Not Covered MEDICAID Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only 0409T Not Covered MEDICAID Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only 0410T Not Covered MEDICAID Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only 0411T Not Covered MEDICAID Removal of permanent cardiac contractility modulation system; pulse 0412T generator only Not Covered MEDICAID Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or 0413T ventricular) Not Covered MEDICAID Removal and replacement of permanent cardiac contractility modulation system pulse generator only 0414T Not Covered MEDICAID Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or 0415T ventricular lead) Not Covered MEDICAID Relocation of skin pocket for implanted cardiac contractility modulation pulse 0416T generator Not Covered MEDICAID Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system 0417T Not Covered MEDICAID

387 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system

0418T Not Covered MEDICAID Destruction neurofibroma, extensive, (cutaneous, dermal extending into subcutaneous); face, head and neck, 0419T greater than 50 neurofibroma Yes MEDICAID Destruction neurofibroma, extensive, (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibroma 0420T Yes MEDICAID Transurethral waterjet ablation of prostate, including control of postoperative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) 0421T Not Covered MEDICAID Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral 0422T Not Covered MEDICAID Secretory type II phospholipase A2 0423T (sPLA2-IIA) Not Covered MEDICAID Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable 0424T pulse generator) Yes MEDICAID Insertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only 0425T Yes MEDICAID Insertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only 0426T Yes MEDICAID Insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only 0427T Yes MEDICAID Removal of neurostimulator system for treatment of central sleep apnea; pulse 0428T generator only No MEDICAID Removal of neurostimulator system for treatment of central sleep apnea; sensing 0429T lead only No MEDICAID Removal of neurostimulator system for treatment of central sleep apnea; 0430T stimulation lead only No MEDICAID Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only 0431T No MEDICAID Repositioning of neurostimulator system for treatment of central sleep apnea; 0432T stimulation lead only No MEDICAID Repositioning of neurostimulator system for treatment of central sleep apnea; 0433T sensing lead only No MEDICAID

388 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea

0434T No MEDICAID Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single 0435T session No MEDICAID Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during 0436T sleep study No MEDICAID Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to primary 0437T procedure) No MEDICAID Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to 0439T primary procedure) Not Covered MEDICAID Ablation, percutaneous, cryoablation, includes imaging guidance; upper 0440T extremity distal/peripheral nerve Yes MEDICAID Ablation, percutaneous, cryoablation, includes imaging guidance; lower 0441T extremity distal/peripheral nerve Yes MEDICAID Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial 0442T plexus, pudendal nerve) Yes MEDICAID Real time spectral analysis of prostate tissue by fluorescence spectroscopy 0443T Not Covered MEDICAID Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, 0444T unilateral or bilateral Not Covered MEDICAID Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral 0445T Not Covered MEDICAID Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training 0446T No MEDICAID Removal of implantable interstitial glucose sensor from subcutaneous pocket via 0447T incision No MEDICAID Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation 0448T No MEDICAID Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; 0449T initial device No MEDICAID Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure)

0450T No MEDICAID

389 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)

0451T Yes MEDICAID Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal 0452T Yes MEDICAID Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano- electrical skin interface 0453T Yes MEDICAID Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode 0454T Yes MEDICAID Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes) 0455T No MEDICAID Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal 0456T No MEDICAID Removal of permanently implantable aortic counterpulsation ventricular assist system; mechano-electrical skin interface 0457T No MEDICAID Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode 0458T No MEDICAID Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano- electrical skin interface and 0459T electrodes No MEDICAID Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode 0460T No MEDICAID Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device 0461T No MEDICAID

390 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day 0462T No MEDICAID Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day 0463T No MEDICAID Visual evoked potential, testing for glaucoma, with interpretation and report 0464T Not Covered MEDICAID Suprachoroidal injection of a pharmacologic agent (does not include 0465T supply of medication) Yes MEDICAID Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary 0466T procedure) No MEDICAID Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing 0467T pulse generator No MEDICAID Removal of chest wall respiratory sensor 0468T electrode or electrode array No MEDICAID Retinal polarization scan, ocular screening with on-site automated results, bilateral 0469T Not Covered MEDICAID Device evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional 0472T Not Covered MEDICAID Device evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional 0473T Not Covered MEDICAID Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space 0474T No MEDICAID Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional

0475T Not Covered MEDICAID

391 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and 0476T storage Not Covered MEDICAID Recording of fetal magnetic cardiac signal using at least 3 channels; signal extraction, technical analysis, and result 0477T Not Covered MEDICAID Recording of fetal magnetic cardiac signal using at least 3 channels; review, interpretation, report by physician or other qualified health care professional 0478T Not Covered MEDICAID Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of 0479T infants and children Yes MEDICAID Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure) 0480T Yes MEDICAID Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when 0481T performed Yes ExGEN MEDICAID Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure) 0482T No MEDICAID Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when 0483T performed Not Covered MEDICAID Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) 0484T Yes MEDICAID Optical coherence tomography (OCT) of middle ear, with interpretation and report; 0485T unilateral Yes MEDICAID Optical coherence tomography (OCT) of middle ear, with interpretation and report; 0486T bilateral Yes MEDICAID Biomechanical mapping, transvaginal, 0487T with report Not Covered MEDICAID Preventive behavior change, online/electronic structured intensive program for prevention of diabetes using a standardized diabetes prevention program curriculum, provided to an 0488T individual, per 30 days No MEDICAID Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells

0489T Not Covered MEDICAID

392 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands 0490T Not Covered MEDICAID Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, total treatment surface area; first 0491T 20 sq cm or less Yes MEDICAID Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 0492T Yes MEDICAID Near-infrared spectroscopy studies of lower extremity wounds (eg, for 0493T oxyhemoglobin measurement) No MEDICAID Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed 0494T No ExGEN MEDICAID Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field

0495T No ExGEN MEDICAID Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; each additional hour (List separately in addition to code for primary procedure)

0496T No ExGEN MEDICAID External patient-activated, physician- or other qualified health care professional- prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; in-office connection

0497T No MEDICAID

393 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines External patient-activated, physician- or other qualified health care professional- prescribed, electrocardiographic rhythm derived event recording without 24 hour attended monitoring; review and interpretation by a physician or other qualified health care professional per 30 days with at least one patient-generated triggered event 0498T No MEDICAID Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed 0499T No MEDICAID INITIAL PRENATAL CARE VISIT (RPT AT 1ST PRENATAL ENCOUNTER W/HLTH CARE PROFESSIONAL PROVIDING OBSTETRICAL CARE. RPT 0500F ALSO DATE VISI No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus (HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping) 0500T No MEDICAID PRENATAL FLOW SHEET DOCUMENTED IN MED RECD BY 1ST PRENATAL VISIT (DOC INCLDS AT MIN BLOOD PRESSURE, WT, URINE 0501F PROTEIN, UTERINE SZ, No MEDICAID Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

0501T No MEDICAID SUBSEQUENT PRENATAL CARE VISIT (EXCLUDES: PTS WHO ARE SEEN FOR A CONDITION UNRELATED TO PREGNANCY OR PRENATAL CARE (EG, UPPER RESP 0502F No MEDICAID Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission 0502T No MEDICAID 0503F POSTPARTUM CARE VISIT No MEDICAID

394 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model 0503T No MEDICAID Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

0504T No MEDICAID HEMODIALYSIS PLAN OF CARE 0505F DOCUMENTED (ESRD)1 Not Covered INFO MEDICAID Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural 0505T roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion

No MEDICAID Macular pigment optical density measurement by heterochromatic flicker photometry, unilateral 0506T or bilateral, with interpretation and report No MEDICAID PERITONEAL DIALYSIS PLAN OF 0507F CARE DOCUMENTED (ESDRD)1 Not Covered INFO MEDICAID Near-infrared dual imaging (ie, simultaneous reflective and trans-illuminated light) of 0507T meibomian glands, unilateral or bilateral, with interpretation and report No MEDICAID Pulse-echo ultrasound bone density 0508T measurement resulting in indicator of axial bone mineral density, tibia No MEDICAID URINARY INCONTINENCE PLAN OF 0509F CARE DOCUMENTED (GER) Not Covered INFO MEDICAID Electroretinography (ERG) with interpretation 0509T and report, pattern (PERG) Yes MEDICAID ELEVATED BLOOD PRESSURE PLAN 0513F OF CARE DOCUMENTED Not Covered INFO MEDICAID PLAN OF CARE FOR ELEVATED HEMOGLOBIN LEVEL DOCUMENTED FOR PATIENT RECEIVING ERYTHROPOIESIS-STIMUALTING AGENT (ESA) THERAPY 0514F Not Covered INFO MEDICAID ANEMIA PLAN OF CARE 0516F DOCUMENTED Not Covered INFO MEDICAID GLAUCOMA PLAN OF CARE 0517F DOCUMENTED Not Covered INFO MEDICAID FALLS PLAN OF CARE DOCUMENTED 0518F Not Covered INFO MEDICAID

395 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Planned chemotherapy regimen, including at a minimum: drug(s) prescribed, dose, and duration, documented prior to initiation of a new treatment regimen 0519F Not Covered INFO MEDICAID Radiation dose limits to normal tissues established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues/organs 0520F Not Covered INFO MEDICAID Plan of care to address pain documented 0521F Not Covered INFO MEDICAID 0525F Initial visit for episode Not Covered INFO MEDICAID 0526F Subsequent visit for episode Not Covered INFO MEDICAID Recommended follow-up interval for repeat colonoscopy of at least 10 years documented in colonoscopy report 0528F Not Covered INFO MEDICAID Interval of 3 or more years since patient's last colonoscopy, documented 0529F Not Covered INFO MEDICAID Dyspnea management plan of care, 0535F documented Not Covered INFO MEDICAID Glucorticoid Management Plan 0540F Documented Not Covered INFO MEDICAID Plan for follow-up care for major 0545F depressive disorder, documented Not Covered INFO MEDICAID Cytopathology report on routine nongynecologic specimen finalized within two working days of accession date 0550F (PATH) Not Covered INFO MEDICAID Cytopathology report on nongynecologic specimen with documentation that the specimen was non-routine (PATH) 0551F Not Covered INFO MEDICAID Symptom management plan of care 0555F documented Not Covered INFO MEDICAID Plan of care to achieve lipid control 0556F documented Not Covered INFO MEDICAID Plan of care to manage anginal symptoms 0557F documented Not Covered INFO MEDICAID HIV RNA control plan of care, 0575F documented Not Covered INFO MEDICAID Multidisciplinary care plan developed or 0580F updated (DSP) Not Covered MEDICAID Patient transferred directly from 0581F anesthetizing location to critical care unit (Peri2) Not Covered MEDICAID Patient not transferred directly from 0582F anesthetizing location to critical care unit (Peri2) Not Covered MEDICAID Transfer of care checklist used (Peri2) 0583F Not Covered MEDICAID Transfer of care checklist not used (Peri2) 0584F Not Covered MEDICAID TOBACCO USE ASSESSED (CAD, CAP, 1000F COPD, PV) (DM) Not Covered INFO MEDICAID ANGINAL SYMPTOMS AND LEVEL OF 1002F ACTIVITY, ASSESSED Not Covered INFO MEDICAID 1003F LEVEL OF ACTIVITY ASSESSED Not Covered INFO MEDICAID CLINICAL SYMPTOMS OF VOLUME 1004F OVERLOAD (EXCESS) ASSESSED Not Covered INFO MEDICAID ASTHMA SYMPTOMS EVALUATED (INCLS PHYS DOCUMENTATION (# FREQ OF SYMP) OR PAT COMPL OF ASTHMA ASSMT 1005F TOOL/SURVEY/QUESTIONAIRE) Not Covered INFO MEDICAID

396 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines OSTEOARTHRITIS SYMP & FUNCT STAT ASSESS (MAY INCL USE OF STAND SCALE OR QUESTIONAIRE SUCH AS SF-36, AAOS HIP&KNEE. 1006F REPORT W ENC Not Covered INFO MEDICAID ASSESSMT OF USE OF ANTI- INFLAMMATORY OR ANALGESIC OTC 1007F MEDS FOR SYMP RELIEF Not Covered INFO MEDICAID GASTROINTESTINAL AND RENAL RISK FACTORS ASSESSED FOR PATS ON RX OR OTC NON-STEROIDAL ANTI- INFLAMMATORY DRUG (NSAID) 1008F Not Covered INFO MEDICAID 1011F Angina present Not Covered INFO MEDICAID 1012F Angina absent Not Covered INFO MEDICAID CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) SYMPTOMS ASSESSED (INCL ASSESSMENT OF AT LEAST ONE OF THE FOLLOWING: DYSPNEA, COUGH/ 1015F Not Covered INFO MEDICAID DYSPNEA ASSESSED, NOT PRESENT 1018F (COPD) Not Covered INFO MEDICAID DYSPNEA ASSESSED, PRESENT 1019F (COPD) Not Covered INFO MEDICAID PNEUMOCOCCUS IMMUNIZATION 1022F STATUS ASSESSED (CAP, COPD) Not Covered INFO MEDICAID CO-MORBID CONDITIONS ASSESSED (CAP) (EG, INCL ASSESS FOR PRESENCE/ABSENCE OF: MALIG, LIVER DIS, CHF, CV DIS, RENAL DIS, COPD, ASTH 1026F Not Covered INFO MEDICAID INFLUENZA IMMUNIZATION STATUS 1030F ASSESSED (CAP) Not Covered INFO MEDICAID Smoking status and exposure to second hand smoke in the home assessed 1031F Not Covered INFO MEDICAID Current tobacco smoker OR currently 1032F exposed to secondhand smoke Not Covered INFO MEDICAID Current tobacco non-smoker AND not currently exposed to secondhand smoke( 1033F Not Covered INFO MEDICAID CURRENT TOBACCO SMOKER (CAD, 1034F CAP, COPD, PV) (DM) Not Covered INFO MEDICAID CURRENT SMOKELESS TOBACCO 1035F USER (EG, CHEW, SNUFF) (PV) Not Covered INFO MEDICAID CURRENT TOBACCO NON-USER 1036F (CAD, CAP, COPD, PV) (DM) Not Covered INFO MEDICAID PERSISTENT ASTHMA (MILD, 1038F MODERATE, OR SEVERE) (ASTHMA) Not Covered INFO MEDICAID 1039F INTERMITTENT ASTHMA (ASTHMA) Not Covered INFO MEDICAID DSM-IV CRITERIA FOR MAJOR DEPRESSIVE DISORDER 1040F DOCUMENTED (MDD) Not Covered INFO MEDICAID HISTORY OBTAINED REAGRDING 1050F NEW OR CHANGING MOLES Not Covered INFO MEDICAID Type, anatomic location, and activity all 1052F assessed Not Covered INFO MEDICAID VISUAL FUNCTIONAL STATUS 1055F ASSESSED Not Covered INFO MEDICAID DOCUMENTATION OF PERMANENT OR PERSISTENT OR PAROXYSMAL 1060F ATRIAL FIBRILLATION Not Covered INFO MEDICAID DOCUMENTATION OF ABSCENCE OF PERMANENT AND PERSISTENT AND PAROXYSMAL ATRIAL FIBRILLATION 1061F Not Covered INFO MEDICAID ISCHEMIC STROKE SYMPTOM ONSET OF LESS THAN 3 HOURS PRIOR TO 1065F ARRIVAL Not Covered INFO MEDICAID

397 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ISCHEMIC STROKE SYMPTOM ONSET GREATER THAN OR EQUAL TO 3 1066F HOURS PRIOR TO ARRIVAL Not Covered INFO MEDICAID ALARM SYMPTOMS (INVOLUNTARY WEIGHT LOSS, DYSPHAGIA, OR GASTROINTESTINAL BLEEDING) 1070F ASSESSED; NONE PRESENT Not Covered INFO MEDICAID ALARM SYMPTOMS (INVOLUNTARY WEIGHT LOSS, DYSPHAGIA, OR GASTROINTESTINAL BLEEDING) ASSESSED; ONE OR MORE PRESENT 1071F Not Covered INFO MEDICAID PRESENCE OR ABSENCE OF URINARY INCONTINENCE ASSESSED 1090F Not Covered INFO MEDICAID URINARY INCONTINENCE CHARACTERIZED (EG FREQUENCY, VOLUME, TIMING, TYPE OF SYMPTOMS, HOW BOTHERSOME) 1091F Not Covered INFO MEDICAID PATIENT SCREENED FOR FUTURE FALL RISK; DOCUMENTATION OF 2 OR MORE FALLS IN THE PAST YEAR OR ANY FALL W/INJURY IN THE PAST 1100F YR (GER) Not Covered INFO MEDICAID PATIENT SCREENED FOR FUTURE FALL RISK; DOCUMENTATION OF NO FALLS IN THE PAST YEAR OR ONLY 1 FALL WITHOUT INJURY IN THE PAST 1101F YEAR Not Covered INFO MEDICAID PATIENT DISCHARGED FROM AN INPT FACILITY (EG HOSPITAL, SNF, OR REHAB FAC) WITHIN THE LAST 60 1110F DAYS Not Covered INFO MEDICAID DISCHARGE MEDICATIONS RECONCILED WITH THE CURRENT MEDICATION LIST IN OUTPATIENT 1111F MEDICAL RECORD Not Covered INFO MEDICAID Auricular or periauricular pain assessed 1116F Not Covered INFO MEDICAID GERD symptoms assessed after 12 1118F months of therapy Not Covered INFO MEDICAID 1119F Initial evaluation for condition Not Covered INFO MEDICAID 1121F Subsequent evaluation for condition Not Covered INFO MEDICAID Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in 1123F the medical record Not Covered INFO MEDICAID Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan 1124F Not Covered INFO MEDICAID 1125F Pain severity quantified; pain present Not Covered INFO MEDICAID Pain severity quantified; no pain present 1126F Not Covered INFO MEDICAID New episode for condition (NMA – No 1127F Measure Associated) Not Covered INFO MEDICAID Subsequent episode for condition (NMA – 1128F No Measure Associated) Not Covered INFO MEDICAID Back pain and function assessed, including all of the following: Pain assessment AND functional status AND patient history, including notation of presence or absence of “red flags” (warning signs) AND assessment of prior treatment and response, AND 1130F employment status Not Covered INFO MEDICAID Episode of back pain lasting six weeks or 1134F less Not Covered INFO MEDICAID

398 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Episode of back pain lasting longer than 1135F six weeks Not Covered INFO MEDICAID Episode of back pain lasting 12 weeks or 1136F less Not Covered INFO MEDICAID Episode of back pain lasting longer than 1137F 12 weeks Not Covered INFO MEDICAID Documentation that a patient has a substantial risk of death within one year 1150F Not Covered INFO MEDICAID Documentation that a patient does not have a substantial risk of death within one 1151F year Not Covered INFO MEDICAID Documentation of advanced disease diagnosis, goals of care prioritize comfort 1152F Not Covered INFO MEDICAID Documentation of advanced disease diagnosis, goals of care do not prioritize 1153F comfort Not Covered INFO MEDICAID Advance care plan or similar legal document present in the medical record 1157F Not Covered INFO MEDICAID Advance care planning discussion 1158F documented in the medical record Not Covered INFO MEDICAID Medication list documented in medical 1159F record Not Covered INFO MEDICAID Review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies and supplements) documented in the medical record 1160F Not Covered INFO MEDICAID 1170F Functional status assessed Not Covered INFO MEDICAID Functional status for dementia assessed 1175F and results reviewed Not Covered INFO MEDICAID All specified thromboembolic risk factors 1180F assessed Not Covered INFO MEDICAID Neuropsychiatric symptoms assessed and 1181F results reviewed Not Covered INFO MEDICAID Neuropsychiatric symptoms, one or more 1182F present Not Covered INFO MEDICAID 1183F Neuropsychiatric symptoms, absent Not Covered INFO MEDICAID Seizure type(s) and current seizure 1200F frequency(ies) documented Not Covered INFO MEDICAID Etiology of epilepsy or epilepsy syndrome(s) reviewed and documented 1205F Not Covered INFO MEDICAID 1220F Patient screened for depression Not Covered INFO MEDICAID Symptoms improved or remained consistent with treatment goals since last 1450F assessment Not Covered INFO MEDICAID Symptoms demonstrated clinically important deterioration since last 1451F assessment Not Covered INFO MEDICAID Qualifying cardiac event/diagnosis in 1460F previous 12 months Not Covered INFO MEDICAID No qualifying cardiac event/diagnosis in 1461F previous 12 months Not Covered INFO MEDICAID 1490F Dementia severity classified, mild Not Covered INFO MEDICAID Dementia severity classified, moderate 1491F Not Covered INFO MEDICAID 1493F Dementia severity classified, severe Not Covered INFO MEDICAID 1494F Cognition assessed and reviewed Not Covered INFO MEDICAID Symptoms and signs of distal symmetric 1500F polyneuropathy reviewed and documented (DSP) Not Covered MEDICAID Not initial evaluation for condition (DSP) 1501F Not Covered MEDICAID Patient queried about pain and pain 1502F interference with function using a valid and reliable instrument (DSP) Not Covered MEDICAID

399 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient queried about symptoms of 1503F respiratory insufficiency (DSP) Not Covered MEDICAID Patient has respiratory insufficiency (DSP) 1504F Not Covered MEDICAID Patient does not have respiratory 1505F insufficiency (DSP) Not Covered MEDICAID 2000F BLOOD PRESSURE MEASURED Not Covered INFO MEDICAID WEIGHT RECORDED (CHF, PAG) 2001F (DESC REVISED 010107) Not Covered INFO MEDICAID CLINICAL SIGNS OF VOLUME 2002F OVERLOAD (EXCESS) ASSESSED Not Covered INFO MEDICAID INITIAL EXAM OF THE INVOLVED JOINTS (INCLS VISUAL INSPECT, PALP, RANGE OF MOTION). REPORT ONLY FOR INIT OA VISIT OR NEW 2004F JOINT Not Covered INFO MEDICAID VITAL SIGNS (TEMPERATURE, PULSE, RESPIRATION RATE, AND BLOOD PRESSURE) DOCUMENTED AND REVIEWED (RVSD 070107) 2010F Not Covered INFO MEDICAID MENTAL STATUS ASSESSED (NORMAL/MILDLY IMPAIRED/SEVERLY IMPAIRED( (CAP) 2014F Not Covered INFO MEDICAID 2015F Asthma impairment assessed Not Covered INFO MEDICAID 2016F Asthma risk assessed Not Covered INFO MEDICAID HYDRATION STATUS ASSESSED (NORMAL/MILDLY DEHYDRATED/SEVERELY 2018F DEHYDRATED) (CAP) Not Covered INFO MEDICAID DILATED MACULAR EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE PRESENCE OR ABSENCE OF MACULAR THICKENING OR HEMORRHAGE AND THE LEVEL OF MACULAR DEGENERATION SEVERITY 2019F Not Covered INFO MEDICAID Dilated fundus evaluation performed within twelve months prior to cataract 2020F surgery Not Covered INFO MEDICAID DILATED MACULAR AND FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE PRESENCE OF ABSENCE OF MACULAR EDEMA AND LEVEL OF SEVERITY OF 2021F RETINOPLATHY Not Covered INFO MEDICAID DILATED RETINAL EYE EXAM WITH INTERP BY AN OPTHALMOLOGIST OR OPTOMETRIST DOCUMENTED AND 2022F REVIEWED (DM) No MEDICAID SEVEN STANDARD FIELD STEREOSCOPIC PHOTOS WITH INTERP BY AN OPTHALMOLOGIST OR OPTOMETRIST DOCUMENTED AND 2024F REVIEWED (DM) No MEDICAID EYE IMAGING VALIDATED TO MATCH DIAGNOSIS FROM SEVEN STANDARD FIELD STEREOSCOPIC PHOTOS RESULTS DOCUMENTED AND 2026F REVIEWED (DM) No MEDICAID OPTIC NERVE HEAD EVALUATION 2027F PERFORMED Not Covered INFO MEDICAID FOOT EXAMINATION PERFORMED (DM) (INCL EXAM THRU VISUAL INSPECTION, SENSORY EXAM W/MONOFILAMENT, & PULSE EXAM-- 2028F RPT WHEN ANY OF THE Not Covered INFO MEDICAID COMPLETE PHYSICAL SKIN EXAM 2029F PERFORMED Not Covered INFO MEDICAID

400 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HYDRATION STATUS DOCUMENTED, NORMALLY HYDRATED (PAG) 1 2030F Not Covered INFO MEDICAID HYDRATION STATUS DOCUMENTED, DEHYDRATED (PAG)1 2031F Not Covered INFO MEDICAID Tympanic membrane mobility assessed with pneumatic otoscopy or tympanometry 2035F Not Covered INFO MEDICAID Physical examination on the date of the initial visit for low back pain performed, in accordance with specifications 2040F Not Covered INFO MEDICAID Documentation of mental health assessment prior to intervention (back surgery or epidural steroid injection) or for back pain episode lasting longer than six 2044F weeks Not Covered INFO MEDICAID Wound characteristics including size AND nature of wound base tissue AND amount of drainage prior to debridement, 2050F documented Not Covered INFO MEDICAID Patient interviewed directly by evaluating clinician on or before date of diagnosis of major depressive disorder 2060F Not Covered INFO MEDICAID CHEST X-RAY RESULTS DOCUMENTED AND REVIEWED (CAP) 3006F Not Covered INFO MEDICAID 3008F Body Mass Index (BMI), documented Not Covered INFO MEDICAID LIPID PANEL RESULTS DOCUMENTED AND REVIEWED (MUST INCLUDE TOTAL CHOLESTEROL, HDL-C, TRIGLYCERIDES & CALCULATED LDL- C) (CAD) 3011F Not Covered INFO MEDICAID SCREENING MAMMOGRAPHY RESULTS DOCUMENTED AND 3014F REVIEWED (PV) Not Covered INFO MEDICAID Cervical cancer screening results 3015F documented and reviewed Not Covered INFO MEDICAID Patient screened for unhealthy alcohol use using a systematic screening method 3016F Not Covered INFO MEDICAID COLORECTAL CANCER SCREENING RESULTS DOCUMENTED AND REVIEWED (PV) 3017F Not Covered INFO MEDICAID Pre-procedure risk assessment AND depth of insertion AND quality of the bowel prep AND complete description of polyp(s) found, including location of each polyp, size, number and gross morphology AND recommendations for follow-up in final colonoscopy report, documented 3018F Not Covered INFO MEDICAID Left ventricular ejection fraction (LVEF) assessment planned post discharge 3019F Not Covered INFO MEDICAID LEFT VENTRICULAR FUNCTION (LFV) ASSESSMENT (EG, ECHOCARDIOGRAPHY, NUCLEAR TEST OR VENTRICULOGRAPHY) DOCUMENTED IN MEDICAL REC (CHF 3020F Not Covered INFO MEDICAID

401 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LEFT VENTRICULAR EJECTION FRACTION (LVEF) , 40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT VENTRIC SYSTOLIC FUNCT ( 3021F Not Covered INFO MEDICAID LEFT VENTRICULAR EJECTION FRACTION (LVEF) > 40% OR DOCUMENTATION AS NORMAL OR MILDLY DEPRESSED LEFT VENTRIC SYSTOLIC FUNCTION (CAD 3022F Not Covered INFO MEDICAID SPIROMETRY RESULTS DOCUMENTED AND REVIEWED 3023F (COPD) Not Covered INFO MEDICAID SPIROMETRY TEST RESULTS DEMONSTRATE FEV/FVC < 70% WITH COPD SYMPTOMS (EG, DYSPNEA, COUGH/SPUTUM, WHEEZING) (CAP, 3025F COPD) Not Covered INFO MEDICAID SPIROMETRY TEST RESULTS DEMONSTRATE FEV/FVC => 70% OR PATIENT DOES NOT HAVE COPD 3027F SYMPTOMS (COPD) Not Covered INFO MEDICAID OXYGEN SATURATION RESULTS DOCUMENTED & REVIEWED (INCL ASSESSMENT THRU PULSE OXIMETRY OR ARTERIAL BLOOD GAS 3028F MEASUREMENT) (CAP, COPD Not Covered INFO MEDICAID OXYGEN SATURATION =< 88% OR A 3035F PA02 <= 55 MM HG (COPD) Not Covered INFO MEDICAID OXYGEN SATURATION > 88% OR PA02 3037F > 55 MMHG (COPD) Not Covered INFO MEDICAID Pulmonary function test performed within 3038F 12 months prior to surgery Not Covered INFO MEDICAID FUNCTIONAL EXPIRATORY VOLUME (FEV) < 40% OF PREDICTED VALUE 3040F (COPD) Not Covered INFO MEDICAID FUNCTIONAL EXPIRATORY VOLUME (FEV) >= 40% OF PREDICTED VOLUME 3042F (COPD) Not Covered INFO MEDICAID MOST RECENT HEMOGLOBIN A1C 3044F LEVEL <7.0% (DM) Not Covered INFO MEDICAID MOST RECENT HEMOGLOBIN A1C 3045F (HBA1C) LEVEL 7.0-9.0% Not Covered INFO MEDICAID MOST RECENT HEMOGLOBIN A1C 3046F LEVEL > 9.0% (DM) Not Covered INFO MEDICAID MOST RECENT LDL-C < 100MG/DL 3048F (DM) Not Covered INFO MEDICAID MOST RECENT LDL-C 100- 129 MG/DL 3049F (DM) Not Covered INFO MEDICAID MOST RECENT LDL-C >= 130 MG/DL 3050F (DM) Not Covered INFO MEDICAID Left ventricular ejection fraction (LVEF) 3055F less than or equal to 35% Not Covered INFO MEDICAID Left ventricular ejection fraction (LVEF) greater than 35% or no LVEF result 3056F available Not Covered INFO MEDICAID POSITIVE MICROALBUMINURIA TEST RESULT DOCUMENTATED AND 3060F REVIEWED (DM) Not Covered INFO MEDICAID NEGATIVE MICROALBUMINURIA TEST RESULT DOCUMENTATED AND 3061F REVIEWED (DM) Not Covered INFO MEDICAID POSITIVE MACROABUMINURIA TEST RESULT DOCUMENTED AND 3062F REVIEWED Not Covered INFO MEDICAID

402 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DOCUMENTATION OF TREATMENT FOR NEPHROPATHY (EG, PATIENT RCVNG DIALYSIS, TREATED FOR ESRD, CRF, ARF, OR RENAL INSUFF, 3066F ANY VISIT TO Not Covered INFO MEDICAID LOW RISK FOR RETINOPATHY (NO EVIDENCE OF RETINOPATHY IN THE 3072F PRIOR YEAR) (DM) Not Covered INFO MEDICAID PRE-SURG (CATARACT) AXIAL LENGTH, CORNEAL POWER MEASUREMENT& METHOD OF INTRAOCULAR LENS POWER CALC 3073F DOC'D (MUST BE PERF W/IN 6 MTH) Not Covered INFO MEDICAID MOST RECENT SYSTLIC BLOOD PRESSURE < 130 MM HG (DM), (HTN) 3074F Not Covered INFO MEDICAID MOST RECENT SYSTOLIC BLOOD PRESSURE 130 - 139MM HG (DM), 3075F (HTN) Not Covered INFO MEDICAID MOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MM HG (HTN) (DM) 3077F Not Covered INFO MEDICAID MOST RECENT DIASTOLIC BLOOD 3078F PRESSURE < 80 MM HG (HTN) (DM) Not Covered INFO MEDICAID MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG (HTN) (DM) 3079F Not Covered INFO MEDICAID MOST RECENT DIASTOLIC BLOOD PRESSURE >= 90 MM HG (HTN) (DM) 3080F Not Covered INFO MEDICAID KT/V < 1.2 (CLEARANCE OF UREA (KT) 3082F VOLUME(V)) (RVSD 070107) Not Covered INFO MEDICAID KT/V EQUAL TO OR GREATER THAN 1.2 AND LESS THAN 1.7 (CLEARANCE OF UREA (KT)/VOLUME (V)) (ESDRD)1 3083F Not Covered INFO MEDICAID KT/V >= 1.7 (CLEARANCE OF UREA 3084F (KT)/VOLUME (V)) (ESRD)1 Not Covered INFO MEDICAID 3085F SUICIDE RISK ASSESSED Not Covered INFO MEDICAID MAJOR DEPRESSIVE DISORDER, MILD 3088F (MDD)1 Not Covered INFO MEDICAID MAJOR DEPRESSIVE DISORDER, 3089F MODERATE (MDD)1 Not Covered INFO MEDICAID MAJOR DEPRESSIVE DISORDER, SEVERE WITHOUT PSYCHOTIC 3090F FEATURES (MDD) Not Covered INFO MEDICAID MAJOR DEPRESSIVE DISORDER, SEVERE WITH PSYCHOTIC 3091F FEATURES (MDD) Not Covered INFO MEDICAID MAJOR DEPRESSIVE DISORDER, IN 3092F REMISSION (MDD)1 Not Covered INFO MEDICAID DOCUMENTATION OF NEW DIAGNOSIS OF INITIAL OR RECURRENT EPISODE OF MAJOR 3093F DEPRESSIVE DISORDER (MDD)1 Not Covered INFO MEDICAID CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS 3095F DOCUMENTED Not Covered INFO MEDICAID CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) ORDERED 3096F Not Covered INFO MEDICAID CAROTID IMAGING STUDY RPRT INCL DIRECT OR INDIRECT REFERENCE TO DISTAL INTERNAL CAROTID DIAMETER AS DENOMINATOR FOR STENOSIS MEASU 3100F Not Covered INFO MEDICAID

403 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PRESENCE OR ABSENCE OF HEMORRHAGE AND MASS LESION AND ACUTE INFARCTION DOCUMENTED IN FINAL CT OR MRI 3110F REPORT Not Covered INFO MEDICAID CT OR MRI OF THE BRAIN PERFORMED WITHIN 24 HOURS OF 3111F ARRIVAL TO HOSPITAL Not Covered INFO MEDICAID CT OR MRI OF THE BRAIN PERFORMED GREATER THAN 24 HOURS AFTER ARRIVAL TO THE 3112F HOSPITAL Not Covered INFO MEDICAID Quantitative results of an evaluation of current level of activity and clinical 3115F symptoms Not Covered INFO MEDICAID Heart Failure disease specific structured assessment tool completed 3117F Not Covered INFO MEDICAID New York Heart Association (NYHA) 3118F Class documented Not Covered INFO MEDICAID No Evaluation of level of activity or clinical 3119F symptoms Not Covered INFO MEDICAID 3120F 12-LEAD ECG PERFORMED Not Covered INFO MEDICAID Patient has documented immunity to 3126F Hepatitis B Not Covered INFO MEDICAID UPPER GASTROINTESTINAL 3130F ENDOSCOPY PERFORMED Not Covered INFO MEDICAID DOCUMENTATION OF REFERRAL FOR 3132F UPPER GASTROINTESTINAL Not Covered INFO MEDICAID UPPER GASTROINTESTINAL ENDOSCOPY REPORT INDICATES SUSPICION OF BARRETT'S 3140F ESOPHAGUS Not Covered INFO MEDICAID UPPER GASTROINTESTINAL ENDOSCOPY REPORT INDICATES NO SUSPICION OF BARRETT'S 3141F ESOPHAGUS Not Covered INFO MEDICAID BARIUM SWALLOW TEST ORDERED 3142F Not Covered INFO MEDICAID FORCEPS ESOPHAGEAL BIOPSY 3150F PERFORMED Not Covered INFO MEDICAID CYTOGENETIC TESTING PERFORMED ON BONE MARROW AT TIME OF DIAGNOSIS OR PRIOR TO INITIATING 3155F TREATMENT Not Covered INFO MEDICAID DOCUMENTATION OF IRON STORES PRIOR TO INITIATING 3160F ERYTHROPOIETIN THERAPY Not Covered INFO MEDICAID FLOW CYTOMETRY STUDIES PERFORMED AT TIME OF DIAGNOSIS OR PRIOR TO INITIATING TREATMENT 3170F Not Covered INFO MEDICAID BARIUM SWALLOW TEST NOT 3200F ORDERED Not Covered INFO MEDICAID GROUP A STREP TEST PERFORMED 3210F Not Covered INFO MEDICAID Patient has documented immunity to 3215F Hepatitis A Not Covered INFO MEDICAID Patient has documented immunity to 3216F Hepatitis B Not Covered INFO MEDICAID RNA testing for Hepatitis C documented as performed within six months prior to initiation of antiviral treatment for Hepatitis 3218F C Not Covered INFO MEDICAID Hepatitis C quantitative RNA testing documented as performed at 12 weeks from initiation of antiviral treatment 3220F Not Covered INFO MEDICAID Documentation that hearing test was performed within 6 months prior to 3230F tympanostomy tube insertion Not Covered INFO MEDICAID

404 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Specimen biopsy site other than anatomic 3250F location of primary tumor Not Covered INFO MEDICAID pT category (primary tumor), pN category (regional lymph nodes), and histologic grade documented in pathology report 3260F Not Covered INFO MEDICAID Ribonucleic acid (RNA) testing for Hepatitis C viremia ordered or results 3265F documented Not Covered INFO MEDICAID Hepatitis C genotype testing documented as performed prior to initiation of antiviral treatment for Hepatitis C 3266F Not Covered INFO MEDICAID Pathology report includes pT category, pN category, Gleason score and statement about margin status (PATH) 3267F Not Covered INFO MEDICAID Prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score documented prior to initiation of 3268F treatment Not Covered INFO MEDICAID Bone scan performed prior to initiation of treatment or at any time since diagnosis 3269F of prostate cancer Not Covered INFO MEDICAID Bone scan not performed prior to initiation of treatment nor at any time since 3270F diagnosis of prostate cancer Not Covered INFO MEDICAID Low risk of recurrence, prostate cancer 3271F Not Covered INFO MEDICAID Intermediate risk of recurrence, prostate 3272F cancer Not Covered INFO MEDICAID High risk of recurrence, prostate cancer 3273F Not Covered INFO MEDICAID Prostate cancer risk of recurrence not determined or neither low, intermediate 3274F nor high Not Covered INFO MEDICAID Serum levels of calcium, phosphorus, intact Parathyroid Hormone (PTH) and lipid profile ordered 3278F Not Covered INFO MEDICAID Hemoglobin level greater than or equal to 3279F 13 g/dL Not Covered INFO MEDICAID Hemoglobin level 11 g/dL to 12.9 g/dL 3280F Not Covered INFO MEDICAID 3281F Hemoglobin level less than 11 g/dL Not Covered INFO MEDICAID Intraocular pressure (IOP) reduced by a value of greater than or equal to 15% 3284F from the pre-intervention level Not Covered INFO MEDICAID Intraocular pressure (IOP) reduced by a value less than 15% from the pre- 3285F intervention level Not Covered INFO MEDICAID 3288F Falls risk assessment documented Not Covered INFO MEDICAID Patient is D (Rh) negative and 3290F unsensitized Not Covered INFO MEDICAID Patient is D (Rh) positive or sensitized 3291F Not Covered INFO MEDICAID HIV testing ordered or documented and reviewed during the first or second 3292F prenatal visit Not Covered INFO MEDICAID ABO and Rh blood typing documented as 3293F performed Not Covered INFO MEDICAID Group B Streptococcus (GBS) screening documented as performed during week 35- 3294F 37 gestation Not Covered INFO MEDICAID American Joint Committee on Cancer (AJCC) stage documented and reviewed prior to the initiation of therapy 3300F Not Covered INFO MEDICAID

405 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Cancer stage documented in medical record as metastatic and reviewed prior to the initiation of therapy 3301F Not Covered INFO MEDICAID Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer 3315F Not Covered INFO MEDICAID Estrogen receptor (ER) and progesterone receptor (PR) negative breast cancer 3316F Not Covered INFO MEDICAID Pathology report confirming malignancy documented in the medical record and reviewed prior to the initiation of 3317F chemotherapy Not Covered INFO MEDICAID Pathology report confirming malignancy documented in the medical record and reviewed prior to the initiation of radiation 3318F therapy Not Covered INFO MEDICAID One of the following diagnostic imaging studies ordered: (chest X-ray, CT, Ultrasound, MRI, PET, or nuclear 3319F medicine scans) Not Covered INFO MEDICAID None of the following diagnostic imaging studies ordered: (chest X-ray, CT, Ultrasound, MRI, PET, or nuclear 3320F medicine scans) Not Covered INFO MEDICAID AJCC Cancer Stage 0 or 1A Melanoma, 3321F documented (ML) Not Covered INFO MEDICAID Melanoma greater than AJCC Stage 0 or 3322F IA (ML) Not Covered INFO MEDICAID Clinical tumor, node and metastases (TNM) staging documented and reviewed 3323F prior to surgery Not Covered INFO MEDICAID MRI or CT scan ordered, reviewed or 3324F requested Not Covered INFO MEDICAID Preoperative assessment of functional or medical indication(s) for surgery prior to the cataract surgery with intraocular lens placement (must be performed within twelve months prior to cataract surgery) 3325F Not Covered INFO MEDICAID Performance status documented and reviewed within 2 weeks prior to surgery 3328F Not Covered INFO MEDICAID 3330F Imaging study ordered Not Covered INFO MEDICAID 3331F Imaging study not ordered Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3340F category 0, documented Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3341F category 1, documented Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3342F category 2, documented Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3343F category 3, documented Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3344F category 4, documented Not Covered INFO MEDICAID Breast Imaging-Reporting and Data System (BI-RADS®) assessment 3345F category 5, documented Not Covered INFO MEDICAID Mammogram assessment category of 3350F "known biopsy proven malignancy" Not Covered INFO MEDICAID Negative screen for depressive symptoms as categorized by using a standardized depression screening/assessment tool 3351F Not Covered INFO MEDICAID

406 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines No significant depressive symtpoms as categorized by using a standardized depression assessment tool 3352F Not Covered INFO MEDICAID Mild to moderate depressive symptoms as categorized by using a standardized depression screening/assessment tool 3353F Not Covered INFO MEDICAID Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment 3354F Not Covered INFO MEDICAID AJCC Breast Cancer Stage 0, 3370F documented (ONC) Not Covered INFO MEDICAID AJCC Breast Cancer Stage I: T1mic, T1a or T1b (tumor size <= 1 cm), documented 3372F (ONC) Not Covered INFO MEDICAID AJCC Breast Cancer Stage I: T1c (tumor size > 1 cm to 2 cm), documented (ONC) 3374F Not Covered INFO MEDICAID AJCC Breast Cancer Stage II, 3376F documented (ONC) Not Covered INFO MEDICAID AJCC Breast Cancer Stage III, 3378F documented (ONC) Not Covered INFO MEDICAID AJCC Breast Cancer Stage IV, 3380F documented (ONC) Not Covered INFO MEDICAID AJCC colon cancer, Stage 0, documented 3382F (ONC) Not Covered INFO MEDICAID AJCC colon cancer, Stage I, documented 3384F (ONC) Not Covered INFO MEDICAID AJCC colon cancer, Stage II, documented 3386F (ONC) Not Covered INFO MEDICAID AJCC colon cancer, Stage III, 3388F documented (ONC) Not Covered INFO MEDICAID AJCC colon cancer, Stage IV, 3390F documented (ONC) Not Covered INFO MEDICAID Quantitative HER2 Immunohistochemistry (IHC) evaluation of breast cancer consistent with the scoring system defined in the ASCO/CAP guidelines (PATH)

3394F Not Covered INFO MEDICAID Quantitative non-HER2 Immunohistochemistry (IHC) evaluation of breast cancer (eg, testing for estrogen or progesterone receptors [ER/PR]) 3395F performed Not Covered INFO MEDICAID Dyspnea screened, no dyspnea or mild 3450F dyspnea (Pall Cr) Not Covered INFO MEDICAID Dyspnea screened, moderate or severe 3451F dyspnea (Pall Cr) Not Covered INFO MEDICAID 3452F Dyspnea not screened (Pall Cr) Not Covered INFO MEDICAID TB screening performed and results interpreted within six months prior to initiation of first-time biologic disease modifying anti-rheumatic drug therapy for 3455F RA (RA) Not Covered INFO MEDICAID Rheumatoid arthritis (RA) disease activity, 3470F low (RA) Not Covered INFO MEDICAID Rheumatoid arthritis (RA) disease activity, 3471F moderate (RA) Not Covered INFO MEDICAID Rheumatoid arthritis (RA) disease activity, 3472F high (RA) Not Covered INFO MEDICAID Disease prognosis for rheumatoid arthritis assessed, poor prognosis documented 3475F (RA) Not Covered INFO MEDICAID Disease prognosis for rheumatoid arthritis assessed, good prognosis documented 3476F (RA) Not Covered INFO MEDICAID History of AIDS-defining condition (HIV) 3490F Not Covered INFO MEDICAID

407 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HIV indeterminate (infants of undetermined HIV status born of HIV- 3491F infected mothers) (HIV) Not Covered INFO MEDICAID History of nadir CD4+ cell count <350 3492F cells/mm3 (HIV) Not Covered INFO MEDICAID No history of nadir CD4+ cell count <350 cells/mm3 AND no history of AIDS- 3493F defining condition (HIV) Not Covered INFO MEDICAID CD4+ cell count <200 cells/mm3 (HIV) 3494F Not Covered INFO MEDICAID CD4+ cell count 200 - 499 cells/mm3 3495F (HIV) Not Covered INFO MEDICAID CD4+ cell count >=500 cells/mm3 (HIV) 3496F Not Covered INFO MEDICAID 3497F CD4+ cell percentage <15% (HIV) Not Covered INFO MEDICAID 3498F CD4+ cell percentage >=15% (HIV) Not Covered INFO MEDICAID CD4+ cell count or CD4+ cell percentage documented as performed (HIV) 3500F Not Covered INFO MEDICAID HIV RNA viral load below limits of 3502F quantification (HIV) Not Covered INFO MEDICAID HIV RNA viral load not below limits of 3503F quantification (HIV) Not Covered INFO MEDICAID Documentation that tuberculosis (TB) screening test performed and results 3510F interpreted (HIV) Not Covered INFO MEDICAID Chlamydia and gonorrhea screenings documented as performed (HIV) 3511F No MEDICAID Syphilis screening documented as 3512F performed (HIV) No MEDICAID Hepatitis B screening documented as 3513F performed (HIV) Not Covered INFO MEDICAID Hepatitis C screening documented as 3514F performed (HIV) Not Covered INFO MEDICAID Patient has documented immunity to 3515F Hepatitis C (HIV) Not Covered INFO MEDICAID Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti- 3517F TNF Not Covered INFO MEDICAID Clostridium difficile testing performed 3520F Not Covered INFO MEDICAID 3550F Low risk for thromboembolism (AFIB) Not Covered INFO MEDICAID Intermediate risk for thromboembolism 3551F (AFIB) Not Covered INFO MEDICAID High risk for thromboembolism (AFIB) 3552F Not Covered INFO MEDICAID Patient had International Normalized Ratio (INR) measurement performed (AFIB) 3555F Not Covered INFO MEDICAID Final report for bone scintigraphy study includes correlation with existing relevant imaging studies (eg, x-ray, MRI, CT) corresponding to the same anatomical region in question (NUC_MED) 3570F Not Covered INFO MEDICAID Patient considered to be potentially at risk for fracture in a weight-bearing site 3572F (NUC_MED) Not Covered INFO MEDICAID Patient not considered to be potentially at risk for fracture in a weight-bearing site 3573F (NUC_MED) Not Covered INFO MEDICAID Electroencephalogram (EEG) ordered, 3650F reviewed or requested Not Covered INFO MEDICAID Psychiatric disorders or disturbances 3700F assessed (Prkns) Not Covered INFO MEDICAID Cognitive impairment or dysfunction 3720F assessed (Prkns) Not Covered INFO MEDICAID 3725F Screening for depression performed Not Covered INFO MEDICAID

408 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient not receiving dose of corticosteroids greater than or equal to 10mg/day* for 60 or greater consecutive 3750F days Not Covered INFO MEDICAID Electrodiagnostic studies for distal symmetric polyneuropathy conducted (or 3751F requested), documented, and reviewed within 6 months of initial evaluation for condition (DSP) Not Covered INFO MEDICAID Electrodiagnostic studies for distal symmetric polyneuropathy not conducted (or requested), documented, or reviewed 3752F within 6 months of initial evaluation for condition (DSP) Not Covered INFO MEDICAID Patient has clear clinical symptoms and signs that are highly suggestive of neuropathy AND cannot be attributed to 3753F another condition, AND has an obvious cause for the neuropathy (DSP) Not Covered INFO MEDICAID Screening tests for diabetes mellitus 3754F reviewed, requested, or ordered (DSP) Not Covered INFO MEDICAID Cognitive and behavioral impairment 3755F screening performed (DSP) Not Covered INFO MEDICAID Patient has pseudobulbar affect, 3756F sialorrhea, or ALS related symptoms (DSP) Not Covered INFO MEDICAID Patient does not have pseudobulbar 3757F affect, sialorrhea, or ALS related symptoms (DSP) Not Covered INFO MEDICAID Patient referred for pulmonary function 3758F testing or peak cough expiratory flow (DSP) Not Covered INFO MEDICAID Patient screened for dysphagia, weight 3759F loss, and impaired nutrition, and results documented (DSP) Not Covered INFO MEDICAID Patient exhibits dysphagia, weight loss, or 3760F impaired nutrition (DSP) Not Covered INFO MEDICAID Patient does not exhibit dysphagia, weight 3761F loss, or impaired nutrition (DSP) Not Covered INFO MEDICAID 3762F Patient is dysarthric (DSP) Not Covered INFO MEDICAID 3763F Patient is not dysarthric (DSP) Not Covered INFO MEDICAID Adenoma(s) or other neoplasm detected during screening colonoscopy (SCADR) 3775F Not Covered INFO MEDICAID Adenoma(s) or other neoplasm not detected during screening colonoscopy 3776F (SCADR) Not Covered INFO MEDICAID TOBACCO USE CESSATION 4000F INTERVENTION, COUNSELING Not Covered INFO MEDICAID TOBACCO USE CESSATION INTERVENTION, PHARMACOLOGIC 4001F THERAPY Not Covered INFO MEDICAID 4002F STATIN THERAPY, PRESCRIBED Not Covered INFO MEDICAID PATIENT EDUCATION, WRITTEN/ORAL, PERFORMED FOR 4003F PATS W HEART FAILURE Not Covered INFO MEDICAID Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user 4004F Not Covered INFO MEDICAID PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR OSTEOPOROSIS PRESCRIBED 4005F Not Covered INFO MEDICAID BETA-BLOCKER THERAPY, 4006F PRESCRIBED Not Covered INFO MEDICAID

409 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Beta-Blocker therapy prescribed or 4008F currently being taken Not Covered INFO MEDICAID Angiotensin converting enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently 4010F being taken Not Covered INFO MEDICAID ORAL ANTIPALTELET THERAPY, 4011F PRESCRIBED Not Covered INFO MEDICAID 4012F WARFARIN THERAPY PRESCRIBED Not Covered INFO MEDICAID Statin therapy prescribed or currently 4013F being taken Not Covered INFO MEDICAID WRITTEN DISCH INSTR PRVD TO HEART FAILURE PATS DXD HOME (INSTR INCL ACTIVITY LVL, DIET, MEDS F/UP APPT, WT MONITOR, IF 4014F SYMP WORS) Not Covered INFO MEDICAID PERSISTENT ASTHMA, PREFERRED LONG TERM CONTROL MEDICATION OR AN ACCEPTABLE ALTERNATIVE TX PRESCRIBED (ASTHMA) 4015F Not Covered INFO MEDICAID ANTI-INFLAMMATORY/ANALGESIC AGENT RX. (USE FOR PRESCRIBED OR CONTINUED MEDS, INCL OTC 4016F MEDS) Not Covered INFO MEDICAID GASTROINTESTINAL PROPHYLAXIS 4017F FOR NSAID USE PRESCRIBED Not Covered INFO MEDICAID THERAPEUTIC EXERCISE FOR INVOLVED JOINT(S) INSTRUCTED OR 4018F PT OR OT PRESCRIBED Not Covered INFO MEDICAID DOCUMENTATION OF RECEIPT OF COUNSELING ON EXERCISE AND EITHER BOTH CALCIUM AND VITAMIN D USE OR COUNSELING REGARDING BOTH CALCIUM AND VITAMIN D USE 4019F Not Covered INFO MEDICAID INHALED BRONCHODILATOR 4025F PRESCRIBED (COPD) Not Covered INFO MEDICAID LONG TERM OXYGEN THERAPY PRESCRIBED (MORE THAN 15 HOURS 4030F A DAY) (COPD) Not Covered INFO MEDICAID PULMONARY REHABILITATION EXERCISE TRAINING RECOMMENDED 4033F (COPD) Not Covered INFO MEDICAID INFLUENZA IMMUNIZATION 4035F RECOMMENDED (COPD) Not Covered INFO MEDICAID INFLUENZA IMMUNIZATION ORDERED OR ADMINISTERED (COPD, PV) 4037F Not Covered INFO MEDICAID PNEUMOCOCCAL IMMUNIZATION ORDERED OR ADMINISTERED (COPD) 4040F Not Covered INFO MEDICAID DOCUMENTATION OF ORDER FOR CEFAZOLIN OR CEFUROXIME FOR 4041F ANTIMICROBIAL PROPHYLAXIS Not Covered INFO MEDICAID DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTICS WERE NEITHER GIVEN W/IN 4 HOURS PRIOR TO SURGICAL INCISION NOR GIVEN INTRAOPERATIVELY 4042F Not Covered INFO MEDICAID DOCUMENTATION THAT AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICS W/IN 48 HRS OF SURGICAL END TIME, 4043F CARDIAC PROCEDURES Not Covered INFO MEDICAID DOCUMENTATION THAT AN ORDER WAS GIVEN FOR VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE GIVEN W/IN 24 4044F HRS PRIOR TO INCISION TIME Not Covered INFO MEDICAID

410 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines APPROPRIATE EMPIRIC ANTIBIOTIC 4045F PRESCRIBED (RVSD 070107) Not Covered INFO MEDICAID DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTICS WERE GIVEN WITHIN 4 HOURS PRIOR TO SURGICAL INCISION OR GIVEN 4046F INTRAOPERATIVELY Not Covered INFO MEDICAID DOCUMENTATION OF ORDER FOR PROPHYLACTIC ANTIBIOTICS TO BE GIVEN W/IN 1 HR (IF FLUOROQUINOLONE OR VANCOMYCIN, 2 HRS) PRIOR TO 4047F SURGI Not Covered INFO MEDICAID DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTIC WAS GIVEN W/IN 1 HR (IF FLUOROQUINOLONE OR VANCOMYCIN, 2 HRS) PRIOR TO 4048F SURGICAL INCISIO Not Covered INFO MEDICAID DOCUMENTATION THAT ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICS W/IN 24 HRS OF SURGICAL END TIME, NON- 4049F CARDIAC PROCEDURE Not Covered INFO MEDICAID HYPERTENSION PLAN OF CARE DOCUMENTED AS APPROPRIATE 4050F (HTN) Not Covered INFO MEDICAID REFERRED FOR AN ARTERIO- 4051F VENOUS (AV) FISTULA (ESRD)1 Not Covered INFO MEDICAID HEMODIALYSIS VIA FUNCTIONING ARTERIO-VENOUS (AV) FISTULA 4052F (ESRD)1 Not Covered INFO MEDICAID HEMODIALYSIS VIA FUNCTIONING ARTERIO-VENOUS (AV) GRAFT 4053F (ESRD)1 Not Covered INFO MEDICAID HEMODIALYSIS VIA CATHETER 4054F (ESRD) 1 Not Covered INFO MEDICAID PATIENT RECEIVING PERITONEAL 4055F DIALYSIS (ESRD) 1 Not Covered INFO MEDICAID APPROPRIATE ORAL REHYDRATION SOLUTION RECOMMNEDED (PAG) 1 4056F Not Covered INFO MEDICAID PEDIATRIC GASTROENTERITIS EDUCATION PROVIDED TO 4058F CAREGIVER (PAG) 1 Not Covered INFO MEDICAID PSYCHOTHERAPY SERVICES 4060F PROVIDED (MDD) 1 Not Covered INFO MEDICAID PATIENT REFERRAL FOR PSYCHOTHERAPY DOCUMENTED 4062F (MDD) 1 Not Covered INFO MEDICAID Antidepressant pharmacotherapy 4063F considered and not prescribed Not Covered INFO MEDICAID ANTIDEPRESSANT PHARMACOTHERAPY PRESCRIBED 4064F (MDD) 1 Not Covered INFO MEDICAID ANTIPSYCHOTIC PHARMACOTHERAPY PRESCRIBED 4065F (MDD) 1 Not Covered INFO MEDICAID ELECTROCONVULSIVE THERAPY 4066F (ECT) PROVIDED (MDD) Not Covered INFO MEDICAID PATIENT REFERRAL FOR ELECTROCONVULSIVE (ECT) 4067F DOCUMENTED (MDD) Not Covered INFO MEDICAID Venous thromboembolism (VTE) 4069F prophylaxis received Not Covered INFO MEDICAID DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RECEIVED BY END OF 4070F HOSPITAL DAY 2 Not Covered INFO MEDICAID ORAL ANTIPLATELET THERAPY 4073F PRESCRIBED AT DISCHARGE Not Covered INFO MEDICAID

411 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ANTICOAGULANT THERAPY 4075F PRESCRIBED AT DISCHARGE Not Covered INFO MEDICAID DOCUMENTATION THAT TISSUE PLASMINOGEN ACTIVATOR (T-PA) ADMINISTRATION WAS CONSIDERED 4077F Not Covered INFO MEDICAID DOCUMENTATION THAT REHABILITATION SERVICES WERE 4079F CONSIDERED Not Covered INFO MEDICAID ASPIRIN RECEIVED WITHIN 24 HOURS BEFORE EMERGENCY DEPARTMENT ARRIVAL OR DURING EMERGENCY DEPARTMENT STAY 4084F Not Covered INFO MEDICAID 4086F Aspirin or clopidogrel prescribed Not Covered INFO MEDICAID PATIENT RECEIVING 4090F ERYTHROPOIETIN THERAPY Not Covered INFO MEDICAID PATIENT NOT RECEIVING 4095F ERYTHROPOIETIN THERAPY Not Covered INFO MEDICAID BISPHOSPHONATE THERAPY, INTRAVENOUS, ORDERED OR 4100F RECEIVED Not Covered INFO MEDICAID INTERNAL MAMMARY ARTERY GRAFT PERFORMED FOR PRIMARY, ISOLATED CORONARY ARTERY 4110F BYPASS GAFT PROCEDURE Not Covered INFO MEDICAID BETA BLOCKER ADMINISTERED WITHIN 24 HOURS PRIOR TO 4115F SURGICAL INCISION Not Covered INFO MEDICAID ANTIBIOTIC PRESCRIBED OR 4120F DISPENSED Not Covered INFO MEDICAID ANTIBIOTIC NEITHER PRESCRIBED 4124F NOR DISPENSED Not Covered INFO MEDICAID Topical preparations (including OTC) 4130F prescribed for acute otitis externa Not Covered INFO MEDICAID Systemic antimicrobial therapy prescribed 4131F Not Covered INFO MEDICAID Systemic antimicrobial therapy not 4132F prescribed Not Covered INFO MEDICAID Antihistamines or decongestants 4133F prescribed or recommended Not Covered INFO MEDICAID Antihistamines or decongestants neither prescribed nor recommended 4134F Not Covered INFO MEDICAID 4135F Systemic corticosteroids prescribed Not Covered INFO MEDICAID Systemic corticosteroids not prescribed 4136F Not Covered INFO MEDICAID 4140F Inhaled corticosteroids prescribed Not Covered INFO MEDICAID Corticosteroid sparing therapy prescribed 4142F Not Covered INFO MEDICAID Alternative long-term control medication 4144F prescribed Not Covered INFO MEDICAID Two or more anti-hypertensive agents prescribed or currently being taken 4145F Not Covered INFO MEDICAID Hepatitis A vaccine injection administered or previously received (HEP-C) 4148F Not Covered INFO MEDICAID Hepatitis B vaccine injection administered or previously received (HEP-C) 4149F Not Covered INFO MEDICAID Patient receiving antiviral treatment for 4150F Hepatitis C Not Covered INFO MEDICAID Patient not receiving antiviral treatment 4151F for Hepatitis C Not Covered INFO MEDICAID Combination peginterferon and ribavirin 4153F therapy prescribed Not Covered INFO MEDICAID Hepatitis A vaccine series previously 4155F received Not Covered INFO MEDICAID Hepatitis B vaccine series previously 4157F received Not Covered INFO MEDICAID

412 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient counseled about risks of alcohol 4158F use Not Covered INFO MEDICAID Counseling regarding contraception received prior to initiation of antiviral 4159F treatment Not Covered INFO MEDICAID Patient counseling at a minimum on all of the following treatment options for clinically localized prostate cancer: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy, provided prior to initiation of treatment 4163F Not Covered INFO MEDICAID Adjuvant (ie, in combination with external beam radiotherapy to the prostate for prostate cancer) hormonal therapy (gonadotropin-releasing hormone [GnRH] agonist or antagonist) prescribed/administered 4164F Not Covered INFO MEDICAID Three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT) received 4165F Not Covered INFO MEDICAID Head of bed elevation (30-45 degrees) on first ventilator day ordered 4167F Not Covered INFO MEDICAID Patient receiving care in the intensive care unit (ICU) and receiving mechanical ventilation, 24 hours or less 4168F Not Covered INFO MEDICAID Patient either not receiving care in the intensive care unit (ICU) OR not receiving mechanical ventilation OR receiving mechanical ventilation greater than 24 4169F hours Not Covered INFO MEDICAID Patient receiving Erythropoiesis- 4171F Stimulating Agents (ESA) therapy Not Covered INFO MEDICAID Patient not receiving Erythropoiesis- 4172F Stimulating Agents (ESA) therapy Not Covered INFO MEDICAID Counseling about the potential impact of glaucoma on visual functioning and quality of life, and importance of treatment adherence provided to patient and/or caregiver(s) 4174F Not Covered INFO MEDICAID Best-corrected visual acuity of 20/40 or better (distance or near) achieved within the 90 days following cataract surgery 4175F Not Covered INFO MEDICAID Counseling about value of protection from UV light and lack of proven efficacy of nutritional supplements in prevention or progression of cataract development provided to patient an/or caregiver(s) 4176F Not Covered INFO MEDICAID Counseling about the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of age-related macular degeneration (AMD) provided to patient and/or caregiver(s) 4177F Not Covered INFO MEDICAID Anti-D immune globulin received between 4178F 26 and 30 weeks gestation Not Covered INFO MEDICAID Tamoxifen or aromatase inhibitor (AI) 4179F prescribed Not Covered INFO MEDICAID Adjuvant chemotherapy referred, prescribed or previously received for 4180F Stage III colon cancer Not Covered INFO MEDICAID 4181F Conformal radiation therapy received Not Covered INFO MEDICAID

413 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Conformal radiation therapy not received 4182F Not Covered INFO MEDICAID Continuous (12-months) therapy with proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) received 4185F Not Covered INFO MEDICAID No continuous (12-months) therapy with either proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) 4186F received Not Covered INFO MEDICAID Disease modifying anti-rheumatic drug therapy prescribed or dispensed 4187F Not Covered INFO MEDICAID Appropriate angiotensin converting enzyme (ACE)/angiotensin receptor blockers (ARB) therapeutic monitoring 4188F test ordered or performed Not Covered INFO MEDICAID Appropriate digoxin therapeutic monitoring 4189F test ordered or performed Not Covered INFO MEDICAID Appropriate diuretic therapeutic 4190F monitoring test ordered or performed Not Covered INFO MEDICAID Appropriate anticonvulsant therapeutic monitoring test ordered or performed 4191F Not Covered INFO MEDICAID Patient not receiving glucocorticoid 4192F therapy (RA) Not Covered INFO MEDICAID Patient receiving <10 mg daily prednisone (or equivalent), or RA activity is worsening, or glucocorticoid use is for less than 6 months (RA)5 4193F Not Covered INFO MEDICAID Patient receiving >= 10 mg daily prednisone (or equivalent) for longer than 6 months, and improvement or no change 4194F in disease activity (RA) Not Covered INFO MEDICAID Patient receiving first-time biologic disease modifying anti-rheumatic drug therapy for rheumatoid arthritis (RA) 4195F Not Covered INFO MEDICAID Patient not receiving first-time biologic disease modifying anti-rheumatic drug therapy for rheumatoid arthritis (RA) 4196F Not Covered INFO MEDICAID External beam radiotherapy as primary therapy to the prostate with or without 4200F nodal irradiation Not Covered INFO MEDICAID External beam radiotherapy with or without nodal irradiation as adjuvant or salvage therapy for prostate cancer 4201F patient Not Covered INFO MEDICAID Angiotensin converting enzyme (ACE) or angiotensin receptor blockers (ARB) medication therapy for 6 months or more 4210F Not Covered INFO MEDICAID Digoxin medication therapy for 6 months 4220F or more Not Covered INFO MEDICAID Diuretic medication therapy for 6 months 4221F or more Not Covered INFO MEDICAID Anticonvulsant medication therapy for 6 4230F months or more Not Covered INFO MEDICAID Instruction in therapeutic exercise with follow-up by the physician provided to patients during episode of back pain lasting longer than 12 weeks 4240F Not Covered INFO MEDICAID Counseling for supervised exercise program provided to patients during episode of back pain lasting longer than 4242F 12 weeks Not Covered INFO MEDICAID

414 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient counseled during the initial visit to maintain or resume normal activities 4245F Not Covered INFO MEDICAID Patient counseled during the initial visit for an episode of back pain against bed rest lasting 4 days or longer 4248F Not Covered INFO MEDICAID Active warming used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time 4250F Not Covered INFO MEDICAID Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record 4255F Not Covered INFO MEDICAID Duration of general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record 4256F Not Covered INFO MEDICAID Wound surface culture technique used 4260F (CWC)5 Not Covered INFO MEDICAID Technique other than surface culture of the wound exudate used (eg, Levine/deep swab technique, semi-quantitative or quantitative swab technique) OR wound surface culture technique not used (CWC) 4261F Not Covered INFO MEDICAID Use of wet to dry dressings prescribed or 4265F recommended (CWC) Not Covered INFO MEDICAID Use of wet to dry dressings neither 4266F prescribed nor recommended (CWC) Not Covered INFO MEDICAID Compression therapy prescribed (CWC) 4267F Not Covered INFO MEDICAID Patient education regarding the need for long term compression therapy including interval replacement of compression stockings, received (CWC) 4268F Not Covered INFO MEDICAID Appropriate method of offloading 4269F (pressure relief) prescribed (CWC) Not Covered INFO MEDICAID Patient receiving potent antiretroviral 4270F therapy for 6 months or longer (HIV) Not Covered INFO MEDICAID Patient receiving potent antiretroviral therapy for less than 6 months or not receiving potent antiretroviral therapy 4271F (HIV) Not Covered INFO MEDICAID Influenza immunization administered or previously received (HIV) (P-ESRD) 4274F Not Covered INFO MEDICAID HEPATITIS B VACCINE INJECTION ADMINISTERED OR PREVIOUSLY 4275F RECEIVED (HIV) Not Covered INFO MEDICAID POTENT ANTIRETROVIRAL THERAPY 4276F PRESCRIBED (HIV) Not Covered INFO MEDICAID PNEUMOCYSTIS JIROVECI PNEUMONIA PROPHYLAXIS 4279F PRESCRIBED (HIV) Not Covered INFO MEDICAID PNEUMOCUSTIS JIROVECI PNEUMONIA PROPHYLAXIS prescribed within 3 months of low CD4+ cell count or 4280F percentage (HIV) Not Covered INFO MEDICAID PATIENT SCREENED FOR INJECTION 4290F DRUG USE (HIV) No MEDICAID PATIENT SCREENED FOR HIGH-RISK 4293F SEXUAL BEHAVIOR (HIV) No MEDICAID

415 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PATIENT RECEIVING WARFARIN THERAPY FOR NONVALVULAR ATRIAL FIBRILLATION OR ATRIAL FLUTTER 4300F (AFIB) Not Covered INFO MEDICAID PATIENT NOT RECEIVING WARFARIN THERAPY FOR NONVALVULAR ATRIAL FIBRILLATION OR ATRIAL FLUTTER (AFIB) 4301F Not Covered INFO MEDICAID PATIENT EDUCATION REGARDING APPROPRIATE FOOT CARE AND daily inspection of the feet, received (CWC) 4305F Not Covered INFO MEDICAID PATIENT COUNSELED REGARDING PSYCHOSOCIAL AND pharmacologic treatment options for opioid addiction 4306F (SUD) Not Covered INFO MEDICAID PATIENT COUNSELED REGARDING PSYCHOSOCIAL AND pharmacologic treatment options for alcohol dependence 4320F (SUD) Not Covered INFO MEDICAID Caregiver provided with education and referred to additional resources for 4322F support Not Covered INFO MEDICAID Patient (or caregiver) queried about 4324F Parkinson’s disease medication related motor complications (Prkns) Not Covered INFO MEDICAID Medical and surgical treatment options 4325F reviewed with patient (or caregiver) (Prkns) Not Covered INFO MEDICAID Patient (Or Caregiver) Queried About 4326F Symptoms Of Autonomic Dysfunction (Prkns) Not Covered INFO MEDICAID Patient (Or Caregiver) Queried About 4328F Sleep Disturbances (Prkns) Not Covered INFO MEDICAID Counseling about epilepsy specific safety issues provided to patient (or caregiver 4330F (s)) Not Covered INFO MEDICAID Counseling for women of childbearing 4340F potential with epilepsy Not Covered INFO MEDICAID Counseling provided on symptom management, end of life decisions, and 4350F palliation Not Covered INFO MEDICAID Rehabilitative therapy options discussed 4400F with patient (or caregiver) (Prkns) Not Covered INFO MEDICAID Self-care education provided to patient 4450F Not Covered INFO MEDICAID Implantable Cardioverter-Defibrillator 4470F (ICD) counseling provided Not Covered INFO MEDICAID Patient receiving ACE Inhibitor/ARB Therapy and Beta-Blocker Therapy for 3 4480F months or longer Not Covered INFO MEDICAID Patient receiving ACE Inhibitor/ARB Therapy and Beta-Blocker Therapy for 4481F less than 3 months Not Covered INFO MEDICAID Referred to an outpatient cardiac 4500F rehabilitation program Not Covered INFO MEDICAID Previous cardiac rehabilitation for 4510F qualifying cardiac event completed Not Covered INFO MEDICAID 4525F Neuropsychiatric intervention ordered Not Covered INFO MEDICAID Neuropsychiatric intervention received 4526F Not Covered INFO MEDICAID Disease modifying pharmacotherapy 4540F discussed (DSP) Not Covered MEDICAID Patient offered treatment for 4541F pseudobulbar affect, sialorrhea, or ALS related symptoms (DSP) Not Covered MEDICAID Options for noninvasive respiratory 4550F support discussed with patient (DSP) Not Covered MEDICAID 4551F Nutritional support offered (DSP) Not Covered MEDICAID

416 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient offered referral to a speech 4552F language pathologist (DSP) Not Covered MEDICAID Patient offered assistance in planning for 4553F end of life issues (DSP) Not Covered MEDICAID Patient received inhalational anesthetic 4554F agent (Peri2) Not Covered MEDICAID Patient did not receive inhalational 4555F anesthetic agent (Peri2) Not Covered MEDICAID Patient exhibits 3 or more risk factors for 4556F post-operative nausea and vomiting (Peri2) Not Covered MEDICAID Patient does not exhibit 3 or more risk 4557F factors for post-operative nausea and vomiting (Peri2) Not Covered MEDICAID Patient received at least 2 prophylactic pharmacologic anti-emetic agents of 4558F different classes preoperatively and intraoperatively (Peri2) Not Covered MEDICAID At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) 4559F recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (Peri2) Not Covered MEDICAID Anesthesia technique did not involve 4560F general or neuraxial anesthesia (Peri2) Not Covered MEDICAID Patient has a coronary artery stent (Peri2) 4561F Not Covered MEDICAID Patient does not have a coronary artery 4562F stent (Peri2) Not Covered MEDICAID Patient received aspirin within 24 hours 4563F prior to anesthesia start time (Peri2) Not Covered MEDICAID PATIENT COUNSELED ON SELF- EXAMINATION FOR NEW OR 5005F CHANGING MOLES Not Covered INFO MEDICAID FINDINGS OF DILATED MACULAR OR FUNDUS EXAM COMMUNICATED TO THE PHYSICIAN MANAGING THE DIABETES CARE 5010F Not Covered INFO MEDICAID DOCUMENTATION OF COMMUNICATION THAT A FRACTURE OCCURRED AND THAT THE PATIENT WAS OR SHOULD BE TESTED OR TREATED FOR OSTEOPOROSIS 5015F Not Covered INFO MEDICAID TREATMENT SUMMARY REPORT COMMUNICATED TO PHYSICIAN(s) managing continuing care and to patient within 1 month of completing treatment 5020F Not Covered INFO MEDICAID TREATMENT PLAN COMMUNICATED TO PROVIDER(s) managing continuing care within one month of diagnosis 5050F Not Covered INFO MEDICAID FINDINGS FROM DIAGNOSTIC MAMMOGRAM communicated to practice managing patient’s on-going care within 3 business days of exam interpretation 5060F Not Covered INFO MEDICAID

417 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DOCUMENTATION OF DIRECT COMMUNICATION OF DIAGNOSTIC MAMMOGRAM FINDINGS BY telephone or in person [by the diagnostic imager or a designee] to the treating or referring physician or his/her representative and confirmation of receipt of the findings within 3 days of exam interpretation 5062F Not Covered INFO MEDICAID POTENTIAL RISK FOR FRACTURE COMMUNICATED TO THE REFERREING PHYSICIAN WITHIN 24 HOURS OF COMPLETION OF THE 5100F IMAGING STUDY (NUC_MED) Not Covered INFO MEDICAID Consideration of referral for a neurological evaluation of appropriateness for surgical therapy for intractable epilepsy within the past 3 years 5200F Not Covered INFO MEDICAID 5250F Asthma discharge plan present Not Covered INFO MEDICAID RATIONALE (EG, SEVERITY OF ILLNESS AND SAFETY) FOR LEVEL OF CARE (EG, HOME, HOSPITAL) 6005F DOCUMENTED (CAP) Not Covered INFO MEDICAID DYSPHAGIA SCREENING CONDUCTED PRIOR TO ORDER FOR OR RECEIPT OF ANY FOODS, FLUIDS 6010F OR MEDICATION BY MOUTH Not Covered INFO MEDICAID PATIENT RECEIVING OR ELIGIBLE TO RECEIVE FOODS, FLUIDS OR 6015F MEDICATION BY MOUTH Not Covered INFO MEDICAID NPO (NOTHING BY MOUTH) ORDERED 6020F Not Covered INFO MEDICAID ALL ELEMENTS OF MAXIMAL STERILE BARRIER TECHNIQUE INCLUDING: cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis, followed 6030F Not Covered INFO MEDICAID USE OF APPROPRIATE RADIATION DOSE REDUCTION DEVICES OR MANUAL TECHNIQUES FOR APPROPRIATE MODERATION OF 6040F EXPOSURE, DOCUMENTED Not Covered INFO MEDICAID RADIATION EXPOSURE OR EXPOSURE TIME IN FINAL REPORT FOR PROCEDURE USING 6045F FLUROSCOPY, DOCUMENTED Not Covered INFO MEDICAID Patient queried and counseled about anti- 6070F epileptic drug (AED) side-effects Not Covered INFO MEDICAID Patient (or caregiver) queried about falls 6080F (Prkns) Not Covered INFO MEDICAID Patient (or caregiver) counseled about 6090F safety issues appropriate to patient’s stage of disease (Prkns) Not Covered INFO MEDICAID Timeout to verify correct patient, correct site, and correct procedure, documented 6100F (PATH) Not Covered INFO MEDICAID Safety counseling for Dementia provided 6101F Not Covered INFO MEDICAID Safety counseling for dementia ordered 6102F Not Covered INFO MEDICAID Counseling provided regarding risks of driving and the alternatives to driving 6110F Not Covered INFO MEDICAID Patient not receiving a first course of anti- TNF (tumor necrosis factor) therapy 6150F Not Covered INFO MEDICAID

418 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PATIENT INFORMATION ENTERED INTO A RECALL SYSTEM WITH THE TARGET DATE FOR THE NEXT EXAM 7010F SPECIFIED Not Covered INFO MEDICAID Mammogram assessment category (eg, Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS], or FDA- approved equivalent categories) entered into an internal database to allow for analysis of abnormal interpretation (recall) rate (RAD) 7020F Not Covered INFO MEDICAID PATIENT INFORMATION ENTERED INTO A REMINDER SYSTEM WITH A TARGET DUE DATE FOR THE NEXT 7025F MAMMOGRAM Not Covered INFO MEDICAID 9001F Aortic aneurysm less than 5.0 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated) Not Covered INFO MEDICAID 9002F Aortic aneurysm 5.0 - 5.4 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated) Not Covered INFO MEDICAID 9003F Aortic aneurysm 5.5 - 5.9 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated) Not Covered INFO MEDICAID 9004F Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated) Not Covered INFO MEDICAID 9005F Asymptomatic carotid stenosis: No history of any transient ischemic attack or stroke in any carotid or vertebrobasilar territory (NMA-No Measure Associated) Not Covered INFO MEDICAID 9006F Symptomatic carotid stenosis: Ipsilateral carotid territory TIA or stroke less than 120 days prior to procedure (NMA-No Measure Associated) Not Covered INFO MEDICAID 9007F Other carotid stenosis: Ipsilateral TIA or stroke 120 days or greater prior to procedure or any prior contralateral carotid territory or vertebrobasilar TIA or stroke (NMA-No Measure Associated) Not Covered INFO MEDICAID AMBULANCE SERVICE, OUTSIDE STATE PER MILE, TRANSPORT A0021 (MEDICAID ONLY) Not Covered MEDICAID NON-EMERGENCY TRANSPORTATION: PER MILE - A0080 VOLUNTEER, (INDIVIDUAL OR No ORGANIZATION) WITH NO VESTED INTEREST MEDICAID NON-EMERGENCY TRANSPORTATION: PER MILE - VEHICLE PROPVIDED BY INDIVIDUAL A0090 (FAMILY MEMBER, SELF, NEIGHBOR) No WITH VESTED INTEREST MEDICAID NON-EMERGENCY A0100 TRANSPORTATION: TAXI - INTRA CITY No MEDICAID

419 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines NON-EMERGENCY TRANSPORTATION A0110 AND BUS, INTRA OR INTER STATE No CARRIER MEDICAID NON-EMERGENCY TRANSPORTATION: MINI-BUS, A0120 MOUNTAIN AREA TRANSPORTS, No OTHER TRANSPORTATION SYSTEMS MEDICAID NON-EMERGENCY A0130 TRANSPORTATION: WHEEL-CHAIR No VAN MEDICAID NON-EMERGENCY TRANSPORTATION: PER MILE - CASE WORKER OR SOCIAL WORKER A0160 Not Covered MEDICAID TRANSPORTATION ANCILLARY: A0170 No PARKING FEES, TOLLS, OTHER MEDICAID NON-EMERGENCY A0180 TRANSPORTATION: ANCILLARY: No LODGING-RECIPIENT MEDICAID NON-EMERGENCY A0190 TRANSPORTATION: ANCILLARY: No MEALS-RECIPIENT MEDICAID NON-EMERGENCY A0200 TRANSPORTATION: ANCILLARY: No LODGING ESCORT MEDICAID NON-EMERGENCY A0210 TRANSPORTATION: ANCILLARY: No MEALS-ESCORT MEDICAID AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAY A0225 No ExGEN MEDICAID A0380 BLS MILEAGE (PER MILE) No ExGEN MEDICAID BLS ROUTINE DISPOSABLE SUPPLIES A0382 No ExGEN MEDICAID BLS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (USED BY ALS AMBULANCES & BLS AMBULANCES IN A0384 JURISDICTIONS WHERE DEFIBR No ExGEN MEDICAID A0390 ALS MILEAGE (PER MILE) No ExGEN MEDICAID ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (TO BE USED ONLY IN JURISDICTIONS WHERE DEFIBRILLATION CANNOT BE PERFO A0392 No ExGEN MEDICAID ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; IV DRUG A0394 THERAPY No ExGEN MEDICAID ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; A0396 ESOPHAGEAL INTUBATION No ExGEN MEDICAID ALS ROUTINE DISPOSABLE SUPPLIES A0398 No ExGEN MEDICAID AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR A0420 INCREMENTS No ExGEN MEDICAID AMBULANCE (ALS OR BLS) OXYGEN AND OXYGEN SUPPLIES, LIFE A0422 SUSTAINING SITUATION No ExGEN MEDICAID EXTRA AMBULANCE ATTENDANT, GROUND (ALS OR BLS) OR AIR (FIXED A0424 OR ROTARY WINGED) No ExGEN MEDICAID GROUND MILEAGE, PER STATUTE A0425 MILE No ExGEN MEDICAID AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY A0426 TRANSPORT, LEVEL (ALS 1) No ExGEN MEDICAID

420 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS1- A0427 EMERGENCY) No ExGEN MEDICAID AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY A0428 TRANSPORT, (BLS) No ExGEN MEDICAID AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT A0429 (BLS-EMERGENCY) No ExGEN MEDICAID AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) A0430 No MEDICAID AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY A0431 WING) No MEDICAID PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY VOULNTEER AMB CO, PROHIBITED BY STATE LAW FROM BILLING 3RD A0432 PARTY PAYE Not Covered ExGEN MEDICAID ADVANCED LIFE SUPPORT, LEVEL 2 A0433 (ALS 2) No ExGEN MEDICAID SPECIALTY CARE TRANSPORT (SCT) A0434 No ExGEN MEDICAID FIXED WING AIR MILEAGE, PER A0435 STATUTE MILE No MEDICAID ROTARY WING AIR MILEAGE, PER A0436 STATUTE MILE No MEDICAID NONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSEST A0888 APPROPRIATE FACILITY) Not Covered MEDICAID AMBULANCE RESPONSE AND A0998 No TREATMENT, NO TRANSPORT MEDICAID A0999 UNLISTED AMBULANCE SERVICE No ExGEN MEDICAID Supplies for maintenance of insulin A4224 infusion catheter, per week No MEDICAID Supplies for external insulin infusion pump, syringe type cartridge, sterile, each A4225 No MEDICAID CERVICAL CAP FOR CONTRACEPTIVE A4261 USE No MEDICAID TEMPORARY, ABSORBABLE A4262 LACRIMAL DUCT IMPLANT, EACH No MEDICAID PERMANENT, LONG TERM, NON- DISSOLVABLE LACRIMAL DUCT A4263 IMPLANT, EACH No MEDICAID PERMANENT IMPLANTABLE CONTRACEPTIVE INTRATUBAL OCCLUSION DEVICE(S) AND A4264 DELIVERY SYSTEM No MEDICAID DIAPHRAGM FOR CONTRACEPTIVE A4266 USE No MEDICAID CONTRACEPTIVE SUPPLY, A4269 PERMICIDE (E.G.,FOAM,GEL), EACH No MEDICAID DISPOSABLE ENDOSCOPE SHEATH, A4270 EACH No MEDICAID SACRAL NERVE STIMULATION TEST A4290 LEAD, EACH No MEDICAID IMPLANTABLE ACCESS CATHETER, A4300 EXTERNAL ACCESS No MEDICAID IMPLANTABLE ACCESS TOTAL A4301 CATHETER, PORT/RESERVOIR No MEDICAID Incontinence supply, rectal insert, any type, A4337 each No MEDICAID Belt, strap, sleeve, garment, or covering, A4467 Yes any type MEDICAID A4470 GRAVLEE JET WASHER No MEDICAID

421 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines A4480 VABRA ASPIRATOR No MEDICAID A4553 Non-disposable underpads, all sizes Not Covered MEDICAID Electrode/transducer for use with electrical stimulation device used for A4555 cancer treatment, replacement only Yes MEDICAID A4561 PESSARY, RUBBER, ANY TYPE Yes MEDICAID A4562 PESSARY, NON RUBBER, ANY TYPE Yes MEDICAID RADIOPHARMACEUTICAL, A4641 DIAGNOSTIC, NOT OTHERWISE Yes CLASSIFIED MEDICAID INDIUM IN-111 SATUMOMAB A4642 PENDETIDE, DIAGNOSTIC, PER Yes STUDY DOSE, UP TO 6 MEDICAID TISSUE MARKER, IMPLANTABLE, ANY A4648 TYPE, EACH No MEDICAID SURGICAL SUPPLY; MISCELLANEOUS A4649 Yes MEDICAID IMPLANTABLE RADIATION A4650 DOSIMETER, EACH No MEDICAID CALIBRATED MICROCAPILLARY TUBE, A4651 EACH No MEDICAID MICROCROCAPILLARY TUBE A4652 SEALANT No MEDICAID PERITONEAL DIALYSIS CATHETER A4653 ANCHORING DEVICE, BELT, EACH No MEDICAID SYRINGE, WITH OR WITHOUT A4657 Yes NEEDLE, FOR DIALYSIS, EACH MEDICAID DISPOSABLE CYCLER SET USED WITH CYCLER DIALYSIS MACHINE, A4671 EACH No MEDICAID DRAINAGE EXTENSION LINE, A4672 STERILE, FOR DIALYSIS, EACH No MEDICAID EXTENSION LINE WITH EASY LOCK CONNECTORS, USED WITH DIALYSIS A4673 No MEDICAID CHEMICALS/ANTISEPTICS SOLUTION USED TO CLEAN/STERILIZE DIALYSIS EQUIPMENT, PER 8 OZ A4674 No MEDICAID ACTIVATED CARBON FILTER FOR A4680 HEMODIALYSIS, EACH No MEDICAID DIALYZERS (ARTIFICIAL KIDNEYS), ALL TYPES, ALL SIZES, FOR A4690 HEMODIALYSIS, EACH No MEDICAID BICARBINATE CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER A4706 GALLON No MEDICAID BICARBINATE CONCENTRATE, POWDER, FOR HEMODIALYSIS, PER A4707 PACKET No MEDICAID ACETATE CONCENTRATE SOLUTION, FOR HEMODIALYSIS, PER GALLON A4708 No MEDICAID ACID CONCENTRATE, SOLUTION FOR A4709 HEMODIALYSIS, PER GALLON No MEDICAID TREATED WATER (DEIONIZED, DISTILLED, REVERSE OSMOSIS) FOR PERITONEAL DIALYSIS, PER GALLON A4714 No MEDICAID Y SET TUBING FOR PERITONEAL A4719 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 249CC, BUT LESS OR EQUAL TO A4720 999CC, FOR PERITONEAL DIALYSIS No MEDICAID

422 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 999CC, BUT LESS THAN OR EQUAL TO 1999CC, FOR PERITONEAL A4721 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 1999CC, BUT LESS THAN OR EQUAL TO 2999CC, FOR PERITONEAL A4722 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 2999CC, BUT LESS THAN OR EQUAL TO 3999CC, FOR PERITONEAL A4723 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 3999CC, BUT LESS THAN OR EQUAL TO 4999CC, FOR PERITONEAL A4724 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 4999CC, BUT LESS THAN OR EQUAL TO 5999CC, FOR PERITONEAL A4725 DIALYSIS No MEDICAID DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN A4726 5999CC No MEDICAID DIALYSATE SOLUTION, NON- A4728 DEXTROSE CONTAINING, 500 ML No MEDICAID FISTULA CANNULATION SET FOR A4730 HEMODIALYSIS, EACH No MEDICAID TOPICAL ANESTHETIC, FOR DIALYSIS, A4736 PER GRAM Not Covered MEDICAID INJECTABLE ANESTHETIC, FOR A4737 DIALYSIS, PER 10 ML Not Covered MEDICAID SHUNT ACCESSORY, FOR A4740 HEMODIALYSIS, ANY TYPE, EACH No MEDICAID BLOOD TUBING, ARTERIAL OR VENOUS, FOR HEMODIALYSIS, EACH A4750 No MEDICAID BLOOD TUBING, ARTERIAL AND VENOUS COMBINED, FOR A4755 HEMODIALYSIS, EACH No MEDICAID DIALYSATE SOLUTION TEST KIT, FOR PERITONEAL DIALYSIS, ANY TYPE, A4760 EACH No MEDICAID DIALYSATE CONCENTRATE, POWDER, ADDITIVE FOR PERITONEAL DIALYSIS, PER PACKET A4765 No MEDICAID DIALYSATE CONCENTRATE, SOLUTION, ADDITIVE FOR A4766 PERITONEAL DIALYSIS, PER 10 ML No MEDICAID BLOOD COLLECTION TUBE, VACUUM, A4770 FOR DIALYSIS, PER 50 No MEDICAID SERUM CLOTTING TIME TUBE, FOR A4771 DIALYSIS, PER 50 No MEDICAID BLOOD GLUCOSE TEST STRIPS, FOR A4772 DIALYSIS, PER 50 No MEDICAID OCCULT BLOOD TEST STRIPS, FOR A4773 DIALYSIS, PER 50 No MEDICAID AMMONIA TEST STRIPS, FOR A4774 DIALYSIS, PER 50 No MEDICAID

423 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PROTAMINE SULFATE, FOR A4802 HEMODIALYSIS, PER 50 MG Not Covered MEDICAID DISPOSABLE CATHETER TIPS FOR A4860 PERITONEAL DIALYSIS, PER 10 No MEDICAID PLUMBING AND/OR ELECTRICAL WORK FOR HOME HEMODIALYSIS A4870 EQUIPMENT No MEDICAID CONTRACTS, REPAIR AND MAINTENANCE, FOR HEMODIALYSIS A4890 EQUIPMENT No MEDICAID DRAIN BAG/BOTTLE, FOR DIALYSIS, A4911 EACH No MEDICAID MISCELLANEOUS DIALYSIS SUPPLIES, NOT OTHERWISE SPECIFIED A4913 No MEDICAID VENOUS PRESSURE CLAMPS, FOR A4918 HEMODIALYSIS, EACH No MEDICAID A4929 TOURNIQUET FOR DIALYSIS, EACH No MEDICAID GRADIENT COMPRESSION WRAP, A6545 NON-ELASTIC, BELOW KNEE, 30-50 Yes MM HG, EACH MEDICAID Oral interface used with respiratory A7047 suction pump, each No MEDICAID A9150 NON-PRESCRIPTION DRUGS Not Covered MEDICAID SINGLE VITAMIN/MINERAL/TRACE ELEMENT, ORAL, PER DOSE, NOT A9152 OTHERWISE SPECIFIED Not Covered MEDICAID MULTIPLE VITAMINS, WITH OR WITHOUT MINERALS AND TRACE ELEMENTS, ORAL, PER DOSE, NOT A9153 OTHERWISE SPECIFIED Not Covered MEDICAID PEDICULOSIS (LICE INFESTATION) TREATMENT, TOPICAL, FOR A9180 ADMINISTRATION BY Not Covered MEDICAID SPIROMETER, NON-ELECTRONIC, A9284 INCLUDES ALL ACCESSORIES No MEDICAID A9285 Inversion/eversion correction device Not Covered MEDICAID Hygienic item or device, disposable or A9286 non-disposable, any type, each Not Covered MEDICAID TECHNETIUM TC 99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE, UP A9500 TO 40 MILLICURIES No MEDICAID TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSE A9501 No MEDICAID TECHNETIUM TC 99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLCURIES A9502 No MEDICAID TECHNETIUM TC99M, MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP A9503 TO 30 MILLICURIES No MEDICAID TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP A9504 TO 20 MILLICURIES No MEDICAID THALLIUM TL-201 THALLOUS A9505 CHLORID, DIAGNOSTIC, PER Yes MILLICURIE MEDICAID INDIUM IN-111 CAPROMAB PENDETITE, DIAGNOSTIC, PER A9507 Yes STUDY DOSE, UP TO 10 MILLICURIES MEDICAID IODINE 1-131 IOBENGUANE SULFATE, A9508 DIAGNOSTIC, PER 0.5 MILLICURIE Yes MEDICAID IODINE I-123 SODIUM IODIDE, A9509 Yes DIAGNOSTIC, PER MILLICURIE MEDICAID TECHNETIUM TC-99M DISOFENIN, A9510 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 15 MILLICURIES MEDICAID

424 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TECHNETIUM TC-99M A9512 PERTECHNETATE, DIAGNOSTIC, PER Yes MILLICURIE MEDICAID Choline c-11, diagnostic, per study dose A9515 Yes up to 20 millicuries MEDICAID IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, A9516 Yes UP TO 999 MICROCURIES MEDICAID IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER A9517 MILLICURIE No MEDICAID Technetium tc-99m, tilmanocept, A9520 diagnostic, up to 0.5 millicuries No MEDICAID TECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP A9521 Yes TO 25 MILLICURIES MEDICAID IODINE I-131 IODINATED SERUM A9524 ALBUMIN, DIAGNOSTIC, PER 5 Yes MICROCURIES MEDICAID NITROGEN N-13 AMMONIA, A9526 DIAGNOSTIC,, PER STUDY DOSE, UP Yes TO 40 MILLICURIES MEDICAID IODINE I-125, SODIUM IODIDE A9527 SOLUTION, THERAPEUTIC, PER Yes MILLICURIE MEDICAID IODINE I-131 SODIUM IODIDE A9528 CAPSULE(S), DIAGNOSTIC, PER Yes MILLICURIE MEDICAID IODINE I-131 SODIUM IODIDE A9529 SOLUTION, DIAGNOSTIC, PER Yes MILLICURIE MEDICAID IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER A9530 MILLICURIE No MEDICAID IODINE I-131 SODIUM IODIDE, A9531 DIAGNOSTIC, PER MICROCURIE (UP Yes TO 100 MICROCURIES) MEDICAID IODINE I-125 SERUM ALBUMIN, A9532 Yes DIAGNOSTIC, PER 5 MICROCURIES MEDICAID TECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 35 MILLICURIES A9536 No MEDICAID TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES A9537 No MEDICAID TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER A9538 Yes STUDY DOSE, UP TO 25 MILLICURIES MEDICAID TECHNETIUM TC-99M PENTETATE, A9539 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 35 MILLICURIES MEDICAID TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, A9540 Yes DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES MEDICAID TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY A9541 Yes DOSE, UP TO 20 MILLICURIES MEDICAID INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES A9542 No MEDICAID

425 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40 A9543 MILLICURIES No MEDICAID COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 A9546 MICROCURIES No MEDICAID INDIUM IN-111 OXYQUINOLINE, A9547 Yes DIAGNOSTIC, PER 0.5 MI MEDICAID INDIUM IN-111 PENTETATE, A9548 Yes DIAGNOSTIC, PER 0.5 MILLICURIES MEDICAID TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES A9550 No MEDICAID TECHNETIUM TC-99M SUCCIMER, A9551 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 10 MILLICURIES MEDICAID FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP A9552 TO 45 MILLICURIES No MEDICAID CHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER A9553 Yes STUDY DOSE, UP TO 250 MICROCURIES MEDICAID IODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, UP A9554 Yes TO 10 MICROCURIES MEDICAID RUBIDIUM RB-82, DIAGNOSTIC, PER A9555 STUDY DOSE, UP TO60 MILLICURIES Yes MEDICAID GALLIUM GA-67 CITRATE, A9556 Yes DIAGNOSTIC, PER MILLICURIE MEDICAID TECHNETIUM TC-99M BICISATE, A9557 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 25 MILLICURIES MEDICAID XENON XE-133 GAS, DIAGNOSTIC, A9558 Yes PER 10 MILLICURIES MEDICAID COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY A9559 DOSE, UP TO 1 MICROCURIE No MEDICAID TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES A9560 No MEDICAID TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP A9561 Yes TO 30 MILLICURIES MEDICAID TECHNETIUM TC-99M MERTIATIDE, A9562 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 15 MILLICURIES MEDICAID SODIUM PHOSPHATE P-32, A9563 Yes THERAPEUTIC, PER MILLICURIE MEDICAID CHROMIC PHOSPHATE P-32 A9564 SUSPENSION, THERAPEUTIC, PER Yes MILLICURIE MEDICAID TECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES A9566 No MEDICAID TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY A9567 Yes DOSE, UP TO 75 MILLICURIES MEDICAID TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES A9568 No MEDICAID

426 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE A9569 BLOOD CELLS, DIAGNOSTIC, PER Yes STUDY DOSE MEDICAID INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, A9570 Yes DIAGNOSTIC, PER STUDY DOSE MEDICAID INDIUM IN-111 LABELED A9571 AUTOLOGOUS PLATELETS, Yes DIAGNOSTIC, PER STUDY DOSE MEDICAID INDIUM IN-111 PENTETREOTIDE, A9572 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 6 MILLICURIES MEDICAID Injection, gadoterate meglumine, 0.1 ml A9575 No MEDICAID INJECTION, GADOTERIDOL, A9576 (PROHANCE MULTIPACK), PER ML No MEDICAID INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE), PER A9577 ML No MEDICAID INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE A9578 MULTIPACK), PER ML No MEDICAID INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML A9579 No MEDICAID SODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP A9580 TO 30 MILLICURIES No MEDICAID A9581 INJECTION, GADOXETATE DISODIUM, 1 ML No MEDICAID IODINE I-123 IOBENGUANE, A9582 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 15 MILLICURIES MEDICAID INJECTION, GADOFOSVESET A9583 Yes TRISODIUM, 1 ML MEDICAID IODINE 1-123 IOFLUPANE, A9584 DIAGNOSTIC, PER STUDY DOSE, UP Yes TO 5 MILLICURIES MEDICAID A9585 INJECTION, GADOBUTROL, 0.1 ML No MEDICAID A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries No MEDICAID Gallium ga-68, dotatate, diagnostic, 0.1 A9587 Yes millicurie MEDICAID Fluciclovine f-18, diagnostic, 1 millicurie A9588 Yes MEDICAID Positron emission tomography radiopharmaceutical, diagnostic, for tumor A9597 Yes identification, not otherwise classified MEDICAID Positron emission tomography radiopharmaceutical, diagnostic, for non- A9598 Yes tumor identification, not otherwise classified MEDICAID STRONTIUM SR-89 CHLORIDE, A9600 Yes THERAPEUTIC, PER MILLICURIE MEDICAID SAMARIUM SM-153 LEXIDRONAM, A9604 THERAPEUTIC, PER TREATMENT Yes DOSE, UP TO 150 MILLICURIES MEDICAID Radium ra-223 dichloride, therapeutic, per A9606 microcurie No MEDICAID NON-RADIOACTIVE CONTRAST IMAGING MATERIAL, NOT A9698 Yes OTHERWISE CLASSIFIED, PER STUDY MEDICAID

427 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE A9699 CLASSIFIED Yes MEDICAID SUPPLY OF INJECTABLE CONTRAST A9700 MATERIAL FOR USE IN Yes ECHOCARDIOGRAPHY, PER STUDY MEDICAID ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO- C1713 BONE (IMPLANTABLE) No MEDICAID CATHETER, TRANSLUMINAL C1714 ATHERECTOMY, DIRECTIONAL No MEDICAID C1715 BRACHYTHERAPY NEEDLE No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, GOLD-198, PER SOURCE C1716 No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, HIGH DOSE RATE C1717 IRIDIUM-192, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, NON-HIGH DOSE RATE C1719 IRIDIUM-192, PER SOURCE No MEDICAID CARDIOVERTER-DEFIBRILLATOR, C1721 DUAL CHAMBER (IMPLANTABLE) No MEDICAID CARDIOVERTER-DEFIBRILLATOR, C1722 SINGLE CHAMBER (IMPLANTABLE) No MEDICAID CATHETER, TRANSLUMINAL C1724 ATHERECTOMY, ROTATIONAL No MEDICAID CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, C1725 INFUSION/PERFUSION CAPABILITY) No MEDICAID CATHETER, BALLOON DILATATION, C1726 NON-VASCULAR No MEDICAID CATHETER, BALLOON TISSUE DISSECTOR, NON-VASCULAR C1727 (INSERTABLE) No MEDICAID CATHETER, BRACHYTHERAPY SEED C1728 ADMINISTRATION No MEDICAID C1729 CATHETER, DRAINAGE No MEDICAID CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (19 OR < C1730 No MEDICAID CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (20 OR > C1731 No MEDICAID CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, 3D OR VECTOR MAPPING C1732 No MEDICAID CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR VECT C1733 No MEDICAID ENDOSCOPE, RETROGRADE IMAGING/ILLUMINATION COLONOSCOPE DEVICE C1749 (IMPLANTABLE) No MEDICAID CATHETER, HEMODIALYSIS, LONG- C1750 TERM No MEDICAID CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR C1751 MIDLINE No MEDICAID CATHETER, HEMODIALYSIS, SHORT- C1752 TERM No MEDICAID CATHETER, INTRAVASCULAR C1753 ULTRASOUND No MEDICAID C1754 CATHETER, INTRADISCAL No MEDICAID C1755 CATHETER, INTRASPINAL No MEDICAID

428 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CATHETER, PACING, C1756 TRANSESOPHAGEAL No MEDICAID CATHETER, C1757 THROMBECTOMY/EMBOLECTOMY No MEDICAID C1758 CATHETER, URETERAL No MEDICAID CATHETER, INTRACARDIAC C1759 ECHOCARDIOGRAPHY No MEDICAID CLOSURE DEVICE, VASCULAR C1760 (IMPLANTABLE/INSERTABLE) No MEDICAID CONNECTIVE TISSUE, HUMAN C1762 (INCLUDES FASCIA LATA) No MEDICAID CONNECTIVE TISSUE, NON-HUMAN C1763 (INCLUDES SYNTHETIC) No MEDICAID EVENT RECORDER, CARDIAC C1764 (IMPLANTABLE) No MEDICAID C1765 ADHESION BARRIER No MEDICAID INTRODUCER/SHEATH, GUIDING, INTRACARDIAC C1766 ELECTROPHYSIOLOGICAL, No MEDICAID GENERATOR, NEUROSTIMULATOR C1767 (IMPLANTABLE) No MEDICAID C1768 GRAFT, VASCULAR Not Covered MEDICAID C1769 GUIDE WIRE No MEDICAID IMAGING COIL, MAGNETIC C1770 RESONANCE (INSERTABLE) No MEDICAID REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT C1771 No MEDICAID INFUSION PUMP, PROGRAMMABLE C1772 (IMPLANTABLE) No MEDICAID RETRIEVAL DEVICE, INSERTABLE (USED TO RETRIEVE FRACTURED C1773 MEDICAL DEVICES) No MEDICAID C1776 JOINT DEVICE (IMPLANTABLE) No MEDICAID LEAD, CARDIOVERTER- DEFIBRILLATOR, ENDOCARDIAL C1777 SINGLE COIL (IMPLANTABLE) No MEDICAID LEAD, NEUROSTIMULATOR C1778 (IMPLANTABLE) No MEDICAID LEAD, PACEMAKER, TRANSVENOUS C1779 VDD SINGLE PASS No MEDICAID LENS, INTRAOCULAR (NEW C1780 TECHNOLOGY) No MEDICAID C1781 MESH (IMPLANTABLE) No MEDICAID C1782 MORCELLATOR No MEDICAID OCULAR IMPLANT, AQUEOUS C1783 DRAINAGE ASSIST DEVICE No MEDICAID OCULAR DEVICE, INTRAOPERATIVE, DETACHED RETINA C1784 No MEDICAID PACEMAKER, DUAL CHAMBER, RATE- C1785 RESPONSIVE (IMPLANTABLE) No MEDICAID PACEMAKER, SINGLE CHAMBER, C1786 RATE-RESPONSIVE (IMPLANTABLE) No MEDICAID PATIENT PROGRAMMER, C1787 NEUROSTIMULATOR No MEDICAID PORT, INDWELLING (IMPLANTABLE) C1788 No MEDICAID PROSTHESIS, BREAST C1789 (IMPLANTABLE) No MEDICAID C1813 PROSTHESIS, PENILE, INFLATABLE No MEDICAID RETINAL TAMPONADE DEVICE, C1814 SILICONE OIL Not Covered MEDICAID PROSTHESIS, URINARY SPHINCTER C1815 (IMPLANTABLE) No MEDICAID RECEIVER AND/OR TRANSMITTER, NEUROSTIMULATOR (IMPLANTABLE) C1816 No MEDICAID SEPTAL DEFECT IMPLANT SYSTEM, C1817 INTRACARDIAC No MEDICAID C1818 INTEGRATED KERATOPROSTHESIS No MEDICAID

429 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SURGICAL TISSUE LOCALIZATION AND EXCISION DEVICE C1819 (IMPLANTABLE) No MEDICAID GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), W/ RECHARGEABLE BATTERY & CHARGING SYSTEM AS AN ALLOWED DEVICE FOR CPT CODE 64590 C1820 No MEDICAID Generator, neurostimulator (implantable), high frequency, with rechargeable battery and C1822 charging system No MEDICAID POWERED BONE MARROW BIOPSY C1830 NEEDLE No MEDICAID LENS, INTRAOCULAR (TELESCOPIC) C1840 No MEDICAID RETINAL PROSTHESIS, INCLUDES ALL INTERNAL AND EXTERNAL C1841 COMPONENTS Not Covered MEDICAID Retinal prosthesis, includes all internal and external components; add-on to C1842 C1841 Not Covered MEDICAID STENT, COATED/COVERED, WITH C1874 DELIVERY SYSTEM No MEDICAID STENT, COATED/COVERED, WITHOUT C1875 DELIVERY SYSTEM No MEDICAID STENT, NON-COATED/NON- COVERED, WITH DELIVERY SYSTEM C1876 No MEDICAID STENT, NON-COATED/NON- COVERED, WITHOUT DELIVERY C1877 SYSTEM No MEDICAID MATERIAL FOR VOCAL CORD MEDIALIZATION, SYNTHETIC C1878 (IMPLANTABLE) No MEDICAID C1880 VENA CAVA FILTER No MEDICAID DIALYSIS ACCESS SYSTEM C1881 (IMPLANTABLE) No MEDICAID CARDIOVERTER-DEFIBRILLATOR, OTHER THAN SINGLE OR DUAL C1882 CHAMBER (IMPLANTABLE) No MEDICAID ADAPTOR/EXTENSION, PACING LEAD OR NEUROSTIMULATOR LEAD C1883 (IMPLANTABLE) No MEDICAID EMBOLIZATION PROTECTIVE SYSTEM C1884 No MEDICAID CATHETER, TRANSLUMINAL C1885 ANGIOPLASTY, LASER No MEDICAID CATHETER, EXTRAVASCULAR TISSUE ABLATION, ANY MODALITY C1886 (INSERTABLE) No MEDICAID CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY) C1887 No MEDICAID CATHETER, ABLATION, NON- CARDIAC, ENDOVASCULAR C1888 (IMPLANTABLE) No MEDICAID Implantable/insertable device for device intensive procedure, not otherwise C1889 classified Yes MEDICAID INFUSION PUMP, NON- PROGRAMMABLE, PERMANENT C1891 (IMPLANTABLE) No MEDICAID INTRODUCER/SHEATH, GUIDING, INTRACARDIAC C1892 ELECTROPHYSIOLOGICAL, No MEDICAID INTRODUCER/SHEATH, GUIDING, INTRACARDIAC C1893 ELECTROPHYSIOLOGICAL, No MEDICAID

430 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIC C1894 No MEDICAID LEAD, CARDIOVERTER- DEFIBRILLATOR, ENDOCARDIAL DUAL C1895 COIL (IMPLANTABLE) No MEDICAID LEAD, CARDIOVERTER- DEFIBRILLATOR, OTHER THAN C1896 ENDOCARDIAL SINGLE OR DUAL No MEDICAID LEAD, NEUROSTIMULATOR TEST KIT C1897 (IMPLANTABLE) No MEDICAID LEAD, PACEMAKER, OTHER THAN C1898 TRANSVENOUS VDD SINGLE PASS No MEDICAID LEAD, PACEMAKER/CARDIOVERTER- DEFIBRILLATOR COMBINATION (IMPLANTABLE) C1899 No MEDICAID LEAD, LEFT VENTRICULAR C1900 CORONARY VENOUS SYSTEM No MEDICAID Lung Biopsy plug with delivery system C2613 No MEDICAID PROBE, PERCUTANEOUS LUMBAR C2614 DISCECTOMY Not Covered MEDICAID C2615 SEALANT, PULMONARY, LIQUID No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, YTTRIUM-90, PER C2616 SOURCE No MEDICAID STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY C2617 SYSTEM No MEDICAID C2618 PROBE, CRYOABLATION No MEDICAID PACEMAKER, DUAL CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE) C2619 No MEDICAID PACEMAKER, SINGLE CHAMBER, NON RATE-RESPONSIVE (IMPLANTABE) C2620 No MEDICAID PACEMAKER, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE) C2621 No MEDICAID PROSTHESIS, PENILE, NON- C2622 INFLATABLE No MEDICAID Catheter, transluminal angioplasty, drug- C2623 coated, non-laser No MEDICAID Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components C2624 Yes MEDICAID STENT, NON-CORONARY, TEMPORARY, WITH DELIVERY C2625 SYSTEM No MEDICAID INFUSION PUMP, NON- PROGRAMMABLE, TEMPORARY C2626 (IMPLANTABLE) No MEDICAID CATHETER, C2627 SUPRAPUBIC/CYSTOSCOPIC No MEDICAID C2628 CATHETER, OCCLUSION No MEDICAID INTRODUCER/SHEATH, INTRACARDIAC C2629 ELECTROPHYSIOLOGICAL, LASER No MEDICAID CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, COOL-TIP C2630 No MEDICAID REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING C2631 GRAFT No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, HIGH ACTIVITY, IODINE- 125, GREATER THAN 1.01 MCI (NIST), C2634 PER SOURCE No MEDICAID

431 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BRACHYTHERAPY SOURCE, NON- STRANDED, HIGH ACTIVITY, PALADIUM-103, GREATER THAN 2.2 C2635 MCI (NIST), PER SOURCE No MEDICAID BRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER C2636 1 MM No MEDICAID BRACHYTHERAPY SOURCE, NON- STRANDED, YTTERBIUM-169, PER C2637 SOURCE No MEDICAID BRACHYTHERAPY SOURCE, C2638 STRANDED, IODINE-125, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, NON- C2639 STRANDED, IODINE-125, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, C2640 STRANDED, PALLADIUM-103, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, NON- C2641 STRANDED, PALLADIUM-103, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, C2642 STRANDED, CESIUM-131, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, NON- C2643 STRANDED, CESIUM-131, PER SOURCE No MEDICAID Brachytherapy source, cesium-131 C2644 chloride solution, per millicurie No MEDICAID Brachytherapy planar source, palladium-103, C2645 per square millimeter No MEDICAID BRACHYTHERAPY SOURCE, C2698 STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE No MEDICAID BRACHYTHERAPY SOURCE, NON- C2699 STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE No MEDICAID Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq C5271 cm or less wound surface area No MEDICAID Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) C5272 No MEDICAID Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and C5273 children No MEDICAID Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

C5274 No MEDICAID

432 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area C5275 No MEDICAID Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) C5276 No MEDICAID Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children C5277 No MEDICAID Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

C5278 No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, C8900 ABDOMEN Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, C8901 ABDOMEN Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, C8902 ABDOMEN Yes MEDICAID MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; C8903 UNILATERAL Yes MEDICAID MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; C8904 UNILATERAL Yes MEDICAID MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; C8905 UNILATERAL Yes MEDICAID MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; C8906 BILATERAL Yes MEDICAID MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; C8907 BILATERAL Yes MEDICAID MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; C8908 BILATERAL Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) C8909 Yes MEDICAID

433 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST ( EXCLUDING MYOCARDIUM) C8910 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) C8911 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, C8912 LOWER EXTREMITY Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, C8913 LOWER EXTREMTIY Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, C8914 LOWER EXTREMTIY Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY W CONTRAST, PELVIS C8918 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, C8919 PELVIS Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, FOLLOWED BY WITH CONTRAST, C8920 PELVIS Yes MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL C8921 CARDIAC ANOMALIES; COMPLETE No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP C8922 OR LIMITED STUDY No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; C8923 COMPLETE No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY C8924 No MEDICAID TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, C8925 INTERPRETATION AND REPORT No MEDICAID TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND C8926 REPORT No MEDICAID

434 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2- DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS C8927 No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT C8928 No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M- MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER C8929 No MEDICAID TRANSTHORACIC ECHOCARDIOGRAPHY, WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M- MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE C8930 No MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS C8931 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS C8932 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS C8933 Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, C8934 UPPER EXTREMITY Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, C8935 UPPER EXTREMITY Yes MEDICAID MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, C8936 UPPER EXTREMITY Yes MEDICAID

435 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATE C8957 PROLONGED INFUSION No MEDICAID C9014 Injection, cerliponase alfa, 1 mg Yes MEDICAID Injection, c-1 esterase inhibitor (human), C9015 haegarda, 10 units Yes ExGEN MEDICAID Injection, triptorelin extended release, C9016 3.75 mg Yes MEDICAID Injection, liposomal, 1 mg daunorubicin C9024 and 2.27 mg cytarabine Yes MEDICAID Injection, inotuzumab ozogamicin, 0.1 mg C9028 Yes MEDICAID C9029 Injection, guselkumab, 1 mg Yes ExGEN MEDICAID C9030 Injection, copanlisib, 1 mg Yes ExGEN MEDICAID Lutetium Lu 177, dotatate, therapeutic, 1 C9031 mCi Yes ExGEN MEDICAID Injection, voretigene neparvovec-rzyl, 1 C9032 billion vector genome Yes ExGEN MEDICAID C9033 Injection, fosnetupitant 235 mg and palono Yes ExGEN MEDICAID C9034 Injection, dexamethasone 9%, intraocular, No MEDICAID INJECTION, PANTOPRAZOLE SODIUM, C9113 PER VIAL No MEDICAID PROTHROMBIN COMPLEX CONCENTRATE (HUMAN) KCENTRA, PER I.U. OF FACTOR IX ACTIVITY C9132 No MEDICAID INJECTION, CLEVIDIPIEN BUTYRATE, C9248 1 MG No MEDICAID HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT- C9250 DETERGENT (ARTISS), 2ML No MEDICAID C9254 INJECTION, LACOSAMIDE, 1 MG No MEDICAID C9257 INJECTION, BEVACIZUMAB, 0.25 MG No MEDICAID C9275 INJECTION, HEXAMINOLEVULINATE HYDROCHLORIDE, 100 MG, PER STUDY DOSE No MEDICAID Lidocaine 70 mg/tetracaine 70 mg, per C9285 patch No MEDICAID C9290 Injection, bupivicaine liposome, 1 mg No MEDICAID C9293 INJECTION, GLUCARPIDASE No MEDICAID MICROPOROUS COLLAGEN IMPLANTABLE TUBE (NEURAGEN NERVE GUIDE), PER CENTIMETER C9352 LENGTH Not Covered MEDICAID MICROPOROUS COLLAGEN IMPLANTABLE SLIT TUBE (NEURAWRAP NERVE PROTECTOR), PER CENTIMETER LENGTH C9353 Not Covered MEDICAID ACCELLULAR PERICARDIAL TISSUE MATRIX OF NON-HUMAN ORIGIN (VERITAS), PER SQUARE C9354 CENTIMETER Not Covered MEDICAID COLLAGEN NERVE CUFF (NEUROMATRIX), PER 0.5 C9355 CENTIMETER IN LENGTH No MEDICAID TENDON, POROUS MATRIX OF CROSS-LINKED COLLAGEN & GLYCOSAMINOGLYCAN MATRIX (TENOGLIDE TENDON PROTECTOR SHEET), PER SQUARE CENTIMETE C9356 Not Covered MEDICAID DERMAL SUBSTITUTE, NATIVE, NON- DENATURED COLLAGEN (SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE C9358 CENTIMETER Not Covered MEDICAID POROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (Integra Mozaik Osteoconductive Scaffold Putty, Integra OS Osteoconductive Scaffold C9359 Putty), per 0.5 cc No MEDICAID

436 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DERMAL SUBSTITUTE, NATIVE, NON- DENATURED COLLAGEN, NEONATAL BOVINE ORIGIN (SURGIMEND COLLAGEN MATRIX), PER 0.5 SQ C9360 CENTIMETERS Not Covered MEDICAID COLLAGEN MATRIX NERVE WRAP (NEUROMEND COLLAGEN NERVE WRAP), PER 0.5 CENTIMETER C9361 LENGTH No MEDICAID POROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (INTEGRA MOZAIK OSTEOCONDUCTIVE SCAFFOLD STRIP), PER 0.5 CC C9362 No MEDICAID SKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER C9363 SQUARE CENTIMETER No MEDICAID PORCINE IMPLANT, PERMACOL, PER C9364 SQUARE CENTIMETER Not Covered MEDICAID Skin substitute, Endoform Dermal C9367 Template, per square centimeter Not Covered MEDICAID UNCLASSIFIED DRUGS OR C9399 BIOLOGICALS No MEDICAID Injection, phenylephrine and ketorolac, 4 C9447 ml vial No MEDICAID Injection, cangrelor, 1 mg BETHESDA, MD 23 Jun 2015—FDA on June 22 announced the approval of cangrelor, a P2Y12 platelet inhibitor, to reduce the risk of thrombotic events in patients undergoing coronary angioplasty procedures. - See more at: http://www.ashp.org/menu/News/Pharma cyNews/NewsArticle.aspx?id=4222#sthas h.z8shlP37.dpuf C9460 No MEDICAID C9462 Injection, delafloxacin, 1 mg No MEDICAID C9463 Injection, aprepitant, 1 mg Yes ExGEN MEDICAID C9464 Injection, rolapitant, 0.5 mg Yes ExGEN MEDICAID C9465 Hyaluronan or derivative, Durolane, for intra-articular injection, per dose No MEDICAID C9466 Injection, benralizumab, 1 mg Yes ExGEN MEDICAID C9467 Injection, rituximab and hyaluronidase, 10 mg Yes ExGEN MEDICAID Injection, factor ix (antihemophilic factor, recombinant), glycopegylated, Rebinyn, 1 C9468 i.u. Yes ExGEN MEDICAID C9482 Injection, sotalol hydrochloride, 1 mg No MEDICAID Injection, conivaptan hydrochloride, 1 mg C9488 Yes ExGEN MEDICAID C9492 Injection, durvalumab, 10 mg Yes ExGEN MEDICAID C9493 Injection, edaravone, 1 mg Yes ExGEN MEDICAID C9497 Loxapine, inhalation powder, 10 mg No MEDICAID C9600 Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed;ásingle major coronary artery or branch No MEDICAID C9601 Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed;á each additional branch of a major coronary artery (list separately in addition to code for primary procedure) No MEDICAID C9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed;ásingle major coronary artery or branch No MEDICAID

437 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines C9603 Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed;áeach additional branch of a major coronary artery (list separately in addition to code for primary procedure) No MEDICAID C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;ásingle vessel No MEDICAID C9605 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;á each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure)

No MEDICAID C9606 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel No MEDICAID C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty;ásingle vessel No MEDICAID C9608 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty;á each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) No MEDICAID CREATIONS OF THERMAL ANAL LESIONS BY RADIOFREQUENCY C9716 ENERGY Not Covered MEDICAID ENDOSCOPIC FULL-THICKNESS PLICATION IN THE GASTRIC CARDIA C9724 USING No MEDICAID PLACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR C9725 BRACHYTHERAPY No MEDICAID PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATION THERAPY C9726 No MEDICAID

438 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INSERTION OF IMPLANTS INTO THE SOFT PALATE; MINIMUM OF THREE C9727 IMPLANTS Not Covered MEDICAID PLACEMENT OF INTERSTITIAL C9728 DEVICE(S) FOR RADIATION THERAPY/SURGERY GUIDANCE No MEDICAID Non-ophthalmic fluorescent vascular C9733 angiography No MEDICAID Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with or without magnetic resonance (MR) guidance C9734 No MEDICAID Laparoscopy, surgical, esophageal sphincter augmentation with device (eg, C9737 magnetic band) No MEDICAID Adjunctive blue light cystoscopy with fluorescent imaging agent (list separately in addition to code for primary procedure) C9738 No MEDICAID Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants C9739 No MEDICAID Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants C9740 No MEDICAID Right heart catheterization with implantation of wireless pressure sensor in the pulmonary artery, including any type of measurement, angiography, imaging supervision, interpretation, and report, includes provision of patient home electronics unit C9741 No MEDICAID Laryngoscopy, flexible fiberoptic, with injection into vocal cord(s), therapeutic, including diagnostic laryngoscopy, if C9742 performed No MEDICAID C9744 Ultrasound, abdominal, with contrast No MEDICAID Nasal endoscopy, surgical; balloon C9745 dilation of eustachian tube No MEDICAID Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed C9746 Not Covered MEDICAID Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), C9747 including imaging guidance No MEDICAID Transurethral destruction of prostate tissue; by radiofrequency water vapor C9748 (steam) thermal therapy No MEDICAID Repair of nasal vestibular lateral wall C9749 stenosis with implant(s) No MEDICAID C9750 Insertion or removal and replacement of int Yes MEDICAID RADIOLABELED PRODUCT PROVIDED DURING A HOSPTIAL INPATIENT STAY C9898 No MEDICAID IMPLANTED PROSTHETIC DEVICE, PAYABLE ONLY FOR INPATIENTS WHO DO NOT HAVE INPATIENT C9899 COVERAGE Not Covered MEDICAID PERIODIC ORAL EVALUATION- D0120 ESTABLISHED PATIENT Not Covered MEDICAID LIMITED ORAL EVALUATION - D0140 PROBLEM FOCUSED Not Covered MEDICAID ORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE AND COUNSELING WITH PRIMARY D0145 CAREGIVER Not Covered MEDICAID

439 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPREHENSIVE ORAL EVALUATION D0150 Not Covered MEDICAID DETAILED AND EXTENSIVE ORAL EVALUATION - PROBLEM FOCUSED, D0160 BY REPORT Not Covered MEDICAID REEVALUATION LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; D0170 NOT POST OPERATIVE VISIT) Not Covered MEDICAID D0171 Re-eval post-op visit Not Covered MEDICAID COMPREHENSIVE PERIDONATAL EVALUATION - NEW OR ESTABLISHED D0180 PATIENT Not Covered MEDICAID D0190 Screening of a patient No MEDICAID D0191 Assessment of a patient Not Covered MEDICAID INTRAORAL-COMPLETE SERIES D0210 (INCLUDING BITEWINGS) Not Covered MEDICAID INTRAORAL-PERIAPICAL-FIRST FILM D0220 Not Covered MEDICAID INTRAORAL-PERIAPICAL-EACH D0230 ADDITIONAL FILM Not Covered MEDICAID D0240 INTRAORAL-0CCLUSAL FILM Not Covered MEDICAID D0250 EXTRAORAL-FIRST FILM Not Covered MEDICAID D0270 BITEWING-SINGLE FILM Not Covered MEDICAID D0272 BITEWINGS-TWO FILMS Not Covered MEDICAID D0273 BITEWINGS - THREE FILMS Not Covered MEDICAID D0274 BITEWINGS-FOUR FILMS Not Covered MEDICAID D0277 VERTICAL BITEWINGS 7 TO 8 FILMS Not Covered MEDICAID POSTERIOR-ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY D0290 FILM Not Covered MEDICAID D0310 SIALOGRAPHY Not Covered MEDICAID TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING D0320 INJECTION Not Covered MEDICAID OTHER TEMPOROMANDIBULAR JOINT D0321 FILMS, BY REPORT Not Covered MEDICAID D0322 TOMOGRAPHIC SURVEY Not Covered MEDICAID D0330 PANORAMIC FILM Not Covered MEDICAID D0340 CEPHALOMETRIC FILM Not Covered MEDICAID ORAL/FACIAL PHOTOGRAPHIC D0350 IMAGES Not Covered MEDICAID D0351 3d photographic image Not Covered MEDICAID CONE BEAM CT - CRANIOFACIAL D0360 DATA CAPTURE Not Covered MEDICAID CONE BEAM - TWO-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA, INCLUDES MULTIPLE D0362 IMAGES Not Covered MEDICAID CONE BEAM - THREE-DIMENSIONAL IMAGE RECONSTRUCTION USING EXISTING DATA, INCLUDES MULTIPLE IMAGES D0363 Not Covered MEDICAID D0364 Cone beam ct capt & interp Not Covered MEDICAID D0365 Cone beam ct interprete man Not Covered MEDICAID D0366 Cone beam ct interprete max Not Covered MEDICAID D0367 Cone beam ct interp both jaw Not Covered MEDICAID D0368 Cone beam ct interprete tmj Not Covered MEDICAID D0369 Max mri capture & interprete Not Covered MEDICAID D0370 Max ultrasound capt & interp Not Covered MEDICAID D0371 Sialoendoscopy capt & interp Not Covered MEDICAID D0380 Cone beam ct capture limited Not Covered MEDICAID D0381 Cone beam ct capt mandible Not Covered MEDICAID D0382 Cone beam ct capt maxilla Not Covered MEDICAID D0383 Cone beam ct both jaws Not Covered MEDICAID D0384 Cone beam ct capture tmj Not Covered MEDICAID D0385 Max mri image capture Not Covered MEDICAID D0386 Max ultrasound image capture Not Covered MEDICAID D0391 Imterprete diagnostic image Not Covered MEDICAID

440 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines D0393 Trtmnt simulation 3d image Not Covered MEDICAID D0394 Digital sub 2 or more images Not Covered MEDICAID D0395 Fusion 2 or more 3d images Not Covered MEDICAID COLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITY D0415 Not Covered MEDICAID D0416 VIRAL CULTURE Not Covered MEDICAID COLLECTION AND PREPARATION OF SALIVA SAMPLE FOR LABORATORY DIAGNOSTIC TESTING D0417 Not Covered MEDICAID D0418 ANALYSIS OF SALIVA SAMPLE Not Covered MEDICAID D0425 CARIES SUSCEPTIBILITY TESTS Not Covered MEDICAID ADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN DETECTION OF D0431 MUCOSAL ABNORMALITIES Not Covered MEDICAID D0460 PULP VITALITY TESTS Not Covered MEDICAID D0470 DIAGNOSTIC CASTS Not Covered MEDICAID ACCESSION OF TISSUE, GROSS EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT D0472 Not Covered MEDICAID ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION D0473 OF WRITTEN REPORT Not Covered MEDICAID ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINATION, INCLUDING ASSESSMENT OF SURGICAL MARGINS FOR PRESENCE OF DISEASE, PREPARATION AND TRANSMISSION OF WRITTEN REPORT D0474 Not Covered MEDICAID D0475 DECALCIFICATION PROCEDURE Not Covered MEDICAID SPECIAL STAINS FOR D0476 MICROORGANISMS Not Covered MEDICAID SPECIAL STAINS, NOT FOR D0477 MICROORGANISMS Not Covered MEDICAID D0478 IMMUNOHISTOCHEMICAL STAINS Not Covered MEDICAID TISSUE IN-SITU HYBRIDIZATION, D0479 INCLUDING INTERPRETATION Not Covered MEDICAID ACCESSION OF EXFOLIATIVE CYTOLOGIC SMEARS, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT D0480 Not Covered MEDICAID ELECTRON MICROSCOPY - D0481 DIAGNOSTIC Not Covered MEDICAID D0482 DIRECT IMMUNOFLUORESCENCE Not Covered MEDICAID INDIRECT IMMUNOFLUORESCENCE D0483 Not Covered MEDICAID CONSULTATION ON SLIDES D0484 PREPARED ELSEWHERE Not Covered MEDICAID CONSULTATION, INCLUDING PREPARATION OF SLIDES FROM D0485 BIOPSY MATERIAL SUPPLIED BY Not Covered MEDICAID ACCESSION OF BRUSH BIOPSY SAMPLE, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT D0486 Not Covered MEDICAID OTHER ORAL PATHOLOGY D0502 PROCEDURES, BY REPORT Not Covered MEDICAID Neurological with Motor D0601 >47.75comorbidity in tier 3 Not Covered MEDICAID Neurological with Motor >37.35 & Motor D0602 <47.75comorbidity in tier 3 Not Covered MEDICAID Neurological with Motor >25.85 & Motor D0603 <37.35comorbidity in tier 3 Not Covered MEDICAID UNSPECIFIED DIAGNOSTIC D0999 PROCEDURE, BY REPORT Not Covered MEDICAID

441 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines D1110 PROPHYLAXIS-ADULT Not Covered MEDICAID D1120 PROPHYLAXIS-CHILD Not Covered MEDICAID TOPICAL APPLICATION OF FLUORIDE (PROPHYLAXIS NOT INCLUDED)- D1203 CHILD Not Covered MEDICAID TOPICAL APPLICATION OF FLUORIDE (PROPHYLAXIS NOT INCLUDED)- D1204 ADULT Not Covered MEDICAID TOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR MODERATE TO HIGH CARIES RISK D1206 PATIENTS Not Covered MEDICAID D1208 Topical app fluorid ex vrnsh Not Covered MEDICAID NUTRITIONAL COUNSELING FOR THE CONTROL OF DENTAL DISEASE D1310 Not Covered MEDICAID TOBACCO COUNSELING FOR THE CONTROL AND PREVENTION OF D1320 ORAL DISEASE Not Covered MEDICAID D1330 ORAL HYGIENE INSTRUCTION Not Covered MEDICAID D1351 SEALANT-PER TOOTH Not Covered MEDICAID D1352 Prev resin rest, perm tooth Not Covered MEDICAID D1353 Sealant repair per tooth Not Covered MEDICAID SPACE MAINTAINER-FIXED D1510 UNILATERAL Not Covered MEDICAID SPACE MAINTAINER-FIXED D1515 BILATERAL Not Covered MEDICAID SPACE MAINTAINER-REMOVABLE D1520 UNILATERAL Not Covered MEDICAID SPACE MAINTAINER-REMOVABLE D1525 BILATERAL Not Covered MEDICAID RECEMENTATION OF SPACE D1550 MAINTAINER Not Covered MEDICAID REMOVAL OF FIXED SPACE D1555 MAINTAINER Not Covered MEDICAID D1999 Unspecified preventive proc Not Covered MEDICAID AMALGAM-ONE SURFACE, PRIMARY D2140 OR PERMANENT Not Covered MEDICAID AMALGAM-TWO SURFACES, PRIMARY D2150 OR PERMANENT Not Covered MEDICAID AMALGAM-THREE SURFACES, D2160 PRIMARY OR PERMANENT Not Covered MEDICAID AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR D2161 PERMANENT Not Covered MEDICAID D2330 RESIN-ONE SURFACE, ANTERIOR Not Covered MEDICAID D2331 RESIN-TWO SURFACES, ANTERIOR Not Covered MEDICAID RESIN-THREE SURFACES, ANTERIOR D2332 Not Covered MEDICAID RESIN-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE D2335 (ANTERIOR) Not Covered MEDICAID RESIN-BASED COMPOSITE CROWN, D2390 ANTERIOR Not Covered MEDICAID RESIN-BASED COMPOSITE - ONE D2391 SURFACE, POSTERIOR Not Covered MEDICAID RESIN-BASED COMPOSITE - TWO D2392 SURFACES, POSTERIOR Not Covered MEDICAID RESIN-BASED COMPOSITE - THREE D2393 SURFACES, POSTERIOR Not Covered MEDICAID RESIN-BASED COMPOSITE - FOUR OR D2394 MORE SURFACES, POSTERIOR Not Covered MEDICAID D2410 GOLD FOIL-ONE SURFACE Not Covered MEDICAID D2420 GOLD FOIL-TWO SURFACES Not Covered MEDICAID D2430 GOLD FOIL-THREE SURFACES Not Covered MEDICAID D2510 INLAY-METALLIC-ONE SURFACE Not Covered MEDICAID D2520 INLAY-METALLIC-TWO SURFACES Not Covered MEDICAID INLAY-METALLIC-THREE OR MORE D2530 SURFACES Not Covered MEDICAID D2542 ONLAY-METALLIC-TWO SURFACES Not Covered MEDICAID

442 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ONLAY - METALLIC - THREE D2543 SURFACES Not Covered MEDICAID ONLAY - METALLIC - FOUR OR MORE D2544 SURFACES Not Covered MEDICAID INLAY-PORCELAIN/CERAMIC-ONE D2610 SURFACE Not Covered MEDICAID INLAY-PORCELAIN/CERAMIC-TWO D2620 SURFACES Not Covered MEDICAID INLAY-PORCELAIN/CERAMIC-THREE D2630 OR MORE SURFACES Not Covered MEDICAID ONLAY - PORCELAIN/CERAMIC - TWO D2642 SURFACES Not Covered MEDICAID ONLAY - PORCELAIN/CERAMIC - D2643 THREE SURFACES Not Covered MEDICAID ONLAY - PORCELAIN/CERAMIC - FOUR D2644 OR MORE SURFACES Not Covered MEDICAID INLAY - RESIN-BASED COMPOSITE - D2650 ONE SURFACE Not Covered MEDICAID INLAY - RESIN-BASED COMPOSITE - D2651 TWO SURFACES Not Covered MEDICAID INLAY - RESIN-BASED COMPOSITE - D2652 THREE OR MORE SURFACES Not Covered MEDICAID ONLAY - RESIN-BASED COMPOSITE - D2662 TWO SURFACES Not Covered MEDICAID ONLAY - RESIN-BASED COMPOSITE - D2663 THREE SURFACES Not Covered MEDICAID ONLAY - - RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES D2664 Not Covered MEDICAID CROWN - RESIN-BASED COMPOSITE D2710 (INDIRECT) Not Covered MEDICAID CROWN - 3/4 RESIN-BASED D2712 COMPOSITE (INDIRECT) Not Covered MEDICAID CROWN-RESIN WITH HIGH NOBLE D2720 METAL Not Covered MEDICAID CROWN-RESIN WITH D2721 PREDOMINANTLY BASE METAL Not Covered MEDICAID CROWN-RESIN WITH NOBLE METAL D2722 Not Covered MEDICAID CROWN-PORCELAIN/CERAMIC D2740 SUBSTRATE Not Covered MEDICAID CROWN-PORCELAIN FUSED TO HIGH D2750 NOBLE METAL Not Covered MEDICAID CROWN-PROCELAIN FUSED TO D2751 PREDOMINANTLY BASE METAL Not Covered MEDICAID CROWN-PORCELAIN FUSED TO D2752 NOBLE METAL Not Covered MEDICAID CROWN - 3/4 CAST HIGH NOBLE D2780 METAL Not Covered MEDICAID CROWN - 3/4 CAST PREDOMINANTLY D2781 BASE METAL Not Covered MEDICAID D2782 CROWN - 3/4 CAST NOBLE METAL Not Covered MEDICAID D2783 CROWN - 3/4 PORCELAIN/CERAMIC Not Covered MEDICAID CROWN-FULL CAST HIGH NOBLE D2790 METAL Not Covered MEDICAID CROWN-FULL CAST PREDOMINANTLY D2791 BASE METAL Not Covered MEDICAID D2792 CROWN-FULL CAST NOBLE METAL Not Covered MEDICAID D2794 CROWN-TITANIUM Not Covered MEDICAID D2799 PROVISIONAL CROWN Not Covered MEDICAID RECEMENT INLAY, ONLAY OR PARTIAL COVERAGE RESTORATION D2910 Not Covered MEDICAID RECEMENT CAST OR D2915 PREFABRICATED POST AND CORE Not Covered MEDICAID D2920 RECEMENT CROWN Not Covered MEDICAID D2921 Reattach tooth fragment Not Covered MEDICAID D2929 Prefab porc/ceram crown pri Not Covered MEDICAID PREFABRICATED STAINLESS STEEL D2930 CROWN-PRIMARY TOOTH Not Covered MEDICAID

443 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH D2931 Not Covered MEDICAID D2932 PREFABRICATED RESIN CROWN Not Covered MEDICAID PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW D2933 Not Covered MEDICAID PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY D2934 TOOTH Not Covered MEDICAID D2940 SEDATIVE FILLING Not Covered MEDICAID D2941 Int therapeutic restoration Not Covered MEDICAID D2949 Restorative foundation Not Covered MEDICAID CORE BUILD-UP, INCLUDING ANY D2950 PINS Not Covered MEDICAID PIN RETENTION-PER TOOTH, IN D2951 ADDITION TO RESTORATION Not Covered MEDICAID POST AND CORE IN ADDITION TO D2952 CROWN, INDIRECTLY FABRICATED Not Covered MEDICAID EACH ADDITIONAL INDIRECTLY D2953 FABRICATED POST - SAME TOOTH Not Covered MEDICAID PREFABRICATED POST AND CORE IN D2954 ADDITION TO CROWN Not Covered MEDICAID POST REMOVAL (NOT IN CONJUCTION WITH ENDODONTIC D2955 THERAPY) Not Covered MEDICAID EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH D2957 Not Covered MEDICAID LABIAL VENEER (LAMINATE)- D2960 CHAIRSIDE Not Covered MEDICAID LABIAL VENEER (RESIN LAMINATE)- D2961 LABORATORY Not Covered MEDICAID LABIAL VENEER (PORCELAIN D2962 LAMINATE)-LABORATORY Not Covered MEDICAID ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN UNDER EXISTING PARTIAL DENTURE D2971 FRAMEWORK Not Covered MEDICAID D2975 COPING Not Covered MEDICAID D2980 CROWN REPAIR, BY REPORT Not Covered MEDICAID D2981 Inlay repair Not Covered MEDICAID D2982 Onlay repair Not Covered MEDICAID D2983 Veneer repair Not Covered MEDICAID D2990 Resin infiltration of lesion Not Covered MEDICAID UNSPECIFIED RESTORATIVE D2999 PROCEDURE, BY REPORT Not Covered MEDICAID PULP CAP-DIRECT (EXCLUDING FINAL D3110 RESTORATION) Not Covered MEDICAID PULP CAP-INDIRECT (EXCLUDING D3120 FINAL RESTORATION) Not Covered MEDICAID THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT D3220 Not Covered MEDICAID PULPAL DEBRIDEMENT, PRIMARY D3221 AND PERMANENT TEETH Not Covered MEDICAID PARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOT D3222 DEVELOPMENT Not Covered MEDICAID PULPAL THERAPY (RESORBABLE FILLING)-ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) D3230 Not Covered MEDICAID PULPAL THERAPY (RESORBABLE FILLING)-POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL D3240 RESTORATION) Not Covered MEDICAID

444 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ANTERIOR (EXCLUDING FINAL D3310 RESTORATION) Not Covered MEDICAID BICUSPID (EXCLUDING FINAL D3320 RESTORATION) Not Covered MEDICAID MOLAR (EXCLUDING FINAL D3330 RESTORATION) Not Covered MEDICAID TREATMENT OF ROOT CANAL OBSTRUCTION; NON-SURGICAL D3331 ACCESS Not Covered MEDICAID INCOMPLETE ENDODONTIC THERAPY; INOPERABLE, UNRESTORABLE OR FRACTURED D3332 TOOTH Not Covered MEDICAID INTERNAL ROOT REPAIR OF D3333 PERFORATION DEFECTS Not Covered MEDICAID RETREATMENT OF PREVIOUS ROOT D3346 CANAL THERAPY-ANTERIOR Not Covered MEDICAID RETREATMENT OF PREVIOUS ROOT D3347 CANAL THERAPY-BICUSPID Not Covered MEDICAID RETREATMENT OF PREVIOUS ROOT D3348 CANAL THERAPY-MOLAR Not Covered MEDICAID APEXIFICATION/RECALCIFICATION- INITIAL VISIT (APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, D3351 ETC.) Not Covered MEDICAID APEXIFICATION/RECALCIFICATION- INTERIM MEDICATION REPLACEMENT (APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.) D3352 Not Covered MEDICAID APEXIFICATION/RECALCIFICATION- FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY-APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT RESORPTION, ETC.) D3353 Not Covered MEDICAID D3355 Pulpal regeneration initial Not Covered MEDICAID D3356 Pulpal regeneration interim Not Covered MEDICAID D3357 Pulpal regeneration complete Not Covered MEDICAID APICOECTOMY/PERIRADICULAR D3410 SURGERY-ANTERIOR Not Covered MEDICAID APICOECTOMY/PERIRADICULAR D3421 SURGERY-BICUSPID (FIRST ROOT) Not Covered MEDICAID APICOECTOMY/PERIRADICULAR D3425 SURGERY-MOLAR (FIRST ROOT). Not Covered MEDICAID APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT) D3426 Not Covered MEDICAID D3427 Periradicular surgery Not Covered MEDICAID D3428 Bone graft peri per tooth Not Covered MEDICAID D3429 Bone graft peri each addl Not Covered MEDICAID D3430 RETROGRADE FILLING-PER ROOT Not Covered MEDICAID D3431 Biological materials Not Covered MEDICAID D3432 Guided tissue regeneration Not Covered MEDICAID D3450 ROOT AMPUTATION-PER ROOT Not Covered MEDICAID ENDODONTIC ENDOSSEOUS IMPLANT D3460 Not Covered MEDICAID INTENTIONAL REPLANTATION (INCLUDING NECESSARY SPLINTING) D3470 Not Covered MEDICAID SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER D3910 DAM Not Covered MEDICAID HEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCLUDING ROOT D3920 CANAL THERAPY Not Covered MEDICAID CANAL PREPARATION AND FITTING D3950 OF PREFORMED DOWEL OR POST Not Covered MEDICAID

445 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNSPECIFIED ENDODONTIC D3999 PROCEDURE, BY REPORT Not Covered MEDICAID GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT D4210 Not Covered MEDICAID GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT D4211 Not Covered MEDICAID D4212 Gingivectomy/plasty rest Not Covered MEDICAID ANATOMICAL CROWN EXPOSURE - FOUR OR MORE CONTIGUOUS TEETH D4230 PER QUADRANT Not Covered MEDICAID ANATOMICAL CROWN EXPOSURE - ONE TO THREE TEETH PER D4231 QUADRANT Not Covered MEDICAID GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER D4240 QUADRANT Not Covered MEDICAID GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER D4241 QUADRANT Not Covered MEDICAID D4245 APICALLY POSITIONED FLAP Not Covered MEDICAID CLINICAL CROWN LENGTHENING- D4249 HARD TISSUE Not Covered MEDICAID OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER D4260 QUADRANT Not Covered MEDICAID BONE REPLACEMENT GRAFT - FIRST D4261 SITE IN QUADRANT Not Covered MEDICAID BONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANT D4263 Not Covered MEDICAID BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS TISSUE D4264 REGENERATION Not Covered MEDICAID GUIDED TISSUE REGENERATION - D4265 RESORBABLE BARRIER, PER SITE Not Covered MEDICAID GUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER, PER SITE, (INCLUDES MEMBRANE D4266 REMOVAL) Not Covered MEDICAID SURGICAL REVISION PROCEDURE, D4267 PER TOOTH Not Covered MEDICAID PEDICLE SOFT TISSUE GRAFT D4268 PROCEDURE Not Covered MEDICAID FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR D4270 SITE SURGERY) Not Covered MEDICAID SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTH D4271 Not Covered MEDICAID DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN CONJUCTION WITH SURGICAL PROCEDURES IN THE D4273 SAME ANATOMICAL AREA) Not Covered MEDICAID D4274 SOFT TISSUE ALLOGRAFT Not Covered MEDICAID COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT, PER D4275 TOOTH Not Covered MEDICAID

446 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PROVISIONAL SPLINTING- D4276 INTRACORONAL Not Covered MEDICAID D4277 Soft tissue graft firsttooth Not Covered MEDICAID D4278 Soft tissue graft addl tooth Not Covered MEDICAID PROVISIONAL SPLINTING- D4320 EXTRACORONAL Not Covered MEDICAID PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH D4321 PER QUADRANT Not Covered MEDICAID PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, D4341 PER QUADRANT Not Covered MEDICAID FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE D4342 EVALUATION AND DIAGNOSIS Not Covered MEDICAID LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED RELEASE VEHICLE INTO DISEASED CREVICULAR TISSUE, D4355 PER TOOTH, BY REPORT Not Covered MEDICAID D4381 PERIODONTAL MAINTENANCE Not Covered MEDICAID UNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN D4910 TREATING DENTIST) Not Covered MEDICAID UNSPECIFIED PERIODONTAL D4920 PROCEDURE, BY REPORT Not Covered MEDICAID D4921 Gingival irrigation per quad Not Covered MEDICAID D4999 COMPLETE DENTURE - MAXILLARY Not Covered MEDICAID COMPLETE DENTURE - MANDIBULAR D5110 Not Covered MEDICAID D5120 IMMEDIATE DENTURE - MAXILLARY Not Covered MEDICAID IMMEDIATE DENTURE - MANDIBULAR D5130 Not Covered MEDICAID UPPER PARTIAL-RESIN BASE (INCLUDING ANY CONVENTIONAL D5140 CLASPS, RESTS AND TEETH) Not Covered MEDICAID LOWER PARTIAL-RESIN BASE (INCLUDING ANY CONVENTIONAL D5211 CLASPS, RESTS AND TEETH) Not Covered MEDICAID MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS D5212 AND TEETH) Not Covered MEDICAID MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS D5213 AND TEETH) Not Covered MEDICAID MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS,RESTS D5214 AND TEETH) Not Covered MEDICAID MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY D5225 CLASPS, RESTS AND Not Covered MEDICAID MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE (INCLUDING ANY D5226 CLASPS, RESTS AND Not Covered MEDICAID REMOVABLE UNILATERAL PARTIAL DENTURE-ONE PIECE CAST METAL D5281 (INCLUDING CLASPS AND TEETH) Not Covered MEDICAID ADJUST COMPLETE DENTURE - D5410 MAXILLARY Not Covered MEDICAID ADJUST COMPLETE DENTURE - D5411 MAXILLARY Not Covered MEDICAID ADJUST COMPLETE DENTURE - D5421 MANDIBULAR Not Covered MEDICAID ADJUST PARTIAL DENTURE - D5422 MAXILLARY Not Covered MEDICAID

447 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ADJUST PARTIAL DENTURE - D5510 MANDIBULAR Not Covered MEDICAID REPAIR BROKEN COMPLETE D5520 DENTURE BASE Not Covered MEDICAID REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH D5610 TOOTH) Not Covered MEDICAID D5620 REPAIR RESIN DENTURE BASE Not Covered MEDICAID D5630 REPAIR CAST FRAMEWORK Not Covered MEDICAID REPAIR OR REPLACE BROKEN CLASP D5640 Not Covered MEDICAID REPLACE BROKEN TEETH-PER D5650 TOOTH Not Covered MEDICAID ADD TOOTH TO EXISTING PARTIAL D5660 DENTURE Not Covered MEDICAID ADD CLASP TO EXISTING PARTIAL D5670 DENTURE Not Covered MEDICAID REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK D5671 (MAXILLARY) Not Covered MEDICAID REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK D5710 (MANDIBULAR) Not Covered MEDICAID REBASE COMPLETE MAXILLARY D5711 DENTURE Not Covered MEDICAID REBASE COMPLETE MANDIBULAR D5720 DENTURE Not Covered MEDICAID REBASE MAXILLARY PARTIAL D5721 DENTURE Not Covered MEDICAID REBASE MANDIBULAR PARTIAL D5730 DENTURE Not Covered MEDICAID RELINE COMPLETE MAXILLARY D5731 DENTURE (CHAIRSIDE) Not Covered MEDICAID RELINE LOWER COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) D5740 Not Covered MEDICAID RELINE MAXILLARY PARTIAL D5741 DENTURE (CHAIRSIDE) Not Covered MEDICAID RELINE MANDIBULAR PARTIAL D5750 DENTURE (CHAIRSIDE) Not Covered MEDICAID RELINE COMPLETE MAXILLARY D5751 DENTURE (LABORATORY) Not Covered MEDICAID RELINE COMPLETE MANDIBULAR D5760 DENTURE (LABORATORY) Not Covered MEDICAID RELINE MAXILLARY PARTIAL D5761 DENTURE (LABORATORY) Not Covered MEDICAID RELINE MANDIBULAR PARTIAL D5810 DENTURE (LABORATORY) Not Covered MEDICAID INTERIM COMPLETE DENTURE D5811 (MAXILLARY) Not Covered MEDICAID INTERIM COMPLETE DENTURE D5820 (MANDIBULAR) Not Covered MEDICAID INTERIM PARTIAL DENTURE D5821 (MAXILLARY) Not Covered MEDICAID INTERIM PARTIAL DENTURE D5850 (MANDIBULAR) Not Covered MEDICAID D5851 TISSUE CONDITIONING, MAXILLARY Not Covered MEDICAID TISSUE CONDITIONING, MANDIBULAR D5860 Not Covered MEDICAID OVERDENTURE-COMPLETE, BY D5861 REPORT Not Covered MEDICAID OVERDENTURE-PARTIAL, BY REPORT D5862 Not Covered MEDICAID D5863 Overdenture complete max Not Covered MEDICAID D5864 Overdenture partial max Not Covered MEDICAID D5865 Overdenture complete mandib Not Covered MEDICAID D5866 Overdenture partial mandib Not Covered MEDICAID REPLACEMENT OF REPLACEABLE PART OF SEMIPRECISION OR PRECISION ATTACHMENT (MALE OR D5867 FEMALE COMPONENT) Not Covered MEDICAID

448 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MODIFICATION OF REMOVABLE PROSTHESIS FOLLOWING IMPLANT D5875 SURGERY Not Covered MEDICAID MODIFICATION OF REMOVABLE PROSTHESIS FOLLOWING IMPLANT D5899 SURGERY Not Covered MEDICAID UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE, BY D5911 REPORT Not Covered MEDICAID D5912 FACIAL MOULAGE (SECTIONAL) Not Covered MEDICAID D5913 FACIAL MOULAGE (COMPLETE) Not Covered MEDICAID D5914 NASAL PROSTHESIS Not Covered MEDICAID D5915 AURICULAR PROSTHESIS Not Covered MEDICAID D5916 ORBITAL PROSTHESIS Not Covered MEDICAID D5919 OCULAR PROSTHESIS Not Covered MEDICAID D5922 FACIAL PROSTHESIS Not Covered MEDICAID D5923 NASAL SEPTAL PROSTHESIS Not Covered MEDICAID D5924 OCULAR PROSTHESIS, INTERIM Not Covered MEDICAID D5925 CRANIAL PROSTHESIS Not Covered MEDICAID FACIAL AUGMENTATION IMPLANT D5926 PROSTHESIS Not Covered MEDICAID NASAL PROSTHESIS, REPLACEMENT D5927 Not Covered MEDICAID AURICULAR PROSTHESIS, D5928 REPLACEMENT Not Covered MEDICAID ORBITAL PROSTHESIS, D5929 REPLACEMENT Not Covered MEDICAID FACIAL PROSTHESIS, REPLACEMENT D5931 Not Covered MEDICAID OBTURATOR PROSTHESIS, D5932 SURGICAL Not Covered MEDICAID OBTURATOR PROSTHESIS, D5933 DEFINITIVE Not Covered MEDICAID OBTURATOR PROSTHESIS, D5934 MODIFICATION Not Covered MEDICAID MANDIBULAR RESECTION D5935 PROSTHESIS WITH GUIDE FLANGE Not Covered MEDICAID MANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE D5936 FLANGE Not Covered MEDICAID OBTURATOR/PROSTHESIS, INTERIM D5937 Not Covered MEDICAID TRISMUS APPLIANCE (NOT FOR TM D5951 TREATMENT) Not Covered MEDICAID D5952 FEEDING AID Not Covered MEDICAID SPEECH AID PROSTHESIS, PEDIATRIC D5953 Not Covered MEDICAID D5954 SPEECH AID PROSTHESIS, ADULT Not Covered MEDICAID PALATAL AUGMENTATION D5955 PROSTHESIS Not Covered MEDICAID PALATAL LIFT PROSTHESIS, D5958 DEFINITIVE Not Covered MEDICAID PALATAL LIFT PROSTHESIS, INTERIM D5959 Not Covered MEDICAID PALATAL LIFT PROSTHESIS, D5960 MODIFICATION Not Covered MEDICAID SPEECH AID PROSTHESIS, D5982 MODIFICATION Not Covered MEDICAID D5983 SURGICAL STENT Not Covered MEDICAID D5984 RADIATION CARRIER Not Covered MEDICAID D5985 RADIATION SHIELD Not Covered MEDICAID D5986 RADIATION CONE LOCATOR Not Covered MEDICAID D5987 FLUORIDE GEL CARRIER Not Covered MEDICAID D5988 COMMISSURE SPLINT Not Covered MEDICAID D5991 TOPICAL MEDICAMENT CARRIER Not Covered MEDICAID D5992 Adjust max prost appliance Not Covered MEDICAID D5993 Main/clean max prosthesis Not Covered MEDICAID D5994 Peridontal medicament Not Covered MEDICAID D5999 SURGICAL SPLINT Not Covered MEDICAID

449 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines UNSPECIFIED MAXILLOFACIAL D6010 PROSTHESIS, BY REPORT Not Covered MEDICAID D6011 Second stage implant surgery Not Covered MEDICAID SURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR TRANSITIONAL PROSTHESIS: ENDOSTEAL IMPLANT D6012 Not Covered MEDICAID D6013 Surgical place mini implant Not Covered MEDICAID ABUTMENT PLACEMENT OR SUBSTITUTION: ENDOSTEAL D6040 IMPLANT Not Covered MEDICAID SURGICAL PLACEMENT: EPOSTEAL D6050 IMPLANT Not Covered MEDICAID D6051 Interim abutment Not Covered MEDICAID D6052 Semi precision attach abut Not Covered MEDICAID SURGICAL PLACEMENT: D6053 TRANSOSTEAL IMPLANT Not Covered MEDICAID IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR D6054 COMPLETELY EDENTULOUS ARCH Not Covered MEDICAID IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR D6055 PARTIALLY EDENTULOUS ARCH Not Covered MEDICAID DENTAL IMPLANT SUPPORTED D6056 CONNECTING BAR Not Covered MEDICAID PREFABRICATED ABUTMENT - D6057 INCLUDES PLACEMENT Not Covered MEDICAID CUSTOM ABUTMENT - INCLUDES D6058 PLACEMENT Not Covered MEDICAID ABUTMENT SUPPORTED D6059 PORCELAIN/CERAMIC CROWN Not Covered MEDICAID ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH D6060 NOBLE METAL) Not Covered MEDICAID ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL) D6061 Not Covered MEDICAID ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE D6062 METAL) Not Covered MEDICAID ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL) D6063 Not Covered MEDICAID ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY BASE D6064 METAL) Not Covered MEDICAID ABUTMENT SUPPORTED CAST METAL D6065 CROWN (NOBLE METAL) Not Covered MEDICAID IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE D6066 METAL) Not Covered MEDICAID IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, D6067 HIGH NOBLE METAL) Not Covered MEDICAID IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, D6068 HIGH NOBLE METAL) Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPD D6069 Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINATELY BASE METAL) D6070 Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL D6071 FPD (NOBLE METAL) Not Covered MEDICAID

450 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL D6072 FPD (NOBLE METAL) Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE D6073 METAL) Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD D6074 (PREDOMINANTLY BASE METAL) Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE D6075 METAL) Not Covered MEDICAID IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (TITANIUM, TITANIUM ALLOY, OR D6076 HIGH NOLBE METAL) Not Covered MEDICAID IMPLANT SUPPORT RETAINER FOR CAST METAL FPD (TITANIUM, TITANIUM ALLOY, OR HIGH NOBLE D6077 METAL) Not Covered MEDICAID IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY D6078 EDENTULOUS ARCH Not Covered MEDICAID IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY D6079 EDENTULOUS ARCH Not Covered MEDICAID IMPLANT MAINTENANCE PROCEDUDRES, INCLUDING: REMOVAL OF PROSTHESIS, CLEANSING OF PROSTHESIS AND ABUTMEN REINSERTION OF D6080 PROSTHESIS Not Covered MEDICAID PROSTHESIS AND ABUTMEN D6090 REINSERTION OF PROSTHESIS Not Covered MEDICAID REPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT (MALE OR FEMALE COMPONENT) OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMENT D6091 Not Covered MEDICAID RECEMENT IMPLANT/ABUTMENT D6092 SUPPORTED CROWN Not Covered MEDICAID RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL D6093 DENTURE Not Covered MEDICAID ABUTMENT SUPPORTED CROWN - D6094 (TITANIUM) Not Covered MEDICAID ABUTMENT SUPPORTED CROWN - D6095 (TITANIUM) Not Covered MEDICAID REPAIR IMPLANT ABUTMENT, BY D6100 REPORT Not Covered MEDICAID D6101 Debridement of a periimplant Not Covered MEDICAID D6102 Debridement & contouring Not Covered MEDICAID D6103 Bone graft repair perimplant Not Covered MEDICAID D6104 Bone graft time of implant Not Covered MEDICAID D6110 Implnt/abut remov dent max Not Covered MEDICAID D6111 Implnt/abut remov dent mand Not Covered MEDICAID D6112 Imp/abut rem dent part max Not Covered MEDICAID D6113 Imp/abut rem dent part mand Not Covered MEDICAID D6114 Implnt/abut fixed dent max Not Covered MEDICAID D6115 Implnt/abut fixed dent mand Not Covered MEDICAID D6116 Imp/abut fixed dent part max Not Covered MEDICAID D6117 Imp/abut fixed dent part man Not Covered MEDICAID RADIOGRAPHIC/SURGICAL IMPLANT D6190 INDEX, BY REPORT Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - (TITANIUM) D6194 Not Covered MEDICAID ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - (TITANIUM) D6199 Not Covered MEDICAID

451 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PONTIC - INDIRECT RESIN BASED D6205 COMPOSITE Not Covered MEDICAID UNSPECIFIED IMPLANT PROCEDURE, D6210 BY REPORT Not Covered MEDICAID D6211 PONTIC-CAST HIGH NOBLE METAL Not Covered MEDICAID PONTIC-CAST PREDOMINANTLY BASE D6212 METAL Not Covered MEDICAID D6214 PONTIC - TITANIUM Not Covered MEDICAID D6240 PONTIC - TITANIUM Not Covered MEDICAID PONTIC-PORCELAIN FUSED TO HIGH D6241 NOBLE METAL Not Covered MEDICAID PONTIC-PORCELAIN FUSED TO D6242 PREDOMINANTLY BASE METAL Not Covered MEDICAID PONTIC-PORCELAIN FUSED TO D6245 NOBLE METAL Not Covered MEDICAID D6250 PONTIC - PORCELAIN/CERAMIC Not Covered MEDICAID PONTIC-RESIN WITH HIGH NOBLE D6251 METAL Not Covered MEDICAID PONTIC-RESIN WITH D6252 PREDOMINANTLY BASE METAL Not Covered MEDICAID D6253 PONTIC-RESIN WITH NOBLE METAL Not Covered MEDICAID D6545 PROVISIONAL PONTIC Not Covered MEDICAID RETAINER-CAST METAL FOR RESIN D6548 BONDED FIXED PROSTHESIS Not Covered MEDICAID D6549 Resin retainer Not Covered MEDICAID RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED D6600 PROSTHESIS Not Covered MEDICAID INLAY-PORCELAIN/CERAMIC, TWO D6601 SURFACES Not Covered MEDICAID INLAY - PORCELAIN/CERAMIC, THREE D6602 OR MORE SURFACES Not Covered MEDICAID INLAY - CAST HIGH NOBLE METAL, D6603 TWO SURFACES Not Covered MEDICAID INLAY - CAST HIGH NOBLE METAL, D6604 THREE OR MORE SURFACES Not Covered MEDICAID INLAY - CAST PREDOMINANTLY BASE D6605 METAL, TWO SURFACES Not Covered MEDICAID INLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACES D6606 Not Covered MEDICAID INLAY - CAST NOBLE METAL, TWO D6607 SURFACES Not Covered MEDICAID INLAY - CAST NOBLE METAL, THREE D6608 OR MORE SURFACES Not Covered MEDICAID ONLAY - PORCELAIN/CERAMIC, TWO D6609 SURFACES Not Covered MEDICAID ONLAY - PORCELAIN/CERAMIC, D6610 THREE OR MORE SURFACES Not Covered MEDICAID ONLAY - CAST HIGH NOBLE METAL, D6611 TWO SURFACES Not Covered MEDICAID ONLAY - CAST HIGH NOBLE METAL, D6612 THREE OR MORE SURFACES Not Covered MEDICAID ONLAY - CAST PREDOMINANTLY D6613 BASE METAL, TWO SURFACES Not Covered MEDICAID ONLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE D6614 SURFACES Not Covered MEDICAID ONLAY - CAST NOBLE METAL, TWO D6615 SURFACES Not Covered MEDICAID D6624 INLAY - TITANIUM Not Covered MEDICAID D6634 ONLAY - TITANIUM Not Covered MEDICAID CROWN - INDIRECT RESIN BASED D6710 COMPOSITE Not Covered MEDICAID CROWN - INDIRECT RESIN BASED D6720 COMPOSITE Not Covered MEDICAID CROWN-RESIN WITH HIGH NOBLE D6721 METAL Not Covered MEDICAID CROWN-RESIN WITH D6722 PREDOMINANTLY BASE METAL Not Covered MEDICAID

452 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CROWN-RESIN WITH NOBLE METAL D6740 Not Covered MEDICAID D6750 CROWN - PORCELAIN/CERAMIC Not Covered MEDICAID CROWN-PORCELAIN FUSED TO HIGH D6751 NOBLE METAL Not Covered MEDICAID CROWN-PORCELAIN FUSED TO D6752 PREDOMINANTLY BASE METAL Not Covered MEDICAID CROWN-PORCELAIN FUSED TO D6780 NOBLE METAL Not Covered MEDICAID CROWN-3/4 CAST HIGH NOBLE D6781 METAL Not Covered MEDICAID CROWN - 3/4 CAST PREDOMINANTLY D6782 BASED METAL Not Covered MEDICAID D6783 CROWN - 3/4 CAST NOBLE METAL Not Covered MEDICAID D6790 CROWN - 3/4 PORCELAIN/CERAMIC Not Covered MEDICAID CROWN-FULL CAST HIGH NOBLE D6791 METAL Not Covered MEDICAID CROWN-FULL CAST PREDOMINANTLY D6792 BASE METAL Not Covered MEDICAID D6793 CROWN-FULL CAST NOBLE METAL Not Covered MEDICAID D6794 CROWN - TITANIUM Not Covered MEDICAID D6920 CROWN - TITANIUM Not Covered MEDICAID D6930 CONNECTOR BAR Not Covered MEDICAID D6940 RECEMENT BRIDGE Not Covered MEDICAID D6950 STRESS BREAKER Not Covered MEDICAID POST AND CORE IN ADDITION TO FIXED PARTIAL DENTURE RETAINER, INDIRECTLY FABRICATED, REVISED D6970 1/07 Not Covered MEDICAID CAST POST AS PART OF BRIDGE D6972 RETAINER Not Covered MEDICAID PREFABRICATED POST AND CORE IN D6973 ADDITION TO BRIDGE RETAINER Not Covered MEDICAID CORE BUILD UP FOR RETAINER, D6975 INCLUDING ANY PINS Not Covered MEDICAID D6976 COPING-METAL Not Covered MEDICAID EACH ADDITIONAL INDIRECTLY D6977 FABRICATED POST - SAME TOOTH Not Covered MEDICAID EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH D6980 Not Covered MEDICAID D6985 BRIDGE REPAIR, BY REPORT Not Covered MEDICAID PEDIATRIC PARTIAL DENTURE, FIXED D6999 Not Covered MEDICAID UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY D7111 REPORT Not Covered MEDICAID EXTRACTION, CORONAL REMNANTS - D7140 DECIDUOUS TOOTH Not Covered MEDICAID SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTEAL FLAP AND REMOVAL OF BONE AND/OR SECTION D7210 OF TOOTH Not Covered MEDICAID AND REMOVAL OF BONE AND/OR D7220 SECTION OF TOOTH Not Covered MEDICAID REMOVAL OF IMPACTED TOOTH- D7230 SOFT TISSUE Not Covered MEDICAID REMOVAL OF IMPACTED TOOTH- D7240 PARTIALLY BONY Not Covered MEDICAID REMOVAL OF IMPACTED TOOTH- D7241 COMPLETELY BONY Not Covered MEDICAID REMOVAL OF IMPACTED TOOTH- COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS D7250 Not Covered MEDICAID D7251 Coronectomy Not Covered MEDICAID SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING D7260 PROCEDURE) Not Covered MEDICAID D7261 ORAL ANTRAL FISTULA CLOSURE Not Covered MEDICAID

453 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TOOTH RE-IMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH D7270 AND/OR ALVEOLUS Not Covered MEDICAID TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FROM ONE SITE TO ANOTHER AND D7272 SPLINTING AND/OR STABILIZATION) Not Covered MEDICAID D7280 SPLINTING AND/OR STABILIZATION) Not Covered MEDICAID SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH TO AID D7282 ERUPTION Not Covered MEDICAID PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED D7283 TOOTH Not Covered MEDICAID PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED D7285 TOOTH Not Covered MEDICAID BIOPSY OF ORAL TISSUE - HARD D7286 (BONE, TOOTH) Not Covered MEDICAID D7287 BIOPSY OF ORAL TISSUE - SOFT Not Covered MEDICAID BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION D7288 Not Covered MEDICAID BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION D7290 Not Covered MEDICAID SURGICAL REPOSITIONING OF TEETH D7291 Not Covered MEDICAID SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE [SCREW RETAINED PLATE] REQUIRING D7292 SURGICAL FLAP Not Covered MEDICAID SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE REQUIRING D7293 SURGICAL FLAP Not Covered MEDICAID SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE WITHOUT D7294 SURGICAL FLAP Not Covered MEDICAID D7295 Bone harvest,auto graft proc Not Covered MEDICAID ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, D7310 PER QUADRANT Not Covered MEDICAID ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE D7311 TEETH OR TOOTH Not Covered MEDICAID ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT D7320 Not Covered MEDICAID ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH D7321 Not Covered MEDICAID VESTIBULOPLASTY-RIDGE EXTENSION (SECOND D7340 EPITHELIALIZATION) Not Covered MEDICAID VESTIBULOPLASTY-RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE RE- ATTACHMENTS, REVISION OF SOFT D7350 TISSUE ATTACHMENT, AND MANA Not Covered MEDICAID HYPERTROPHIED AND D7410 HYPERPLASTIC TISSUE) Not Covered MEDICAID EXCISION OF BENIGN LESION UP TO D7411 1.25 CM Not Covered MEDICAID EXCISION OF BENIGN LESION D7412 GREATER THAN 1.25 CM Not Covered MEDICAID

454 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EXCISION OF BENIGN LESION, D7413 COMPLICATED Not Covered MEDICAID EXCISION OF MALIGNANT LESION UP D7414 TO 1.25 CM Not Covered MEDICAID EXCISION OF MALIGNANT LESION D7415 GREATER THAN 1.25 CM Not Covered MEDICAID EXCISION OF MALIGNANT LESION, D7440 COMPLICATED Not Covered MEDICAID EXCISION OF MALIGNANT TUMOR- D7441 LESION DIAMETER UP TO 1.25 CM Not Covered MEDICAID EXCISION OF MALIGNANT TUMOR- LESION DIAMETER GREATER THAN D7450 1.25 CM Not Covered MEDICAID REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER D7451 UP T0 1.25 CM Not Covered MEDICAID REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CM D7460 Not Covered MEDICAID REMOVAL OF NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER D7461 GREATER THAN 1.25 CM Not Covered MEDICAID DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, D7465 BY REPORT Not Covered MEDICAID DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, D7471 BY REPORT Not Covered MEDICAID REMOVAL OF LATERAL EXOSTOSIS D7472 (MAXILLA OR MANDIBLE) Not Covered MEDICAID D7473 REMOVAL OF TORUS PALATINUS Not Covered MEDICAID REMOVAL OF TORUS MANDIBULARIS D7485 Not Covered MEDICAID SURGICAL REDUCTION OF OSSEOUS D7490 TUBEROSITY Not Covered MEDICAID RADICAL RESECTION OF MAXILLA OR D7510 MANDIBLE Not Covered MEDICAID INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - D7511 COMPLICATED Not Covered MEDICAID (INCLUDES DRAINAGE OF MULTIPLE D7520 FASCIAL SPACES) Not Covered MEDICAID INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE D7521 - COMPLICATED Not Covered MEDICAID (INCLUDES DRAINAGE OF MULTIPLE D7530 FASCIAL SPACES) Not Covered MEDICAID REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE D7540 Not Covered MEDICAID REMOVAL OF REACTION-PRODUCING FOREIGN BODIES- D7550 MUSCULOSKELETAL SYSTEM Not Covered MEDICAID PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONE D7560 Not Covered MEDICAID MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR D7610 FOREIGN BODY Not Covered MEDICAID MAXILLA-OPEN REDUCTION (TEETH D7620 IMMOBILIZED IF PRESENT) Not Covered MEDICAID MAXILLA-CLOSED REDUCTION D7630 (TEETH IMMOBILIZED IF PRESENT) Not Covered MEDICAID MANDIBLE-OPEN REDUCTION (TEETH D7640 IMMOBILIZED IF PRESENT) Not Covered MEDICAID MANDIBLE-CLOSED REDUCTION D7650 (TEETH IMMOBILIZED IF PRESENT) Not Covered MEDICAID

455 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MALAR AND/OR ZYGOMATIC ARCH- D7660 OPEN REDUCTION Not Covered MEDICAID MALAR AND/OR ZYGOMATIC ARCH- D7670 CLOSED REDUCTION Not Covered MEDICAID ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF D7671 TEETH Not Covered MEDICAID FACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MUL- TIPLE SURGICAL APPROACHES D7680 Not Covered MEDICAID D7710 MAXILLA-OPEN REDUCTION Not Covered MEDICAID D7720 MAXILLA-OPEN REDUCTION Not Covered MEDICAID D7730 MAXILLA-CLOSED REDUCTION Not Covered MEDICAID D7740 MANDIBLE-OPEN REDUCTION Not Covered MEDICAID D7750 MANDIBLE-CLOSED REDUCTION Not Covered MEDICAID MALAR AND/OR ZYGOMATIC ARCH- D7760 OPEN REDUCTION Not Covered MEDICAID MALAR AND/OR ZYGOMATIC ARCH- D7770 CLOSED REDUCTION Not Covered MEDICAID ALVEOLUS - OPEN REDUCTION D7771 STABILIZATION OF TEETH Not Covered MEDICAID FACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES D7780 Not Covered MEDICAID OPEN REDUCTION OF DISLOCATION D7810 Not Covered MEDICAID CLOSED REDUCTION OF D7820 DISLOCATION Not Covered MEDICAID MANIPULATION UNDER ANESTHESIA D7830 Not Covered MEDICAID D7840 CONDYLECTOMY Not Covered MEDICAID SURGICAL DISCECTOMY; D7850 WITH/WITHOUT IMPLANT Not Covered MEDICAID D7852 DISC REPAIR Not Covered MEDICAID D7854 SYNOVECTOMY Not Covered MEDICAID D7856 MYOTOMY Not Covered MEDICAID D7858 JOINT RECONSTRUCTION Not Covered MEDICAID D7860 ARTHROTOMY Not Covered MEDICAID D7865 ARTHROPLASTY Not Covered MEDICAID D7870 ARTHROCENTESIS Not Covered MEDICAID NON-ARTHROSCOPIC LYSIS AND D7871 LAVAGE Not Covered MEDICAID ARTHROSCOPY-DIAGNOSIS, WITH OR D7872 WITHOUT BIOPSY Not Covered MEDICAID ARTHROSCOPY-SURGICAL: LAVAGE D7873 AND LYSIS OF ADHESIONS Not Covered MEDICAID ARTHROSCOPY-SURGICAL: DISC REPOSITIONING AND STABILIZATION D7874 Not Covered MEDICAID ARTHROSCOPY-SURGICAL: D7875 SYNOVECTOMY Not Covered MEDICAID ARTHROSCOPY-SURGICAL: D7876 DISCECTOMY Not Covered MEDICAID ARTHROSCOPY-SURGICAL: D7877 DEBRIDEMENT Not Covered MEDICAID D7880 OCCLUSAL ORTHOTIC APPLIANCE Not Covered MEDICAID UNSPECIFIED TMD THERAPY, BY D7899 REPORT Not Covered MEDICAID SUTURE OF RECENT SMALL WOUNDS D7910 UP TO 5 CM Not Covered MEDICAID COMPLICATED SUTURE-UP TO 5 CM D7911 Not Covered MEDICAID COMPLICATED SUTURE-GREATER D7912 THAN 5 CM Not Covered MEDICAID SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION, AND TYPE OF D7920 GRAFT) Not Covered MEDICAID D7921 Collect & appl blood product Not Covered MEDICAID

456 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines OSTEOPLASTY-FOR ORTHOGNATHIC D7940 DEFORMITIES Yes MEDICAID D7941 OSTEOTOMY - MANDIBULAR RAMI Not Covered MEDICAID OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES D7943 OBTAINING THE GRAFT Not Covered MEDICAID OSTEOTOMY-SEGMENTED OR D7944 SUBAPICAL Not Covered MEDICAID D7945 OSTEOTOMY-BODY OF MANDIBLE Not Covered MEDICAID D7946 LEFORT I (MAXILLA-TOTAL) Not Covered MEDICAID D7947 LEFORT I (MAXILLA-SEGMENTED) Not Covered MEDICAID LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION)-WITHOUT BONE GRAFT D7948 Not Covered MEDICAID LEFORT II OR LEFORT III-WITH BONE D7949 GRAFT Not Covered MEDICAID OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA - AUTOGENOUS OR D7950 NONAUTOGENOUS, BY REPORT Not Covered MEDICAID SINUS AUGMENTATION WITH BONE D7951 OR BONE SUBSTITUTES Not Covered MEDICAID D7952 Sinus augmentation vertical Not Covered MEDICAID BONE REPLACEMENT GRAFT FOR D7953 RIDGE PRESERVATION - PER SITE Not Covered MEDICAID REPAIR OF MAXILLOFACIAL SOFT D7955 AND/OR HARD TISSUE DEFECT Not Covered MEDICAID FRENULECTOMY (FRENECTOMY OR FRENOTOMY)-SEPARATE D7960 PROCEDURE No MEDICAID D7963 FRENULOPLASTY Not Covered MEDICAID EXCISION OF HYPERPLASTIC TISSUE- D7970 PER ARCH Not Covered MEDICAID EXCISION OF PERICORONAL GINGIVA D7971 Not Covered MEDICAID SURGICAL REDUCTION OF FIBROUS D7972 TUBEROSITY Not Covered MEDICAID D7980 SIALOLITHOTOMY Not Covered MEDICAID EXCISION OF SALIVARY GLAND, BY D7981 REPORT Not Covered MEDICAID D7982 SIALODOCHOPLASTY Not Covered MEDICAID D7983 CLOSURE OF SALIVARY FISTULA Not Covered MEDICAID D7990 EMERGENCY TRACHEOTOMY Not Covered MEDICAID D7991 CORONOIDECTOMY Not Covered MEDICAID SYNTHETIC GRAFT-MANDIBLE OR D7995 FACIAL BONES, BY REPORT Not Covered MEDICAID IMPLANT-MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR RIDGE), BY D7996 REPORT Not Covered MEDICAID APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OF ARCHBAR D7997 Not Covered MEDICAID INTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN D7998 CONJUNCTION WITH A FRACTURE Not Covered MEDICAID UNSPECIFIED ORAL SURGERY D7999 PROCEDURE, BY REPORT Not Covered MEDICAID LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION D8010 Not Covered MEDICAID LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION D8020 Not Covered MEDICAID LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION D8030 Not Covered MEDICAID

457 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION D8040 Not Covered MEDICAID INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY D8050 DENTITION Not Covered MEDICAID INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL D8060 DENTITION Not Covered MEDICAID COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL D8070 DENTITION Not Covered MEDICAID COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT D8080 DENTITION Not Covered MEDICAID COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT D8090 DENTITION Not Covered MEDICAID D8210 REMOVABLE APPLIANCE THERAPY Not Covered MEDICAID D8220 FIXED APPLIANCE THERAPY Not Covered MEDICAID D8660 PRE-ORTHODONTIC VISIT Not Covered MEDICAID PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF D8670 CONTRACT) Not Covered MEDICAID ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF D8680 RETAINER(S)) Not Covered MEDICAID ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A D8690 CONTRACT FEE) Not Covered MEDICAID REPAIR OF ORTHODONTIC D8691 APPLIANCE Not Covered MEDICAID REPLACEMENT OF LOST OR BROKEN D8692 RETAINER Not Covered MEDICAID REBONDING OR RECEMENTING; AND/OR REPAIR, AS REQUIRED, OF D8693 FIXED RETAINERS Not Covered MEDICAID D8694 Repair fixed retainers Not Covered MEDICAID UNSPECIFIED ORTHODONTIC D8999 PROCEDURE, BY REPORT Not Covered MEDICAID PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR D9110 PROCEDURES Not Covered MEDICAID FIXED PARTIAL DENTURE D9120 SECTIONING Not Covered MEDICAID LOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPERATIVE OR D9210 SURGICAL PROCEDURES Not Covered MEDICAID D9211 REGIONAL BLOCK ANESTHESIA Not Covered MEDICAID TRIGEMINAL DIVISION BLOCK D9212 ANESTHESIA Not Covered MEDICAID D9215 LOCAL ANESTHESIA Not Covered MEDICAID D9219 Eval for deep sed/gen anesth Not Covered MEDICAID DEEP SEDATION/GENERAL D9222 ANESTHESIA--FIRST 15 MINUTES Yes MEDICAID Deep sedation/general anesthesia — D9223 each 15 minute increment Yes MEDICAID ANALGESIA, ANXIOLYSIS, D9230 INHALATION OF NITROUS OXIDE Not Covered MEDICAID INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH D9242 ADDITIONAL 15 MINUTES Not Covered MEDICAID NON-INTRAVENOUS CONSCIOUS D9248 SEDATION Not Covered MEDICAID CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN D9310 Not Covered MEDICAID

458 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOUSE/EXTENDED CARE FACILITY D9410 CALL Not Covered MEDICAID D9420 HOSPITAL CALL Not Covered MEDICAID OFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) NO OTHER SERVICES D9430 PERFORMED Not Covered MEDICAID OFFICE VISIT-AFTER REGULARLY D9440 SCHEDULED HOURS Not Covered MEDICAID CASE PRESENTATION, DETAILED AND EXTENSIVE TREATMENT PLANNING D9450 Not Covered MEDICAID THERAPEUTIC PARENTERAL DRUG, D9610 SINGLE ADMINISTRATION Not Covered MEDICAID THERAPEUTIC PARENTERAL DRUGS, TWO OR MORE ADMINISTRATIONS, DIFFERENT MEDICATIONS D9612 Not Covered MEDICAID OTHER DRUGS AND/OR D9630 MEDICAMENTS, BY REPORT Not Covered MEDICAID APPLICATION OF DESENSITIZING D9910 MEDICAMENT Not Covered MEDICAID APPLICATION OF DESENSITIZING RESIN FOR CERVICAL AND/OR ROOT D9911 SURFACE, PER TOOTH Not Covered MEDICAID BEHAVIOR MANAGEMENT, BY D9920 REPORT Not Covered MEDICAID TREATMENT OF COMPLICATIONS (POSTSURGICAL) - UNUSUAL D9930 CIRCUMSTANCES, BY REPORT Not Covered MEDICAID D9940 OCCLUSAL GUARDS, BY REPORT Not Covered MEDICAID FABRICATION OF ATHLETIC D9941 MOUTHGUARD Not Covered MEDICAID REPAIR AND/OR RELINE OF D9942 OCCLUSAL GUARD Not Covered MEDICAID OCCLUSION ANALYSIS-MOUNTED D9950 CASE Not Covered MEDICAID D9951 OCCLUSAL ADJUSTMENT-LIMITED Not Covered MEDICAID OCCLUSAL ADJUSTMENT-COMPLETE D9952 Not Covered MEDICAID D9970 ENAMEL MICROABRASION Not Covered MEDICAID ODONTOPLASTY 1 - 2 TEETH; INCLUDES REMOVAL OF ENAMEL D9971 PROJECTIONS Not Covered MEDICAID EXTERNAL BLEACHING - PER ARCH D9972 Not Covered MEDICAID EXTERNAL BLEACHING - PER TOOTH D9973 Not Covered MEDICAID INTERNAL BLEACHING - PER TOOTH D9974 Not Covered MEDICAID D9975 External bleaching home app Not Covered MEDICAID D9985 Sales tax Not Covered MEDICAID D9986 Missed appointment Not Covered MEDICAID D9987 Cancelled appointment Not Covered MEDICAID UNSPECIFIED ADJUNCTIVE D9999 PROCEDURE, BY REPORT Not Covered MEDICAID ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT E0485 No MEDICAID ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND E0486 ADJUSTMENT No MEDICAID IMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, E0616 ACTIVATOR AND No MEDICAID

459 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF NAUSEA AND E0765 VOMITING Not Covered MEDICAID INFUSION PUMP, IMPLANTABLE, NON- PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, E0782 CATHETER, CONNECTORS, ETC.) No MEDICAID INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, E0783 ETC.) No MEDICAID IMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLE INFUSION PUMP, REPLACEMENT E0785 No MEDICAID IMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLE E0786 INTRASPINAL CATHETER) No MEDICAID ADMINISTRATION OF INFLUENZA G0008 VIRUS VACCINE No MEDICAID ADMINISTRATION OF G0009 PNEUMOCOCCAL VACCINE No MEDICAID ADMINISTRATION OF HEPATITIS B G0010 VACCINE No MEDICAID SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM G0027 EXCLUDING HUHNER No MEDICAID CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL G0101 BREAST EXAM No MEDICAID PROSTATE CANCER SCREENING; G0102 DIGITAL RECTAL EXAMINATION No MEDICAID PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST G0103 (PSA), TOTAL No MEDICAID COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY G0104 No MEDICAID COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT G0105 HIGH RISK No MEDICAID COLORECTAL CANCER SCREENING; SCREENING SIGMOIDOSCOPY, G0106 BARIUM ENEMA No MEDICAID DIABETES OUTPATIENT SELF- MANAGEMENT TRAINING SERVICES, G0108 INDIVIDUAL, 30 MIN No MEDICAID DIABETES OUTPATIENT SELF- MANAGEMENT TRAINING SERVICES, G0109 GROUP SESSION No MEDICAID GLAUCOMA SCREENING FOR HIGH G0117 RISK PATIENTS FURNISHED BY AN No MEDICAID GLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER G0118 THE DIRECT No MEDICAID COLORECTAL CANCER SCREENING; SCREENING COLONOSCOPY, BARIUM G0120 ENEMA No MEDICAID COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT G0121 MEETING No MEDICAID COLORECTAL CANCER SCREENING; G0122 BARIUM ENEMA No MEDICAID SCREENING CYTOPATHOLOGY, G0123 CERVICAL OR VAGINAL No MEDICAID SCREENING CYTOPATHOLOGY, G0124 CERVICAL OR VAGINAL No MEDICAID

460 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TRIMMING OF DYSTROPHIC NAILS, G0127 ANY NUMBER No * MEDICAID DIRECT (FACE-TO-FACE WITH PATIENT) SKILLED NURSING SERVICES OF A REGISTERED NURSE PROVIDED IN A COMPREHENSIVE OUTPATIENT REHABILIT G0128 Not Covered MEDICAID OCCUPATIONAL THERAPY REQUIRING THE SKILLS OF A QUALIFIED OCCUPATIONAL THERAPIST, FURNISHED AS A COMPONENT OF A PARTIAL G0129 HOSPITALIZATION No MEDICAID SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON G0130 (PERIPHERAL) (E.G.,RADIUS, No MEDICAID SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, G0141 PERFORMED BY No MEDICAID SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY G0143 REPORTING SYSTEM), No MEDICAID SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY G0144 REPORTING SYSTEM), No MEDICAID SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY G0145 REPORTING SYSTEM), No MEDICAID SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, G0147 PERFORMED BY No MEDICAID SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, G0148 PERFORMED BY No MEDICAID SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN G0151 THE HOME HEALTH OR HOSPICE Yes SETTING, EACH 15 MINUTES MEDICAID SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL G0152 THERAPIST IN THE HOME HEALTH OR Yes HOSPICE SETTING, EACH 15 MINUTES MEDICAID SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE G0153 PATHOLOGIST IN THE HOME HEALTH Yes OR HOSPICE SETTING, EACH 15 MINUTES MEDICAID SERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH SETTING, G0155 EACH 15 MINUTES No ExGEN MEDICAID SERVICES OF HOME HEALTH AIDE IN HOME HEALTH SETTING EACH 15 G0156 MINUTES No ExGEN MEDICAID SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST ASSISTANT IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES G0157 No ExGEN MEDICAID SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST ASSISTANT IN THE HOME HEALTH OR HOSPICE SETTING, EACH G0158 15 MINUTES No ExGEN MEDICAID

461 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES G0159 No ExGEN MEDICAID SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES G0160 No ExGEN MEDICAID SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES G0161 No ExGEN MEDICAID SKILLED SERVICES BY A REGISTERED NURSE (RN) IN THE DELIVERY OF MANAGEMENT & EVALUATION OF THE PLAN OF CARE; EACH 15 MINUTES (THE PATIENT'S UNDERLYING CONDITION OR COMPLICATION REQUIRES AN RN TO ENSURE THAT ESSENTIAL NON- SKILLED CARE ACHIEVE ITS PURPOSE IN THE HOME HEALTH OR HOSPICE SETTING) G0162 No ExGEN MEDICAID SKILLED SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE DELIVERY OF OBSERVATION & ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (WHEN THE LIKELIHOOD OF CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TO IDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE MODIFICATION OF TREATMENT IN THE HOME HEALTH OR HOSPICE SETTING)

G0163 No ExGEN MEDICAID SKILLED SERVICES OF A LICENSED NURSE, IN THE TRAINING AND/OR EDUCATION OF A PATIENT OR FAMILY MEMBER, IN THE HOME HEALTH OR HOSPICE SETTING, EACH G0164 15 MINUTES No ExGEN MEDICAID EXTERNAL COUNTERPULSATION, G0166 PER TREATMENT SESSION No MEDICAID WOUND CLOSURE UTILIZING TISSUE G0168 ADHESIVE(S) ONLY No MEDICAID SCHEDULED INTERDISCIPLINARY TEAM CONFERENCE (MINIMUM OF G0175 THREE EXCLUSIVE) Not Covered MEDICAID ACTIVITY THERAPY, SUCH AS MUSIC, DANCE, ART OR PLAY THERAPIES NOT FOR RECREATION, RELATED TO THE CARE AND TREATMENT OF PATIENT'S D G0176 Yes * MEDICAID

462 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TRAINING AND EDUCATIONAL SERVICES RELATED TO THE CARE AND TREATMENT OF PATIENT'S DISABLING MENTAL HEALTH G0177 PROBLEMS PER SESSION (45 Yes MEDICAID PHYSICIAN CERTIFICATION SERVICES FOR MEDICARE-COVERED SERVICES PROVIDED BY G0180 No MEDICAID DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDAL NEOVASCULARIZATION); G0186 PHOTOCOAGULATION, FEEDER Yes VESSEL TECHNIQUE MEDICAID PET IMAGING WHOLE BODY; MELANOMA FOR NONCOVERED G0219 INDICATIONS Not Covered MEDICAID PET IMAGING, ANY SITE, NOT G0235 OTHERWISE SPECIFIED Yes MEDICAID THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, FACE TO FACE, ONE ON ONE, EACH 15 MIN (INCLUDES G0237 MONITORING) No MEDICAID THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY G0237, ONE ON ONE, FACE TO FACE, PER 15 MINUTES (INCLUDES MONITORING)

G0238 No MEDICAID THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, TWO OR MORE INDIVIDUALS (INCLUDES G0239 MONITORING) No MEDICAID INITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF DIABETIC PATIENT W ITH DIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) G0245 WHICH MUST INCLUDE: No MEDICAID FOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) TO INCLUDE AT LEAST THE FOLLOWING: G0246 No MEDICAID ROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) TO INCLUDE, THE LOCAL CARE OF SUPERFICIAL WOUNDS (I.E., SUPERFICIAL TO MUSCLE AND FASCIA) AND AT LEAST THE G0247 FOLLOWING: No * MEDICAID

463 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing and report results G0248 No MEDICAID Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing material, billing units of service include 4 tests

G0249 No MEDICAID Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests G0250 No MEDICAID PET IMAGING, FULL AND PARTIAL- RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF BREAST CANCER AND / OR SURGICAL G0252 PLANNING FOR BREAST Not Covered MEDICAID Current Perception Threshold/Sensory G0255 Nerve Conduction Test, Per Limb, No MEDICAID UNSCHEDULED OR EMERGENCY DIALYSIS TREATMENT FOR AN ESRD G0257 PATIENT IN A HOSPITAL No MEDICAID INJECTION PROCEDURE FOR G0259 SACROILIAC JOINT; ARTHROGRAPY Yes MEDICAID INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OT WITHOUT ARTHROGRAPHY G0260 Yes MEDICAID REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN G0268 ON SAME DATE No MEDICAID PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR G0269 ARTERIAL ACCESS SITE, No MEDICAID MEDICAL NUTRITION THERAPY; REASSESSMENT AND SUBSEQUENT G0270 INTERVENTION(S) No MEDICAID MEDICAL NUTRITION THERAPY, REASSESSMENT AND SUBSEQUENT G0271 INTERVENTION(S) No MEDICAID

464 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical trial

G0276 Yes MEDICAID Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval G0277 No MEDICAID ILIAC ARTERY ANGIOGRAPHY PERFORMED AT THE SAME TIME OF G0278 CARDIAC No MEDICAID Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to g0204 or g0206) G0279 No MEDICAID ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE III OR STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS STASIS ULCERS NOT DEMONSTRTING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CARE G0281 No MEDICAID ELECTRICAL STIMULATION, (UNATTENDED), TO MORE OR MORE G0282 AREAS, FOR WOUND CARE Yes MEDICAID ELECTRICAL STIMULATION (UNATTENDED), TO ONE MORE G0283 AREAS FOR INDICATION(S) No * MEDICAID Reconstruction, computed tomographic angiography of aorta for surgical planning for vascular surgery G0288 No MEDICAID ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, G0289 FOREIGN BODY, No MEDICAID NONCOVERED SURGICAL PROCEDURE(S) USING CONSCIOUS SEDATION, REGIONAL, GENERAL OR G0293 Not Covered MEDICAID NONCOVERED PROCEDURE(S) USING EITHER NO ANESTHESIA OR LOCAL G0294 ANESTHESIA ONLY, IN Not Covered MEDICAID ELECTROMAGNETIC STIMULATION, TO ONE OR MORE AREAS FOR WOUND CARE OTH THAN DESCRIBED IN G0329 OR FOR OTHER USES G0295 Not Covered MEDICAID Counseling visit to discuss need for lung cancer screening (ldct) using low dose ct scan (service is for eligibility determination and shared G0296 decision making) No MEDICAID Low dose ct scan (ldct) for lung cancer G0297 screening No MEDICAID Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, G0299 each 15 minutes No ExGEN MEDICAID Direct skilled nursing services of a license practical nurse (lpn) in the home health or G0300 hospice setting, each 15 minutes No ExGEN MEDICAID PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR G0302 PREPARATION FOR LVRS, No MEDICAID PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR G0303 PREPARATION FOR LVRS, No MEDICAID

465 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR G0304 PREPARATION FOR LVRS, 1 TO No MEDICAID POST-DISCHARGE PULMONARY SURGERY SERVICES AFTER LVRS, G0305 MINIMUM OF 6 DAYS OF No MEDICAID COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT PLATELET G0306 COUNT) AND No MEDICAID COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT PLATELET G0307 COUNT) No MEDICAID COLORECTAL CANCER SCREENING; FECAL OCCULT BLOOD TEST, G0328 IMMUNOASSAY, 1-3 No MEDICAID ELECTROMAGNTIC TX FOR ULCER TO 1 OR MORE AREAS FOR CHRONIC STAGE III & STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIAB ULCERS & VENOUS STASIS ULCERS G0329 NOT DEMO No MEDICAID PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY G0333 SUPPLY AS A BENEFICIARY Not Covered MEDICAID HOSPICE EVALUATION AND COUNSELING SERVICES, PRE- G0337 ELECTION No MEDICAID IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR BASE STEROTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE G0339 SESSION, OR 1ST SESSION No MEDICAID IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR BASED STEROTACTIC RADIOSURGERY, DELIVERY INCLUDE COLLIMATOR CHANGES/CUSTOM G0340 PLUGGING/FX No MEDICAID PERCUTANEOUS ISLET CELL TRANS G0341 No ExGEN MEDICAID G0342 LAPAROSCOPY ISLET CELL TRANS No ExGEN MEDICAID G0343 LAPAROTOMY ISLET CELL TRANSP No ExGEN MEDICAID VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES G0365 FOR No MEDICAID ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS G0366 A COMPONENT No MEDICAID PHYSICIAN SERVICE REQUIRED TO ESTABLISH AND DOCUMENT THE G0372 NEED FOR A No MEDICAID HOSPITAL OBSERVATION SERVICE, G0378 PER HOUR No MEDICAID DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE G0379 No MEDICAID

466 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LEVEL 1 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 IS BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)

G0380 No MEDICAID LEVEL 2 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 IS BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)

G0381 No MEDICAID

467 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LEVEL 3 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 IS BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)

G0382 No MEDICAID LEVEL 4 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 IS BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)

G0383 No MEDICAID

468 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LEVEL 5 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1) IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC (BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR §489.24 IS BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)

G0384 No MEDICAID TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL G0390 CRITICAL CARE No MEDICAID ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT (E.G., AUDIT, DAST), AND BRIEF G0396 INTERVENTION 15 TO 30 MINUTES No MEDICAID ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT (E.G., AUDIT, DAST), AND INTERVENTION, G0397 GREATER THAN 30 MINUTES No MEDICAID FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, LIMITED, PHYSICIANS TYPICALLY SPEND 15 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH G0406 No MEDICAID FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, INTERMEDIATE, PHYSICIANS TYPICALLY SPEND 25 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH G0407 No MEDICAID FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, COMPLEX, PHYSICIANS TYPICALLY SPEND 35 MINUTES OR MORE COMMUNICATING WITH THE PATIENT VIA TELEHEALTH G0408 No MEDICAID

469 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACTURE(S), UNILATERAL OR BILATERAL FOR PELVIC BONE FRACTURE PATTERNS WHICH DO NOT DISRUPT THE PELVIC RING INCLUDES INTERNAL FIXATION, WHEN PERFORMED G0412 No MEDICAID PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) G0413 No MEDICAID OPEN TREATMENT OF ANTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION WHEN PERFORMED (INCLUDES PUBIC SYMPHYSIS AND/OR SUPERIOR/INFERIOR RAMI) G0414 No MEDICAID OPEN TREATMENT OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ILIUM, SACROILIAC JOINT G0415 AND/OR SACRUM) No MEDICAID SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLE SATURATION BIOPSY SAMPLING, 1-20 SPECIMENS G0416 No MEDICAID G0420 FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE; INDIVIDUAL, PER SESSION, PER ONE HOUR No MEDICAID G0421 FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY DISEASE; GROUP, PER SESSION, PER ONE HOUR No MEDICAID INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT G0422 CONTINUOUS ECG MONITORING Yes WITH EXERCISE, PER SESSION MEDICAID INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT G0423 CONTINUOUS ECG MONITORING; Yes WITHOUT EXERCISE, PER SESSION MEDICAID PULMONARY REHABILITATION, INCLUDING EXERCISE (INCLUDES G0424 MONITORING), ONE HOUR, PER Yes SESSION, UP TO TWO SESSIONS PER DAY MEDICAID G0425 INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 30 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH No MEDICAID

470 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G0426 INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 50 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH No MEDICAID G0427 INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 70 MINUTES OR MORE COMMUNICATING WITH THE PATIENT VIA TELEHEALTH No MEDICAID Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) G0428 Not Covered MEDICAID Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g.,as a result of highy active G0429 antiretroviral therapy) No MEDICAID G0432 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple- step method, HIV-1 or HIV-2, screening No MEDICAID G0433 Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV- 2, screening No MEDICAID G0434 DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER No MEDICAID G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening No MEDICAID G0438 ANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE (PPS), INITIAL VISIT No MEDICAID G0439 ANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE (PPS), SUBSEQUENT VISIT No MEDICAID G0442 Annual alcohol misuse screening, 15 minutes No MEDICAID G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes No MEDICAID G0444 Annual depression screening, 15 minutes No MEDICAID G0445 High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes No MEDICAID G0446 Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, bi-annual, 15 minutes No MEDICAID G0447 Face-to-face behavioral counseling for obesity, 15 minutes No MEDICAID

471 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G0448 INSERTION OR REPLACEMENT OF A PERMANENT PACING CARDIOVERTER- DEFIBRILLATOR SYSTEM WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER WITH INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING No MEDICAID G0449 Annual face-to-face obesity screening, 15 minutes No MEDICAID G0450 Screening for sexually transmitted infections, includes laboratory tests for chlamydia, gonorrhea, syphilis and hepatitis B No MEDICAID G0451 DEVELOPMENT TESTING, WITH INTERPRETATION AND REPORT, PER STANDARDIZED INSTRUMENT FORM Not Covered INFO MEDICAID G0452 Molecular pathology procedure; physician interpretation and report No MEDICAID G0453 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) No MEDICAID G0454 Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist Not Covered MEDICAID G0455 Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen No MEDICAID G0458 Low dose rate (ldr) prostate brachytherapy services, composite rate Not Covered INFO MEDICAID G0459 TELEHEALTH INP PHARM MGMT No MEDICAID G0460 Autologous prp for ulcers Not Covered INFO MEDICAID Hospital outpatient clinic visit for assessment and management of a patient G0463 No MEDICAID A medically-necessary, face to face encounter( one- on- one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit. G0466 No MEDICAID A medically-necessary, face to face encounter( one- on- one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit. G0467 No MEDICAID A FQHC visit that includes an Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV) and includes a typical bundle of Medicare- covered services that would be furnished per diem to a patient receiving an IPPE or G0468 AWV No MEDICAID

472 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines A medically-necessary, face-to-face mental health encounter(one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit. G0469 No MEDICAID A medically-necessary, face-to-face mental health encounter(one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit. G0470 No MEDICAID Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health G0471 agency (HHA) No MEDICAID Hepatitis C antibody screening for individual at high risk and other covered G0472 indication(s) No MEDICAID Face-to-face behavioral counseling for G0473 obesity, group (2-10), 30 minutes No MEDICAID HIV antigen/antibody, combination assay, G0475 screening No MEDICAID Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test G0476 No MEDICAID Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

G0477 No MEDICAID Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

G0478 No MEDICAID Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service. G0479 No MEDICAID

473 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or 13 tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed

G0480 No MEDICAID Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed.

G0481 No MEDICAID Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed.)

G0482 No MEDICAID Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed

G0483 No MEDICAID Face-to-face home health nursing visit by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) in an area with a shortage of home health agencies. (Services limited to RN or LPN G0490 only). No MEDICAID

474 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Dialysis procedure at a medicare certified esrd facility for acute kidney injury without G0491 esrd No MEDICAID Dialysis procedure with single evaluation by a physician or other qualified health care professional for acute kidney injury G0492 without esrd No MEDICAID Skilled services of a registered nurse (rn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)

G0493 No MEDICAID Skilled services of a licensed practical nurse (lpn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting) G0494 No MEDICAID Skilled services of a registered nurse (rn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes G0495 No MEDICAID Skilled services of a licensed practical nurse (lpn), in the training and/or education of a patient or family member, in the home health or hospice setting, G0496 each 15 minutes No MEDICAID Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living) using a portable pump provided by the office/other outpatient setting, includes follow up office/other outpatient visit at the conclusion of the infusion

G0498 No MEDICAID Hepatitis B screening in non-pregnant, high risk individual includes hepatitis B surface antigen (HBSAG) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to HBSAG (anti-HBS) and hepatitis B core antigen (anti-HBC) G0499 No MEDICAID

475 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)

G0500 No MEDICAID Resource-intensive services for patients for whom the use of specialized mobility- assistive technology (such as adjustable height chairs or tables, patient lift, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient, evaluation and management visit (list separately in addition to primary service)

G0501 No MEDICAID Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care G0506 management service) No MEDICAID Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and G0508 providers via telehealth No MEDICAID Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth G0509 No MEDICAID Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month G0511 No MEDICAID Rural health clinic or federally qualified health center (rhc/fqhc) only, psychiatric collaborative care model (psychiatric cocm), 60 minutes or more of clinical staff time for psychiatric cocm services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month

G0512 No MEDICAID Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service) G0513 No MEDICAID

476 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code g0513 for additional 30 minutes of preventive service) G0514 No MEDICAID G0515 Cognitive skills development No MEDICAID Insertion of non-biodegradable drug delivery implants, 4 or more (services for G0516 subdermal rod implant) No MEDICAID Removal of non-biodegradable drug delivery implants, 4 or more (services for G0517 subdermal implants) No MEDICAID Removal with reinsertion, non- biodegradable drug delivery implants, 4 or more (services for subdermal implants) G0518 No MEDICAID Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between G0659 structural isomers No MEDICAID IMPROVEMENT IN VISUAL FUNCTION ACHIEVED WITHIN 90 DAYS FOLLOWING CATARACT SURGERY G0913 Not Covered INFO MEDICAID PATIENT CARE SURVEY WAS NOT G0914 COMPLETED BY PATIENT Not Covered INFO MEDICAID IMPROVEMENT IN VISUAL FUNCTION NOT ACHIEVED WITHIN 90 DAYS FOLLOWING CATARACT SURGERY G0915 Not Covered INFO MEDICAID SATISFACTION WITH CARE ACHIEVED WITHIN 90 DAYS FOLLOWING G0916 CATARACT SURGERY Not Covered INFO MEDICAID PATIENT SATISFACTION SURVEY G0917 WAS NOT COMPLETED BY PATIENT Not Covered INFO MEDICAID SATISFACTION WITH CARE NOT ACHIEVED WITHIN 90 DAYS G0918 FOLLOWING CATARACT SURGERY Not Covered INFO MEDICAID Ultrasonic guidance for placement of G6001 radiation therapy fields No MEDICAID Stereoscopic x-ray guidance for localization of target volume for the G6002 delivery of radiation therapy No MEDICAID Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no G6003 blocks: up to 5mev No MEDICAID Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no G6004 blocks: 6-10mev No MEDICAID Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no G6005 blocks: 11-19mev No MEDICAID Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no G6006 blocks: 20mev or greater No MEDICAID Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple G6007 blocks: up to 5mev No MEDICAID Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple G6008 blocks: 6-10mev No MEDICAID

477 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple G6009 blocks: 11-19mev No MEDICAID Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple G6010 blocks: 20 mev or greater No MEDICAID Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev G6011 No MEDICAID Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev G6012 No MEDICAID Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev G6013 No MEDICAID Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater G6014 No MEDICAID Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per G6015 treatment session No MEDICAID Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session G6016 No MEDICAID Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg,3d positional tracking, gating, 3d surface tracking), G6017 each fraction of treatment No MEDICAID Colonoscopy through stoma; with transendoscopic stent placement G6020 (includes predilation) No MEDICAID LEFT VENTRICULAR EJECTION FRACTION (LVEF) >= 40% OR DOCUMENTATION AS NORMAL OR MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION G8395 Not Covered INFO MEDICAID LEFT VENTRICULAR EJECTION FRACTION (LVEF) NOT PERFORMED G8396 OR DOCUMENTED Not Covered INFO MEDICAID DILATED MACULAR OR FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE PRESENCE OR ABSENCE OF MACULAR EDEMA AND LEVEL OF SEVERITY OF G8397 RETINOPATHY Not Covered INFO MEDICAID DILATED MACULAR OR FUNDUS EXAM G8398 NOT PERFORMED Not Covered INFO MEDICAID

478 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PATIENT WITH CENTRAL DUAL- ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS DOCUMENTED OR ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR G8399 OSTEOPOROSIS PRESCRIBED) Not Covered INFO MEDICAID PATIENT WITH CENTRAL DUAL- ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS NOT DOCUMENTED OR NOT ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR OSTEOPOROSIS NOT PRESCRIBED G8400 Not Covered INFO MEDICAID LOWER EXTREMITY NEUROLOGICAL EXAM PERFORMED AND G8404 DOCUMENTED Not Covered INFO MEDICAID LOWER EXTREMITY NEUROLOGICAL EXAM NOT PERFORMED G8405 Not Covered INFO MEDICAID FOOTWEAR EVALUATION G8410 PERFORMED AND DOCUMENTED Not Covered INFO MEDICAID FOOTWEAR EVALUATION WAS NOT G8415 PERFORMED Not Covered INFO MEDICAID CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FOOTWEAR G8416 EVALUATION MEASURE Not Covered INFO MEDICAID BMI >= 30 WAS CALCULATED AND A FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL G8417 RECORD Not Covered INFO MEDICAID BMI < 22 WAS CALCULATED AND A FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL G8418 RECORD Not Covered INFO MEDICAID BMI >= 30 OR < 22 WAS CALCULATED, BUT NO FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL G8419 RECORD Not Covered INFO MEDICAID BMI < 30 AND >= 22 WAS G8420 CALCULATED AND DOCUMENTED Not Covered INFO MEDICAID G8421 BMI NOT CALCULATED Not Covered INFO MEDICAID PATIENT NOT ELIGIBLE FOR BMI G8422 CALCULATION Not Covered INFO MEDICAID LIST OF CURRENT MEDICATIONS (INCLUDES PRESCRIPTION, OVER- THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) DOCUMENTED BY THE PROVIDER, INCLUDING DRUG NAME, DOSAGE, G8427 FREQUENCY AND ROUTE Not Covered INFO MEDICAID CURRENT MEDICATIONS (INCLUDES PRESCRIPTION, OVER-THE- COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) WITH DRUG NAME, DOSAGE, FREQUENCY AND ROUTE NOT DOCUMENTED BY THE PROVIDER, REASON NOT G8428 SPECIFIED Not Covered INFO MEDICAID DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR MEDICATION G8430 ASSESSMENT Not Covered INFO MEDICAID DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A G8431 STANDARDIZED TOOL Not Covered INFO MEDICAID

479 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines NO DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A G8432 STANDARDIZED TOOL Not Covered INFO MEDICAID PATIENT NOT ELIGIBLE/NOT APPROPRIATE FOR CLINICAL G8433 DEPRESSION SCREENING Not Covered INFO MEDICAID DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PAIN G8442 ASSESSMENT Not Covered INFO MEDICAID BETA-BLOCKER THERAPY PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION G8450 Not Covered INFO MEDICAID CLINICIAN DOCUMENTED PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPY G8451 Not Covered INFO MEDICAID BETA-BLOCKER THERAPY NOT PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION G8452 Not Covered INFO MEDICAID HIGH RISK OF RECURRENCE OF G8465 PROSTATE CANCER Not Covered INFO MEDICAID ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY PRESCRIBED G8473 Not Covered INFO MEDICAID ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY NOT PRESCRIBED FOR REASONS DOCUMENTED BY THE CLINICIAN G8474 Not Covered INFO MEDICAID ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY NOT PRESCRIBED, REASON NOT SPECIFIED G8475 Not Covered INFO MEDICAID MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF <130 MM/HG AND A DIASTOLIC G8476 MEASUREMENT OF <80 MM/HG Not Covered INFO MEDICAID MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF >=130 MM/HG AND/OR A DIASTOLIC MEASUREMENT OF >=80 MM/HG G8477 Not Covered INFO MEDICAID BLOOD PRESSURE MEASUREMENT NOT PERFORMED OR DOCUMENTED, REASON NOT SPECIFIED G8478 Not Covered INFO MEDICAID INFLUENZA IMMUNIZATION WAS G8482 ORDERED OR ADMINISTERED Not Covered INFO MEDICAID

480 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED FOR REASONS DOCUMENTED BY G8483 CLINICIAN Not Covered INFO MEDICAID INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED, REASON NOT SPECIFIED G8484 Not Covered INFO MEDICAID PATIENT RECEIVING ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY G8506 Not Covered INFO MEDICAID DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND DESCRIPTION) PRIOR TO INITIATION OF THERAPY OR DOCUMENTATION OF THE ABSENCE OF PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDING THE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, REASON NOT SPECIFIED

G8509 Not Covered INFO MEDICAID NEGATIVE SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL, PATIENT NOT ELIGIBLE/APPROPRIATE FOR G8510 FOLLOW-UP PLAN DOCUMENTED Not Covered INFO MEDICAID SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL DOCUMENTED, FOLLOW UP PLAN NOT DOCUMENTED, REASON NOT SPECIFIED G8511 Not Covered INFO MEDICAID NO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, PATIENT G8535 NOT ELIGIBLE Not Covered INFO MEDICAID NO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, REASON G8536 NOT SPECIFIED Not Covered INFO MEDICAID DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED TOOL AND CARE PLAN BASED ON IDENTIFIED G8539 DEFICIENCIES Not Covered INFO MEDICAID DOCUMENTATION THAT THE PATIENT IS NOT ELIGIBLE FOR A FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED TOOL G8540 Not Covered INFO MEDICAID NO DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED TOOL, REASON NOT G8541 SPECIFIED Not Covered INFO MEDICAID DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED TOOL; NO DOCUMENTATION OF A CARE PLAN, G8542 PATIENT NOT ELIGIBLE Not Covered INFO MEDICAID DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED TOOL; NO DOCUMENTATION OF A CARE PLAN, G8543 REASON NOT SPECIFIED Not Covered INFO MEDICAID

481 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8559 PATIENT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION Not Covered INFO MEDICAID G8560 PATIENT HAS A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THE PREVIOUS 90 DAYS Not Covered INFO MEDICAID G8561 PATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION FOR PATIENTS WITH A HISTORY OF ACTIVE DRAINAGE MEASURE Not Covered INFO MEDICAID G8562 PATIENT DOES NOT HAVE A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THE PREVIOUS 90 DAYS Not Covered INFO MEDICAID G8563 PATIENT NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED Not Covered INFO MEDICAID G8564 PATIENT WAS REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED) Not Covered INFO MEDICAID G8565 VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLY PROGRESSIVE HEARING LOSS Not Covered INFO MEDICAID G8566 PATIENT IS NOT ELIGIBLE FOR THE "REFERRAL FOR OTOLOGIC EVALUATION FOR SUDDEN OR RAPIDLY PROGRESSIVE HEARING LOSS" MEASURE Not Covered INFO MEDICAID G8567 PATIENT DOES NOT HAVE VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLY PROGRESSIVE HEARING LOSS Not Covered INFO MEDICAID G8568 PATIENT WAS NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED) Not Covered INFO MEDICAID G8569 PROLONGED INTUBATION (>24 HRS) REQUIRED Not Covered INFO MEDICAID G8570 PROLONGED INTUBATION (>24 HRS) NOT REQUIRED Not Covered INFO MEDICAID G8571 DEVELOPMENT OF DEEP STERNAL WOUND INFECTION WITHIN 30 DAYS POSTOPERATIVELY Not Covered INFO MEDICAID G8572 NO DEEP STERNAL WOUND INFECTION Not Covered INFO MEDICAID G8573 STROKE/CBA FOLLOWING ISOLATED CABG SURGERY Not Covered INFO MEDICAID G8574 NO STROKE/CVA FOLLOWING ISOLATED CABG SURGERY Not Covered INFO MEDICAID G8575 DEVELOPED POSTOPERATIVE RENAL INSUFFICIENCY OR REQUIRED DIALYSIS Not Covered INFO MEDICAID G8576 NO POSTOPERATIVE RENAL INSUFFICIENCY/DIALYSIS NOT REQUIRED Not Covered INFO MEDICAID

482 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8577 REOPERATION REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHER CARDIAC REASON Not Covered INFO MEDICAID G8578 REOPERATION NOT REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHER CARDIAC REASON Not Covered INFO MEDICAID G8598 ASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY USED Not Covered INFO MEDICAID G8599 ASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY NOT USED, REASON NOT OTHERWISE SPECIFIED Not Covered INFO MEDICAID G8600 IV T-PA INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN WELL Not Covered INFO MEDICAID G8601 IV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN WELL FOR REASONS DOCUMENTED BY CLINICIAN Not Covered INFO MEDICAID G8602 IV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN WELL, REASON NOT SPECIFIED Not Covered INFO MEDICAID G8627 SURGICAL PROCEDURE PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FOR MAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS, DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE) Not Covered INFO MEDICAID G8628 SURGICAL PROCEDURE NOT PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FOR MAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS, DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE) Not Covered INFO MEDICAID G8633 PHARMACOLOGIC THERAPY (OTHER THAN MINIERALS/VITAMINS) FOR OSTEOPOROSIS PRESCRIBED Not Covered INFO MEDICAID G8635 PHARMACOLOGIC THERAPY FOR OSTEOPOROSIS WAS NOT PRESCRIBED, REASON NOT OTHERWISE SPECIFIED Not Covered INFO MEDICAID G8647 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0) Not Covered INFO MEDICAID G8648 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID

483 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8649 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8650 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED

Not Covered INFO MEDICAID G8651 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0) Not Covered INFO MEDICAID G8652 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID G8653 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8654 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED

Not Covered INFO MEDICAID G8655 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOT OR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO(>0) Not Covered INFO MEDICAID G8656 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOT OR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID

484 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8657 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOT OR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8658 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOT OR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED Not Covered INFO MEDICAID G8659 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINE SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0) Not Covered INFO MEDICAID G8660 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINE SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID G8661 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8662 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED Not Covered INFO MEDICAID G8663 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDER SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0) Not Covered INFO MEDICAID G8664 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDER SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID

485 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8665 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8666 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED

Not Covered INFO MEDICAID G8667 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST OR HAND SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0) Not Covered INFO MEDICAID G8668 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST OR HAND SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID G8669 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST OR HAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE Not Covered INFO MEDICAID G8670 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST OR HAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED Not Covered INFO MEDICAID G8671 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM, MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0)

Not Covered INFO MEDICAID

486 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8672 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM, MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0) Not Covered INFO MEDICAID G8673 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM, MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT APPROPRIATE

Not Covered INFO MEDICAID G8674 RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM, MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED

Not Covered INFO MEDICAID LEFT VENTRIUCULAR EJECTION G8694 FRACTION (LVEF) < 40% Not Covered INFO MEDICAID PATIENT NOT PRESCRIBED OR G8708 DISPENSED ANTIBIOTIC Not Covered INFO MEDICAID PATIENT PRESCRIBED OR DISPENSED ANTIBIOTIC FOR DOCUMENTED MEDICAL REASON(S) G8709 Not Covered INFO MEDICAID PATIENT PRESCRIBED OR G8710 DISPENSED ANTIBIOTIC Not Covered INFO MEDICAID PRESCRIBED OR DISPENSED G8711 ANTIBIOTIC Not Covered INFO MEDICAID ANTIBIOTIC NOT PRESCRIBED OR G8712 DISPENSED Not Covered INFO MEDICAID PT CATEGORY (PRIMARY TUMOR), PN CATEGORY (REGIONAL LYMPH NODES), AND HISTOLOGIC GRADE WERE DOCUMENTED IN PATHOLOGY G8721 REPORT Not Covered INFO MEDICAID MEDICAL REASON(S) DOCUMENTED FOR NOT INCLUDING PT CATEGORY, PN CATEGORY AND HISTOLOGIC GRADE IN THE PATHOLOGY REPORT

G8722 Not Covered INFO MEDICAID SPECIMEN SITE IS OTHER THAN ANATOMIC LOCATION OF PRIMARY G8723 TUMOR Not Covered INFO MEDICAID PT CATEGORY, PN CATEGORY AND HISTOLOGIC GRADE WERE NOT DOCUMENTED IN THE PATHOLOGY REPORT, REASON NOT OTHERWISE G8724 SPECIFIED Not Covered INFO MEDICAID

487 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PAIN ASSESSMENT DOCUMENTED AS POSITIVE UTILIZING A STANDARDIZED TOOL AND A FOLLOW-UP PLAN IS DOCUMENTED G8730 Not Covered INFO MEDICAID PAIN ASSESSMENT DOCUMENTED AS NEGATIVE, NO FOLLOW-UP PLAN IS G8731 REQUIRED Not Covered INFO MEDICAID NO DOCUMENTATION OF PAIN G8732 ASSESSMENT Not Covered INFO MEDICAID DOCUMENTATION OF A POSITIVE ELDER MALTREATMENT SCREEN AND DOCUMENTED FOLLOW-UP PLAN G8733 Not Covered INFO MEDICAID ELDER MALTREATMENT SCREEN DOCUMENTED AS NEGATIVE, NO G8734 FOLLOW-UP REQUIRED Not Covered INFO MEDICAID ELDER MALTREATMENT SCREEN DOCUMENTED AS POSITIVE, FOLLOW- UP PLAN NOT DOCUMENTED, REASON NOT SPECIFIED G8735 Not Covered INFO MEDICAID ABSENCE OF SIGNS OF MELANOMA (COUGH, DYSPNEA, TENDERNESS, LOCALIZED NEUROLOGIC SIGNS SUCH AS WEAKNESS, JAUNDICE OR ANY OTHER SIGN SUGGESTING SYSTEMIC SPREAD) OR ABSENCE OF SYMPTOMS OF MELANOMA (PAIN, PARESTHESIA, OR ANY OTHER SYMPTOM SUGGESTING THE POSSIBILITY OF SYSTEMIC SPREAD OF MELANOMA) G8749 Not Covered INFO MEDICAID MOST RECENT SYSTOLIC BLOOD G8752 PRESSURE < 140MMHG Not Covered INFO MEDICAID MOST RECENT SYSTOLIC BLOOD G8753 PRESSURE >= 140MMHG Not Covered INFO MEDICAID MOST RECENT DIASTOLIC BLOOD G8754 PRESSURE < 90MMHG Not Covered INFO MEDICAID MOST RECENT DIASTOLIC BLOOD G8755 PRESSURE >= 90MMHG Not Covered INFO MEDICAID NO DOCUMENTATION OF BLOOD PRESSURE MEASUREMENT, REASON NOT OTHERWISE SPECIFIED G8756 Not Covered INFO MEDICAID BLOOD PRESSURE SCREENING PERFORMED AS RECOMMENDED BY THE DEFINED SCREENING INTERVAL G8783 Not Covered INFO MEDICAID BLOOD PRESSURE SCREENING NOT PERFORMED AS RECOMMENDED BY SCREENING INTERVAL, REASON NOT OTHERWISE SPECIFIED G8785 Not Covered INFO MEDICAID SPECIMEN SITE OTHER THAN ANATOMIC LOCATION OF G8797 ESOPHAGUS Not Covered INFO MEDICAID SPECIMEN SITE OTHER THAN ANATOMIC LOCATION OF PROSTATE G8798 Not Covered INFO MEDICAID PERFORMANCE OF TRANS- ABDOMINAL OR TRANS-VAGINAL G8806 ULTRASOUND Not Covered INFO MEDICAID TRANS-ABDOMINAL OR TRANS- VAGINAL ULTRASOUND NOT PERFORMED FOR REASONS G8807 DOCUMENTED BY CLINICIAN Not Covered INFO MEDICAID PERFORMANCE OF TRANS- ABDOMINAL OR TRANS-VAGINAL ULTRASOUND NOT ORDERED, G8808 REASON NOT SPECIFIED Not Covered INFO MEDICAID

488 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RH-IMMUNOGLOBULIN (RHOGAM) G8809 ORDERED Not Covered INFO MEDICAID R-IMMUNOGLOBULIN (RHOGAM) NOT ORDERED FOR REASONS G8810 DOCUMENTED BY CLINICIAN Not Covered INFO MEDICAID DOCUMENTATION RH- IMMUNOGLOBULIN (RHOGAM) WAS NOT ORDERED, REASON NOT G8811 SPECIFIED Not Covered INFO MEDICAID STATIN THERAPY NOT PRESCRIBED FOR DOCUMENTED REASONS G8815 Not Covered INFO MEDICAID STATIN MEDICATION PRESCRIBED AT G8816 DISCHARGE Not Covered INFO MEDICAID STATIN THERAPY NOT PRESCRIBED AT DISCHARGE, REASON NOT G8817 SPECIFIED Not Covered INFO MEDICAID PATIENT DISCHARGE TO HOME NO LATER THAN POST-OPERATIVE DAY G8818 #7 Not Covered INFO MEDICAID PATIENT NOT DISCHARGED TO HOME G8825 BY POST-OPERATIVE DAY #7 Not Covered INFO MEDICAID PATIENT DISCHARGE TO HOME NO LATER THAN POST-OPERATIVE DAY G8826 #2 FOLLOWING EVAR Not Covered INFO MEDICAID PATIENT NOT DISCHARGE TO HOME BY POST-OPERATIVE DAY #2 G8833 FOLLOWING EVAR Not Covered INFO MEDICAID PATIENT DISCHARGED TO HOME NO LATER THAN POST-OPERATIVE DAY G8834 #2 FOLLOWING CEA Not Covered INFO MEDICAID PATIENT NOT DISCHARGED TO HOME G8838 BY POST-OPERATIVE DAY #2 Not Covered INFO MEDICAID SLEEP APNEA SYMPTOMS ASSESSED, INCLUDING PRESENCE OR ABSENCE OF SNORING AND DAYTIME SLEEPINESS G8839 Not Covered INFO MEDICAID DOCUMENTATION OF REASON(S) FOR NOT PERFORMING AN ASSESSMENT OF SLEEP SYMPTOMS (E.G., PATIENT DIDN'T HAVE INITIAL DAYTIME SLEEPINESS, PATIENT VISITS BETWEEN INITIAL TESTING AND INITIATION OF THERAPY) G8840 Not Covered INFO MEDICAID SLEEP APNEA SYMPTOMS NOT ASSESSED, REASON NOT G8841 OTHERWISE SPECIFIED Not Covered INFO MEDICAID APNEA HYPOPNEA INDEX (AHI) OR RESPIRATORY DISTURBANCE INDEX (RDI) MEASURED AT THE TIME OF G8842 INITIAL DIAGNOSIS Not Covered INFO MEDICAID DOCUMENTATION OF REASON(S) FOR NOT MEASURING AN APNEA HYPOPNEA INDEX (AHI) OR A RESPIRATORY DISTURBANCE INDEX (RDI) AT THE TIME OF INITIAL G8843 DIAGNOSIS Not Covered INFO MEDICAID APNEA HYPOPNA INDEX (AHI) OR RESPIRATORY DISTURBANCE INDEX (RDI) NOT MEASURED AT THE TIME OF INITIAL DIAGNOSIS, REASON NOT G8844 SPECIFIED Not Covered INFO MEDICAID POSITIVE AIRWAY PRESSURE G8845 THERAPY PRESCRIBED Not Covered INFO MEDICAID MODERATE OR SEVERE OBSTRUCTIVE SLEEP APNEA (APNEA HYPOPNEA INDEX (AHI) OR RESPIRATORY DISTURBANCE INDEX G8846 (RDI) OF 15 OR GREATER) Not Covered INFO MEDICAID

489 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DOCUMENTATION OF REASON(S) FOR NOT PRESCRIBING POSITIVE G8849 AIRWAY PRESSURE THERAPY Not Covered INFO MEDICAID POSITIVE AIRWAY PRESSURE THERAPY NOT PRESCRIBED, REASON NOT OTHERWISE SPECIFIED G8850 Not Covered INFO MEDICAID OBJECTIVE MEASUREMENT OF ADHERENCE TO POSITIVE AIRWAY PRESSURE THERAPY, DOCUMENTED G8851 Not Covered INFO MEDICAID POSITIVE AIRWAY PRESSURE G8852 THERAPY PRESCRIBED Not Covered INFO MEDICAID DOCUMENTATION OF REASON(S) FOR NOT OBJECTIVELY MEASURING ADHERENCE TO POSITIVE AIRWAY PRESSURE THERAPY G8854 Not Covered INFO MEDICAID OBJECTIVE MEASUREMENT OF ADHERENCE TO POSITIVE AIRWAY PRESSURE THERAPY NOT PERFORMED, REASON NOT G8855 OTHERWISE SPECIFIED Not Covered INFO MEDICAID REFERRAL TO A PHYSICIAN FOR AN OTOLOGIC EVALUATION PERFORMED G8856 Not Covered INFO MEDICAID PATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION MEASURE (E.G., PATIENTS WHO ARE ALREADY UNDER THE CARE OF A PHYSICIAN FOR ACUTE OR CHRONIC DIZZINESS) G8857 Not Covered INFO MEDICAID REFERRAL TO A PHYSICIAN FOR AN OTOLOGIC EVALUATION NOT PERFORMED, REASON NOT G8858 SPECIFIED Not Covered INFO MEDICAID CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) ORDERED OR DOCUMENTED, REVIEW OF SYSTEMS AND MEDICATION HISTORY OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR OSTEOPOROSIS PRESCRIBED

G8861 Not Covered INFO MEDICAID PATIENTS NOT ASSESSED FOR RISK OF BONE LOSS, REASON NOT G8863 OTHERWISE SPECIFIED Not Covered INFO MEDICAID PNEUMOCOCCAL VACCINE ADMINISTERED OR PREVIOUSLY G8864 RECEIVED Not Covered INFO MEDICAID DOCUMENTATION OF MEDICAL REASON(S) FOR NOT ADMINISTERING OR PREVIOUSLY RECEIVING PNEUMOCOCCAL VACCINE (E.G., PATIENT ALLERGIC REACTION, POTENTIAL ADVERSE DRUG G8865 REACTION) Not Covered INFO MEDICAID DOCUMENTATION OF PATIENT REASON(S) FOR NOT ADMINISTERING OR PREVIOUSLY RECEIVING PNEUMOCOCCAL VACCINE (E.G., G8866 PATIENT REFUSAL) Not Covered INFO MEDICAID PNEUMOCOCCAL VACCINE NOT ADMINISTERED OR PREVIOUSLY RECEIVED, REASON NOT G8867 OTHERWISE SPECIFIED Not Covered INFO MEDICAID

490 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PATIENT HAS DOCUMENTED IMMUNITY TO HEPATITIS B AND IS RECEIVING A FIRST COURSE OF ANTI- G8869 TNF THERAPY Not Covered INFO MEDICAID EXCISED TISSUE EVALUATED BY IMAGING INTRAOPERATIVELY TO CONFIRM SUCCESSFUL INCLUSION G8872 OF TARGETED LESION Not Covered INFO MEDICAID PATIENTS WITH NEEDLE LOCALIZATION SPECIMENS WHICH ARE NOT AMENABLE TO INTRAOPERATIVE IMAGING SUCH AS MRI NEEDLE WIRE LOCALIZATION, OR TARGETS WHICH ARE TENTATIVELY IDENTIFIED ON MAMMOGRAM OR ULTRASOUND WHICH DO NOT CONTAIN A BIOPSY MARKER BUT WHICH CAN BE VERIFIED ON INTRAOPERATIVE INSPECTION OR PATHOLOGY G8873 Not Covered INFO MEDICAID EXCISED TISSUE NOT EVALUATED BY IMAGING INTRAOPERATIVELY TO CONFIRM SUCCESSFUL INCLUSION G8874 OF TARGETED LESION Not Covered INFO MEDICAID CLINICIAN DIAGNOSED BREAST CANCER PREOPERATIVELY BY A MINIMALLY INVASIVE BIOPSY G8875 METHOD Not Covered INFO MEDICAID DOCUMENTATION OF REASON(S) FOR NOT PERFORMING MINIMALLY INVASIVE BIOPSY TO DIAGNOSE G8876 BREAST CANCER PROPERATIVELY Not Covered INFO MEDICAID CLINICIAN DID NOT ATTEMPT TO ACHIEVE THE DIAGNOSIS OF BREAST CANCER PREOPERATIVELY BY A MINIMALLY INVASIVE BIOPSY METHOD, REASON NOT OTHERWISE SPECIFIED G8877 Not Covered INFO MEDICAID SENTINEL LYMPH NODE BIOPSY G8878 PROCEDURE PERFORMED Not Covered INFO MEDICAID DOCUMENTATION OF REASON(S) SENTINEL LYMPH NODE BIOPSY NOT G8880 PERFORMED Not Covered INFO MEDICAID STAGE OF BREAST CANCER IS GREATER THAN T1N0M0 OR T2N0M0 G8881 Not Covered INFO MEDICAID SENTINEL LYMPH NODE BIOPSY G8882 PROCEDURE NOT PERFORMED Not Covered INFO MEDICAID BIOPSY RESULTS REVIEWED, COMMUNICATED, TRACKED AND G8883 DOCUMENTED Not Covered INFO MEDICAID CLINICIAN DOCUMENTED REASON THAT PATIENT'S BIOPSY RESULTS G8884 WERE NOT REVIEWED Not Covered INFO MEDICAID BIPSY RESULTS NOT REVIEWED, COMMUNICATED, TRACKED OR G8885 DOCUMENTED Not Covered INFO MEDICAID Patient documented not to have experienced any of the following events: a burn prior to discharge, a fall within the facility, wrong site/side/patient/procedure/implant event, a hospital transfer or hospital admission upon discharge from the facility G8907 Not Covered INFO MEDICAID Patient documented to have received a G8908 burn prior to discharge Not Covered INFO MEDICAID Patient documented not to have received G8909 a burn prior to discharge Not Covered INFO MEDICAID

491 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient documented to have experienced G8910 a fall within ASC Not Covered INFO MEDICAID Patient documented not to have G8911 experienced a fall within ASC Not Covered INFO MEDICAID Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event G8912 Not Covered INFO MEDICAID Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong G8913 implant event Not Covered INFO MEDICAID Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC G8914 Not Covered INFO MEDICAID Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC G8915 Not Covered INFO MEDICAID Patient with preoperative order for IV antibiotic surgical site infection (SSI ) prophylaxis, antibiotic initiated on time G8916 Not Covered INFO MEDICAID Patient with preoperative order for IV antibiotic surgical site infection (SSI ) prophylaxis, antibiotic not initiated on time G8917 Not Covered INFO MEDICAID Patient without preoperative order for IV antibiotic surgical site infection ( SSI ) G8918 prophylaxis Not Covered INFO MEDICAID G8923 Left ventricular ejection fraction (lvef) < 40% or documentation of moderately or severely depressed left ventricular systolic function Not Covered INFO MEDICAID G8924 Spirometry test results demonstrate fev1/fvc <60% with copd symptoms (e. G. , dyspnea, cough/sputum, wheezing) Not Covered INFO MEDICAID G8925 Spirometry test results demonstrate fev1/fvc >=60% or patient does not have copd symptoms Not Covered INFO MEDICAID G8926 Spirometry test not performed or documented, reason not given Not Covered INFO MEDICAID G8934 Left ventricular ejection fraction (lvef) <40% or documentation of moderately or severely depressed left ventricular systolic function Not Covered INFO MEDICAID G8935 Clinician prescribed angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy Not Covered INFO MEDICAID G8936 Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy Not Covered INFO MEDICAID G8937 Clinician did not prescribe angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy, reason not given Not Covered INFO MEDICAID G8938 Bmi is calculated, but patient not eligible for follow-up plan Not Covered INFO MEDICAID G8939 Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate Not Covered INFO MEDICAID G8941 Elder maltreatment screen documented, patient not eligible for follow-up Not Covered INFO MEDICAID

492 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8942 Documented functional outcomes assessment and care plan within the previous 30 days Not Covered INFO MEDICAID G8944 Ajcc melanoma cancer stage 0 through iic melanoma Not Covered INFO MEDICAID G8946 Minimally invasive biopsy method attempted but not diagnostic of breast cancer (e. G. , high risk lesion of breast such as atypical ductal hyperplasia, lobular neoplasia, atypical lobular carcinoma in situ, atypical columnar hyperplasica, flat epithelial atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle cells) Not Covered INFO MEDICAID G8950 Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up documented Not Covered INFO MEDICAID G8952 Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given Not Covered INFO MEDICAID G8954 Complete and appropriate patient data were reported to a qualified clinical database registry Not Covered INFO MEDICAID G8955 Most recent assessment of adequacy of volume management Not Covered INFO MEDICAID G8956 Patient receiving maintenance hemodialysis in an outpatient dialysis facility Not Covered INFO MEDICAID G8958 Assessment of adequacy of volume management not documented, reason not given Not Covered INFO MEDICAID G8959 Clinician treating major depressive disorder communicates to clinician treating comorbid condition Not Covered INFO MEDICAID G8960 Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition, reason not given Not Covered INFO MEDICAID G8961 Cardiac stress imaging test primarily performed on low-risk surgery patient for preoperative evaluation within 30 days preceding this surgery Not Covered INFO MEDICAID G8962 Cardiac stress imaging test performed on patient for any reason including those who did not have low risk surgery or test that was performed more than 30 days preceding low risk surgery Not Covered INFO MEDICAID G8963 Cardiac stress imaging performed primarily for monitoring of asymptomatic patient who had pci wihin 2 years Not Covered INFO MEDICAID G8964 Cardiac stress imaging test performed primarily for any other reason than monitoring of asymptomatic patient who had pci wthin 2 years (e. G. , symptomatic patient, patient greater than 2 years since pci, initial evaluation, etc) Not Covered INFO MEDICAID G8965 Cardiac stress imaging test primarily performed on low chd risk patient for initial detection and risk assessment Not Covered INFO MEDICAID G8966 Cardiac stress imaging test performed on symptomatic or higher than low chd risk patient or for any reason other than initial detection and risk assessment Not Covered INFO MEDICAID

493 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8967 Warfarin or another oral anticoagulant that is fda approved prescribed Not Covered INFO MEDICAID G8968 Documentation of medical reason(s) for not prescribing warfarin or another oral anticoagulant that is fda approved not prescribed (e. G. , allergy, risk of bleeding, transient or reversible causes of atrial fibrillation, other medical reasons including, but not limited to pregnancy, mitral stenosis, prosthetic heart valve or patient is in the postoperative period) Not Covered INFO MEDICAID G8969 Documentation of patient reason(s) for not prescribing warfarin or another oral anticoagulant that is fda approved (e. G. , economic, social, and/or religious impediments, noncompliance or patient refusal, other patient reasons) Not Covered INFO MEDICAID G8970 No risk factors or one moderate risk factor for thromboembolism Not Covered INFO MEDICAID G8973 Most recent hemoglobin (hgb) level < 10 g/dl Not Covered INFO MEDICAID G8974 Hemoglobin level measurement not documented, reason not given Not Covered INFO MEDICAID G8975 Documentation of medical reason(s) for patient having a hemoglobin level < 10 g/dl (e. G. , patients who have non-renal etiologies of anemia [e. G. , sickle cell anemia or other hemoglobinopathies, hypersplenism, primary bone marrow disease, anemia related to chemotherapy for diagnosis of malignancy, postoperative bleeding, active bloodstream or peritoneal infection], other medical reasons)

Not Covered INFO MEDICAID G8976 Most recent hemoglobin (hgb) level >= 10 g/dl Not Covered INFO MEDICAID G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Not Covered INFO MEDICAID G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Not Covered INFO MEDICAID G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID

494 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G8985 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Not Covered INFO MEDICAID G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8990 Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Not Covered INFO MEDICAID G8992 Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8993 Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Not Covered INFO MEDICAID G8994 Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Not Covered INFO MEDICAID G8995 Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Not Covered INFO MEDICAID G8996 Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G8997 Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G8999 Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID COORDINATED CARE FEE, INITIAL G9001 No RATE MEDICAID COORDINATED CARE FEE, G9002 No MAINTENANCE RATE MEDICAID COORDINATED CARE FEE, RISK G9003 ADJUSTED HIGH, INITIAL Not Covered INFO MEDICAID COORDINATED CARE FEE, RISK G9004 ADJUSTED LOW, INITIAL Not Covered INFO MEDICAID COORDINATED CARE FEE, RISK G9005 ADJUSTED MAINTENANCE Not Covered INFO MEDICAID COORDINATED CARE FEE, HOME G9006 MONITORING Not Covered INFO MEDICAID

495 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COORDINATED CARE FEE, G9007 No SCHEDULED TEAM CONFERENCE MEDICAID COORDINATED CARE FEE, PHYSICIAN G9008 COORDINATED CARE OVERSIGHT No SERVICES MEDICAID COORDINATED CARE FEE, RISK G9009 ADJUSTED MAINTENANCE, LEVEL 3 Not Covered INFO MEDICAID COORDINATED CARE FEE, RISK G9010 ADJUSTED MAINTENANCE, LEVEL 4 Not Covered INFO MEDICAID COORDINATED CARE FEE, RISK G9011 ADJUSTED MAINTENANCE, LEVEL 5 Not Covered INFO MEDICAID OTHER SPECIFIED CASE MANAGEMENT SERVICE NOT G9012 ELSEWHERE CLASSIFIED No MEDICAID ESRD DEMO BASIC BUNDLE LEVEL I G9013 Not Covered INFO MEDICAID ESRD DEMO EXPANDED BUNDLE INCLUDING VENOUS ACCESS AND G9014 RELATED SERVICES Not Covered INFO MEDICAID SMOKING CESSATION COUNSELING, INDIVIDUAL, IN THE ABSENCE OF OR IN ADDITION TO ANY OTHER EVALUATION AND MANAGEMENT G9016 SERVICE, PER SES Not Covered INFO MEDICAID AMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE AS A G9017 MEDICARE APPROVED Not Covered INFO MEDICAID ZANAMIVIR, INHALATION POWDER ADMINISTERED THROUGH INHALER, G9018 PER 10 MG (FOR USE Not Covered INFO MEDICAID OSELTAMIVIR PHOSPHATE, ORAL, PER 75 MG (FOR USE AS A MEDICARE G9019 APPROVED Not Covered INFO MEDICAID RIMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE AS A G9020 MEDICARE APPROVED Not Covered INFO MEDICAID AMANTADINE HYDROCHLORIDE, ORAL BRAND, PER 100 MG (FOR USE IN A MEDICARE-APPROVED G9033 DEMONSTRATION PROJECT) Not Covered INFO MEDICAID SERVICES PROVIDED BY OCCUPATIONAL THERAPIST G9034 (DEMONSTRATION PROJECT) Not Covered INFO MEDICAID SERVICES PROVIDED BY ORIENTATION AND MOBILITY SPECIALIST (DEMONSTRATION G9035 PROJECT) Not Covered INFO MEDICAID SERVICES PROVIDED BY LOW VISION THERAPIST (DEMONSTRATION G9036 PROJECT) Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; WORK-UP, EVALUATION, OR G9050 STAGING AT Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; TREATMENT DECISION-MAKING G9051 AFTER DISEASE Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; SURVEILLANCE FOR DISEASE G9052 RECURRENCE Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; EXPECTANT MANAGEMENT OF G9053 PATIENT Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; SUPERVISING, COORDINATING G9054 OR MANAGING Not Covered INFO MEDICAID ONCOLOGY; PRIMARY FOCUS OF VISIT; OTHER, UNSPECIFIED SERVICE G9055 NOT OTHER- Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT ADHERES TO G9056 GUIDELINES Not Covered INFO MEDICAID

496 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM G9057 GUIDELINES AS A Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM G9058 GUIDELINES Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM G9059 GUIDELINES Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM G9060 GUIDELINES FOR Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; PATIENT'S CONDITION NOT G9061 ADDRESSED BY Not Covered INFO MEDICAID ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM G9062 GUIDELINES Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG G9063 CANCER; EXTENT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG G9064 CANCER; EXTENT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG G9065 CANCER; EXTENT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG G9066 CANCER; STAGE III Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG G9067 CANCER; EXTENT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO SMALL CELL AND G9068 COMBINED SMALL CELL/ Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED G9069 TO SMALL CELL Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED G9070 TO SMALL CELL Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER G9071 (DOES NOT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER G9072 (DOES NOT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER G9073 (DOES NOT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER G9074 (DOES NOT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER G9075 (DOES NOT Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO G9077 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO G9078 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO G9079 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO G9080 ADENOCARCINOMA; Not Covered INFO MEDICAID

497 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO G9083 ADENOCARCINOMA; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9084 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9085 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9086 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9087 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9088 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO G9089 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9090 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9091 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9092 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9093 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9094 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO G9095 INVASIVE CANCER, Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO G9096 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO G9097 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO G9098 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO G9099 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO G9100 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO G9101 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO G9102 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO G9103 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO G9104 ADENOCARCINOMA Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO G9105 ADENOCARCINOMA Not Covered INFO MEDICAID

498 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO G9106 ADENOCARCINOMA; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO G9107 ADENOCARCINOMA; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO G9108 ADENOCARCINOMA; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO G9109 CANCERS OF Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO G9110 CANCERS OF Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO G9111 CANCERS OF Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO G9112 CANCERS OF Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9113 EPITHELIAL CANCER; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9114 EPITHELIAL CANCER; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9115 EPITHELIAL CANCER; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9116 EPITHELIAL CANCER; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9117 EPITHELIAL CANCER; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; NON- HODGKIN'S LYMPHOMA, LIMITED TO G9123 FOLLICULAR Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; NON- HODGKIN'S LYMPHOMA, LIMITED TO G9124 FOLLICULAR Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; NON- HODGKIN'S LYMPHOMA, LIMITED TO G9125 FOLLICULAR Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO G9126 PATHOLOGICALLY STAGE Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, G9128 SYSTEMIC DISEASE; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, G9129 LIMITED TO Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, G9130 SYSTEMIC DISEASE; Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: INVASIVE FEMALE BREAST CANCER; ADENOCARCINOMA AS PREDOM CELL TYPE; EXTENT UNKNOWN, STAGING IN PROGRESS G9131 Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: PROSTATE CANCER, LMTD TO ADENOCARCINOMA; HORMONE- REFRACTORY/ANDROGEN- INDEPENDENT; CLINICAL G9132 METASTASES Not Covered INFO MEDICAID

499 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ONCOLOGY; DISEASE STATUS: PROSTATE CANCER, LMTD TO ADENOCARCINOMA; HORMONE- RESPONSIVE; CLINICAL METASTASES OR M1 AT DIAGNOSIS (FOR G9133 Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: NON- HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; STAGE I, II AT DIAGN, NOT RELAPSED, NOT G9134 REFRACTORY Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: NON- HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; STAGE III, IV, NOT RELAPSED, NOT G9135 REFRACTORY (FOR US Not Covered INFO MEDICAID ONCOLGOY; DISEASE STATUS: NON- HODGKIN'S LYMPHOMA, TRANSFORMED FROM ORIGINAL CELLULAR DIAGNOSIS TO A SECOND CELLULAR CLASSIFICATION G9136 Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: NON- HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; RELAPSED/REFRACTORY (FOR USE G9137 IN A MEDICARE-APPROVED Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: NON- HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION; DIAGN EVALUATION, STAGE NOT KNOWN, G9138 EVAL OF RELAPSE Not Covered INFO MEDICAID ONCOLOGY; DISEASE STATUS: CHRONIC MYELOGENOUS LEUKEMIA, LMTD TO PHILADELPHIA CHROMOSOME POSITIVE &/OR BCR- G9139 ABL POSITIVE; EXTENT UNK Not Covered INFO MEDICAID FRONTIER EXTENDED STAY CLINIC DEMONSTRATION; FOR A PATIENT STAY IN A CLINIC APPROVED FOR THE CMS DEMONSTRATION PROJECT; THE FOLLOWING MEASURES SHOULD BE PRESENT: THE STAY MUST BE EQUAL TO OR GREATER THAN 4 HOURS; WEATHER OR OTHER CONDITIONS MUST PREVENT TRANSFER OR THE CASE FALLS INTO A CATEGORY OF MONITORING AND OBSERVATION CASES THAT ARE PERMITTED BY THE RULES OF THE DEMONSTRATION; THERE IS A MAXIMUM FRONTIER EXTENDED STAY CLINIC (FESC) VISIT OF 48 HOURS, EXCEPT IN THE CASE WHEN WEATHER OR OTHER CONDITIONS PREVENT TRANSFER; PAYMENT IS MADE ON EACH PERIOD UP TO 4 HOURS, AFTER THE FIRST 4 HOURS

G9140 Not Covered MEDICAID Warfarin responsiveness testing by genetic technique using any method, any G9143 number of specimen(s) Not Covered MEDICAID Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration G9147 Not Covered MEDICAID

500 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G9148 Medical Home Level I Not Covered INFO MEDICAID G9149 Medical Home Level II Not Covered INFO MEDICAID G9150 Medical Home Level III Not Covered INFO MEDICAID G9151 MAPCP demo State Not Covered INFO MEDICAID G9152 MAPCP demo community Not Covered INFO MEDICAID G9153 MAPCP demo physician Not Covered INFO MEDICAID EVALUATION FOR WHEELCHAIR REQUIRING FACE TO FACE VISIT G9156 WITH PHYSICIAN Not Covered INFO MEDICAID TRANSESOPHAGEAL DOPPLER USED G9157 WITH CARDIAC MONITORING No MEDICAID G9158 Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9159 Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G9160 Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9161 Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9162 Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G9163 Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9164 Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9165 Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G9166 Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9167 Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9168 Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G9169 Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9170 Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9171 Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID

501 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G9172 Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9173 Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9174 Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Not Covered INFO MEDICAID G9175 Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID G9176 Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation Not Covered INFO MEDICAID G9186 Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy Not Covered INFO MEDICAID Beta-blocker therapy not prescribed, G9188 reason not given Not Covered MEDICAID Beta-blocker therapy prescribed or G9189 currently being taken Not Covered MEDICAID Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical G9190 reasons) Not Covered MEDICAID Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons) G9191 Not Covered MEDICAID Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system) G9192 Not Covered MEDICAID Documentation of medical reason(s) for not ordering first or second generation cephalosporin for antimicrobial G9196 prophylaxis Not Covered MEDICAID Documentation of order for first or second generation cephalosporin for antimicrobial G9197 prophylaxis Not Covered MEDICAID Order for first or second generation cephalosporin for antimicrobial prophylaxis was not documented, reason G9198 not given Not Covered MEDICAID Dsm-ivtm criteria for major depressive disorder documented at the initial G9212 evaluation Not Covered MEDICAID Dsm-iv-tr criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified G9213 Not Covered MEDICAID Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15% G9223 Not Covered MEDICAID Foot exam was not performed, reason not G9225 given Not Covered MEDICAID

502 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam - report when all of the 3 components are completed) G9226 Not Covered MEDICAID Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible G9227 for a care plan Not Covered MEDICAID Chlamydia, gonorrhea and syphilis screening results documented (report when results are present for all of the 3 G9228 screenings) Not Covered MEDICAID Chlamydia, gonorrhea, and syphilis not screened, due to documented reason (patient refusal is the only allowed G9229 exclusion) Not Covered MEDICAID Chlamydia, gonorrhea, and syphilis not G9230 screened, reason not given Not Covered MEDICAID Documentation of end stage renal disease (esrd), dialysis, renal transplant or G9231 pregnancy Not Covered MEDICAID Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition for specified G9232 patient reason Not Covered MEDICAID Documentation of reasons for patient initiaiting maintenance hemodialysis with a catheter as the mode of vascular access (eg, patient has a maturing avf/avg, time-limited trial of hemodialysis, patients undergoing palliative dialysis, other medical reasons, patient declined avf/avg, other patient reasons, patient followed by reporting nephrologist for fewer than 90 days, other system reasons) G9239 Not Covered MEDICAID Patient whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated G9240 Not Covered MEDICAID Patient whose mode of vascular access is not a catheter at the time maintenance hemodialysis is initiated G9241 Not Covered MEDICAID Documentation of viral load equal to or G9242 greater than 200 copies/ml Not Covered MEDICAID Documentation of viral load less than 200 G9243 copies/ml Not Covered MEDICAID Patient did not have at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical G9246 visits Not Covered MEDICAID Patient had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits G9247 Not Covered MEDICAID Documentation of patient pain brought to a comfortable level within 48 hours from G9250 initial assessment Not Covered MEDICAID Documentation of patient with pain not brought to a comfortable level within 48 hours from initial assessment G9251 Not Covered MEDICAID Documentation of patient discharged to home later than post-operative day 2 G9254 following cas Not Covered MEDICAID

503 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation of patient discharged to home no later than post operative day 2 G9255 following cas Not Covered MEDICAID Documentation of patient death following G9256 cas Not Covered MEDICAID Documentation of patient stroke following G9257 cas Not Covered MEDICAID Documentation of patient stroke following G9258 cea Not Covered MEDICAID Documentation of patient survival and G9259 absence of stroke following cas Not Covered MEDICAID Documentation of patient death following G9260 cea Not Covered MEDICAID Documentation of patient survival and G9261 absence of stroke following cea Not Covered MEDICAID Documentation of patient death in the hospital following endovascular aaa repair G9262 Not Covered MEDICAID Documentation of patient survival in the hospital following endovascular aaa repair G9263 Not Covered MEDICAID Documentation of patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter for documented reasons (eg, patient is undergoing palliative dialysis with a catheter, patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant, other medical reasons, patient declined avf/avg, other patient reasons) G9264 Not Covered MEDICAID Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter as the mode of G9265 vascular access Not Covered MEDICAID Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a catheter as the mode of G9266 vascular access Not Covered MEDICAID Documentation of patient with one or more complications or mortality within 30 G9267 days Not Covered MEDICAID Documentation of patient with one or G9268 more complications within 90 days Not Covered MEDICAID Documentation of patient without one or more complications and without mortality G9269 within 30 days Not Covered MEDICAID Documentation of patient without one or G9270 more complications within 90 days Not Covered MEDICAID Blood pressure has a systolic value of < G9273 140 and a diastolic value of < 90 Not Covered MEDICAID Blood pressure has a systolic value of =140 and a diastolic value of = 90 or systolic value < 140 and diastolic value = 90 or systolic value = 140 and diastolic G9274 value < 90 Not Covered MEDICAID Documentation that patient is a current G9275 non-tobacco user Not Covered MEDICAID Documentation that patient is a current G9276 tobacco user Not Covered MEDICAID

504 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation that the patient is on daily aspirin or has documentation of a valid contraindication to aspirin automatic contraindications include anti-coagulant use, allergy, and history of gastrointestinal bleed; additionally, any reason documented by the physician as a reason for not taking daily aspirin is acceptable (examples include non-steroidal anti- inflammatory agents, risk for drug interaction, or uncontrolled hypertension defined as > 180 systolic or > 110 diastolic) G9277 Not Covered MEDICAID Documentation that the patient is not on G9278 daily aspirin regimen Not Covered MEDICAID Pneumococcal screening performed and documentation of vaccination received G9279 prior to discharge Not Covered MEDICAID Pneumococcal vaccination not administered prior to discharge, reason G9280 not specified Not Covered MEDICAID Screening performed and documentation that vaccination not indicated/patient G9281 refusal Not Covered MEDICAID Documentation of medical reason(s) for not reporting the histological type or nsclc- nos classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of non-small cell lung cancer or other documented medical reasons) G9282 Not Covered MEDICAID Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an G9283 explanation Not Covered MEDICAID Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos G9284 with an explanation Not Covered MEDICAID Specimen site other than anatomic location of lung or is not classified as non G9285 small cell lung cancer Not Covered MEDICAID Documentation of antibiotic regimen prescribed within 7 days of diagnosis or within 10 days after onset of symptoms G9286 Not Covered MEDICAID No antibiotic regimen prescribed within 7 days of diagnosis or within 10 days after G9287 onset of symptoms Not Covered MEDICAID Documentation of medical reason(s) for not reporting the histological type or nsclc- nos classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of non-small cell carcinoma or other documented medical reasons ) G9288 Not Covered MEDICAID Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an G9289 explanation Not Covered MEDICAID Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos G9290 with an explanation Not Covered MEDICAID

505 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Specimen site other than anatomic location of lung, is not classified as non small cell lung cancer or classified as G9291 nsclc-nos Not Covered MEDICAID Documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons) G9292 Not Covered MEDICAID Pathology report does not include the pt category and a statement on thickness and ulceration and for pt1, mitotic rate G9293 Not Covered MEDICAID Pathology report includes the pt category and a statement on thickness and ulceration and for pt1, mitotic rate G9294 Not Covered MEDICAID Specimen site other than anatomic G9295 cutaneous location Not Covered MEDICAID Patients with documented shared decision- making including discussion of conservative (non-surgical) therapy prior to the procedure G9296 Not Covered MEDICAID Shared decision-making including discussion of conservative (non-surgical) therapy prior to the procedure not documented, reason not given G9297 Not Covered MEDICAID Patients who are evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke G9298 Not Covered MEDICAID Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke, reason not given G9299 Not Covered MEDICAID Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was G9300 not used) Not Covered MEDICAID Patients who had the prophylactic antibiotic completely infused prior to the G9301 inflation of the proximal tourniquet Not Covered MEDICAID Prophylactic antibiotic not completely infused prior to the inflation of the G9302 proximal tourniquet, reason not given Not Covered MEDICAID Operative report does not identify the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant, reason G9303 not given Not Covered MEDICAID Operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant G9304 Not Covered MEDICAID Intervention for presence of leak of endoluminal contents through an G9305 anastomosis not required Not Covered MEDICAID

506 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Intervention for presence of leak of endoluminal contents through an G9306 anastomosis required Not Covered MEDICAID No return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative G9307 procedure Not Covered MEDICAID Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative G9308 procedure Not Covered MEDICAID No unplanned hospital readmission within G9309 30 days of principal procedure Not Covered MEDICAID Unplanned hospital readmission within 30 G9310 days of principal procedure Not Covered MEDICAID G9311 No surgical site infection Not Covered MEDICAID G9312 Surgical site infection Not Covered MEDICAID Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason (eg, cystic fibrosis, immotile cilia disorders, ciliary dyskinesia, immune deficiency, prior history of sinus surgery within the past 12 months, and anatomic abnormalities, such as deviated nasal septum, resistant organisms, allergy to medication, recurrent sinusitis, chronic sinusitis, or other reasons)

G9313 Not Covered MEDICAID Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given G9314 Not Covered MEDICAID Documentation amoxicillin, with or without clavulanate, prescribed as a first line antibiotic at the time of diagnosis G9315 Not Covered MEDICAID Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family

G9316 Not Covered MEDICAID Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family not completed G9317 Not Covered MEDICAID Imaging study named according to G9318 standardized nomenclature Not Covered MEDICAID Imaging study not named according to standardized nomenclature, reason not G9319 given Not Covered MEDICAID Count of previous ct (any type of ct) and cardiac nuclear medicine (myocardial perfusion) studies documented in the 12- month period prior to the current study G9321 Not Covered MEDICAID Count of previous ct and cardiac nuclear medicine (myocardial perfusion) studies not documented in the 12-month period prior to the current study, reason not G9322 given Not Covered MEDICAID

507 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Ct studies performed not reported to a radiation dose index registry, reason not G9326 given Not Covered MEDICAID Ct studies performed reported to a radiation dose index registry with all G9327 necessary data elements Not Covered MEDICAID Dicom format image data available to non- affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12- month period after the study not documented in final report, reason not given G9329 Not Covered MEDICAID Final report documented that dicom format image data available to non- affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12- month period after the study G9340 Not Covered MEDICAID Search conducted for prior patient ct imaging studies completed at non- affiliated external entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being G9341 performed Not Covered MEDICAID Search conducted for prior patient imaging studies completed at non- affiliated external entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed not completed, reason not G9342 given Not Covered MEDICAID Search for prior patient completed dicom format images not completed due to system reasons (ie, facility does not have archival abilities through a shared archival G9344 system) Not Covered MEDICAID Follow-up recommendations according to recommended guidelines for incidentally detected pulmonary nodules (eg, follow- up ct imaging studies needed or that no follow-up is needed) based at a minimum on nodule size and patient risk factors documented G9345 Not Covered MEDICAID Follow-up recommendations according to recommended guidelines for incidentally detected pulmonary nodules not documented, reason not given G9347 Not Covered MEDICAID Ct scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons (eg, persons with sinusitis symptoms lasting at least 7 to 10 days, antibiotic resistance, immunocompromised, recurrent sinusitis, acute frontal sinusitis, acute sphenoid sinusitis, periorbital cellulitis, or other G9348 medical) Not Covered MEDICAID Documentation of a ct scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after G9349 date of diagnosis Not Covered MEDICAID Ct scan of the paranasal sinuses not ordered at the time of diagnosis or received within 28 days after date of G9350 diagnosis Not Covered MEDICAID

508 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines More than one ct scan of the paranasal sinuses ordered or received within 90 days after diagnosis G9351 Not Covered MEDICAID More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis, reason G9352 not given Not Covered MEDICAID More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis for documented reasons (eg, patients with complications, second ct obtained prior to surgery, other medical reasons)

G9353 Not Covered MEDICAID More than one ct scan of the paranasal sinuses not ordered within 90 days after the date of diagnosis G9354 Not Covered MEDICAID Elective delivery or early induction not G9355 performed Not Covered MEDICAID Elective delivery or early induction G9356 performed Not Covered MEDICAID Post-partum screenings, evaluations and G9357 education performed Not Covered MEDICAID Post-partum screenings, evaluations and G9358 education not performed Not Covered MEDICAID Documentation of negative or managed positive tb screen with further evidence G9359 that tb is not active Not Covered MEDICAID No documentation of negative or G9360 managed positive tb screen Not Covered MEDICAID Medical indication for induction G9361 (documentation of reason(s) for elective delivery or early induction Not Covered INFO MEDICAID Sinusitis caused by, or presumed to be G9364 caused by, bacterial infection Not Covered MEDICAID G9365 One high-risk medication ordered Not Covered MEDICAID G9366 One high-risk medication not ordered Not Covered MEDICAID At least two different high-risk G9367 medications ordered Not Covered MEDICAID At least two different high-risk G9368 medications not ordered Not Covered MEDICAID Patient offered assistance with end of life issues during the measurement period G9380 Not Covered MEDICAID Patient not offered assistance with end of life issues during the measurement period G9382 Not Covered MEDICAID Patient received screening for hcv infection within the 12 month reporting G9383 period Not Covered MEDICAID Documentation of medical reason(s) for not receiving screening for hcv infection within the 12 month reporting period (e.g., decompensated cirrhosis including advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, or waitlist for organ transplant, limited life expectancy, other medical reasons) G9384 Not Covered MEDICAID Documentation of patient reason(s) for not receiving screening for hcv infection within the 12 month reporting period (e.g., patient declined, other patient reasons) G9385 Not Covered MEDICAID

509 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Screening for hcv infection not received within the 12 month reporting period, G9386 reason not given Not Covered MEDICAID Unplanned rupture of the posterior G9389 capsule requiring vitrectomy Not Covered MEDICAID No unplanned rupture of the posterior capsule requiring vitrectomy G9390 Not Covered MEDICAID Patient with an initial phq-9 score greater than nine who achieves remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score of G9393 less than five Not Covered MEDICAID Patient who had a diagnosis of bipolar disorder or personality disorder, death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement or G9394 assessment period Not Covered MEDICAID Patient with an initial phq-9 score greater than nine who did not achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score greater than or equal to five G9395 Not Covered MEDICAID Patient with an initial phq-9 score greater than nine who was not assessed for remission at twelve months (+/- 30 days) G9396 Not Covered MEDICAID Documentation in the patient record of a discussion between the physician/clinician and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward the outcome of the treatment

G9399 Not Covered MEDICAID Documentation of medical or patient reason(s) for not discussing treatment options; medical reasons: patient is not a candidate for treatment due to advanced physical or mental health comorbidity (including active substance use); currently receiving antiviral treatment; successful antiviral treatment (with sustained virologic response) prior to reporting period; other documented medical reasons; patient reasons: patient unable or unwilling to participate in the discussion or other patient reasons

G9400 Not Covered MEDICAID No documentation of a discussion in the patient record of a discussion between the physician or other qualfied healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

G9401 Not Covered MEDICAID Patient received follow-up on the date of discharge or within 30 days after G9402 discharge Not Covered MEDICAID

510 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Clinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up) G9403 Not Covered MEDICAID Patient did not receive follow-up on the date of discharge or within 30 days after G9404 discharge Not Covered MEDICAID Patient received follow-up within 7 days G9405 from discharge Not Covered MEDICAID Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e patient death prior to follow-up visit, patient non-compliance for visit follow-up) G9406 Not Covered MEDICAID Patient did not receive follow-up on or G9407 within 7 days after discharge Not Covered MEDICAID Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 G9408 days Not Covered MEDICAID Patients without cardiac tamponade and/or pericardiocentesis occurring within G9409 30 days Not Covered MEDICAID Patient admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision G9410 Not Covered MEDICAID Patient not admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical G9411 revision Not Covered MEDICAID Patient admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision G9412 Not Covered MEDICAID Patient not admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical G9413 revision Not Covered MEDICAID Patient had one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays G9414 Not Covered MEDICAID Patient did not have one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays G9415 Not Covered MEDICAID Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (tdap) or one tetanus, diphtheria toxoids vaccine (td) on or between the patient's 10th and 13th birthdays or one tetanus and one diptheria vaccine on or between the patient's 10th and 13th birthdays G9416 Not Covered MEDICAID Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (tdap) or one tetanus, diphtheria toxoids vaccine (td) on or between the patient's 10th and 13th birthdays or one tetanus and one diptheria vaccine on or between the patient's 10th and 13th birthdays G9417 Not Covered MEDICAID

511 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Primary non-small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an G9418 explanation Not Covered MEDICAID Documentation of medical reason(s) for not reporting the histological type or nsclc- nos classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of primary non-small cell lung cancer or other documented medical reasons) G9419 Not Covered MEDICAID Specimen site other than anatomic location of lung or is not classified as G9420 primary non-small cell lung cancer Not Covered MEDICAID Primary non-small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos G9421 with an explanation Not Covered MEDICAID Non-small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an G9422 explanation Not Covered MEDICAID Documentation of medical reason(s) for not reporting the histological type or nsclc- nos classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of non-small cell carcinoma or other documented medical reasons) G9423 Not Covered MEDICAID Specimen site other than anatomic location of lung, is not classified as non- small cell lung cancer or classified as G9424 nsclc-nos Not Covered MEDICAID Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos G9425 with an explanation Not Covered MEDICAID Improvement in median time from ed arrival to initial ed oral or parenteral pain medication administration performed for G9426 ed admitted patients Not Covered MEDICAID Improvement in median time from ed arrival to initial ed oral or parenteral pain medication administration not performed G9427 for ed admitted patients Not Covered MEDICAID Pathology report includes the pt category and a statement on thickness and ulceration and for pt1, mitotic rate G9428 Not Covered MEDICAID Documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons) G9429 Not Covered MEDICAID Specimen site other than anatomic G9430 cutaneous location Not Covered MEDICAID Pathology report does not include the pt category and a statement on thickness and ulceration and for pt1, mitotic rate G9431 Not Covered MEDICAID Asthma well-controlled based on the act, c-act, acq, or ataq score and results G9432 documented Not Covered MEDICAID

512 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Asthma not well-controlled based on the act, c-act, acq, or ataq score, or specified asthma control tool not used, reason not G9434 given Not Covered MEDICAID Patients who were born in the years G9448 1945?1965 Not Covered MEDICAID History of receiving blood transfusions G9449 prior to 1992 Not Covered MEDICAID G9450 History of injection drug use Not Covered MEDICAID Patient received one-time screening for G9451 hcv infection Not Covered MEDICAID Documentation of medical reason(s) for not receiving one-time screening for hcv infection (e.g., decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) G9452 Not Covered MEDICAID Documentation of patient reason(s) for not receiving one-time screening for hcv infection (e.g., patient declined, other G9453 patient reasons) Not Covered MEDICAID One-time screening for hcv infection not received within 12 month reporting period and no documentation of prior screening for hcv infection, reason not given G9454 Not Covered MEDICAID Patient underwent abdominal imaging with ultrasound, contrast enhanced ct or G9455 contrast mri for hcc Not Covered MEDICAID Documentation of medical or patient reason(s) for not ordering or performing screening for hcc. medical reason: comorbid medical conditions with expected survival < 5 years, hepatic decompensation and not a candidate for liver transplantation, or other medical reasons; patient reasons: patient declined or other patient reasons (e.g., cost of tests, time related to accessing testing equipment) G9456 Not Covered MEDICAID Patient did not undergo abdominal imaging and did not have a documented reason for not undergoing abdominal imaging in the reporting period G9457 Not Covered MEDICAID Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user

G9458 Not Covered MEDICAID G9459 Currently a tobacco non-user Not Covered MEDICAID Tobacco assessment or tobacco cessation intervention not performed, G9460 reason not otherwise specified Not Covered MEDICAID

513 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient not receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater G9468 for all fills Not Covered MEDICAID Patients who have received or are receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater for all fills G9469 Not Covered MEDICAID Patients not receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater G9470 for all fills Not Covered MEDICAID Within the past 2 years, central dual- energy x-ray absorptiometry (dxa) not G9471 ordered or documented Not Covered MEDICAID Within the past 2 years, central dual- energy x-ray absorptiometry (dxa) not ordered and documented, no review of systems and no medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis G9472 prescribed Not Covered MEDICAID Services performed by chaplain in the G9473 hospice setting, each 15 minutes Not Covered MEDICAID Services performed by dietary counselor in the hospice setting, each 15 minutes G9474 Not Covered MEDICAID Services performed by other counselor in the hospice setting, each 15 minutes G9475 Not Covered MEDICAID Services performed by volunteer in the G9476 hospice setting, each 15 minutes Not Covered MEDICAID Services performed by care coordinator in the hospice setting, each 15 minutes G9477 Not Covered MEDICAID Services performed by other qualified therapist in the hospice setting, each 15 G9478 minutes Not Covered MEDICAID Services performed by qualified pharmacist in the hospice setting, each 15 G9479 minutes Not Covered MEDICAID Admission to medicare care choice model G9480 program (mccm) Not Covered MEDICAID

514 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: • A problem focused history; • A problem focused examination; and straightforward medical decision making,furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology.

G9481 Not Covered MEDICAID Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: • An expanded problem focused history; • An expanded problem focused examination; • Straightforward medical decision making, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology.

G9482 Not Covered MEDICAID

515 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: • A detailed history; • A detailed examination; • Medical decision making of low complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology.

G9483 Not Covered MEDICAID Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: • A comprehensive history; • A comprehensive examination; • Medical decision making of moderate complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9484 Not Covered MEDICAID

516 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: ;A comprehensive history • A comprehensive examination; • Medical decision making of high complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9485 Not Covered MEDICAID Remote in-home visit for the evaluation and management of an established patient for use only in the Medicare- approved Comprehensive Care for Joint Replacement model, which requires at least 2 of the following 3 key components: • A problem focused history; • A problem focused examination; • Straightforward medical decision making, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9486 Not Covered MEDICAID

517 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Remote in-home visit for the evaluation and management of an established patient for use only in the Medicare- approved Comprehensive Care for Joint Replacement model, which requires at least 2 of the following 3 key components: • An expanded problem focused history; • An expanded problem focused examination; • Medical decision making of low complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9487 Not Covered MEDICAID Remote in-home visit for the evaluation and management of an established patient for use only in the Medicare- approved Comprehensive Care for Joint Replacement model, which requires at least 2 of the following 3 key components: • A detailed history; • A detailed examination; • Medical decision making of moderate complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9488 Not Covered MEDICAID

518 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Remote in-home visit for the evaluation and management of an established patient for use only in the Medicare- approved Comprehensive Care for Joint Replacement model, which requires at least 2 of the following 3 key components: • A comprehensive history; • A comprehensive examination; • Medical decision making of high complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology

G9489 Not Covered MEDICAID Comprehensive Care for Joint Replacement model, home visit for patient assessment performed by clinical staff for an individual not considered homebound, including, but not necessarily limited to patient assessment of clinical status, safety/fall prevention, functional status/ambulation, medication reconciliation/management, compliance with orders/plan of care, performance of activities of daily living, and ensuring beneficiary connections to community and other services. (for use only in the Medicare-approved Comprehensive Care for Joint Replacement model); may not be billed for a 30 day period covered by a transitional care management code.

G9490 Not Covered MEDICAID Seen pre-operatively by anesthesiologist or proxy prior to the day of surgery G9497 Not Covered MEDICAID G9498 Antibiotic regimen prescribed Not Covered MEDICAID Radiation exposure indices, exposure time or number of fluorographic images in final report for procedures using fluoroscopy, documented G9500 Not Covered MEDICAID Radiation exposure indices, exposure time or number of fluorographic images not documented in final report for procedure using fluoroscopy, reason not given G9501 Not Covered MEDICAID Documentation of medical reason for not performing foot exam (i.e., patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period) G9502 Not Covered MEDICAID Patient taking tamsulosin hydrochloride G9503 Not Covered MEDICAID

519 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documented reason for not assessing hepatitis b virus (hbv) status (e.g. patient not receiving a first course of anti-tnf therapy, patient declined) within one year prior to first course of anti-tnf therapy G9504 Not Covered MEDICAID Antibiotic regimen prescribed within 10 days after onset of symptoms for G9505 documented medical reason Not Covered MEDICAID Biologic immune response modifier G9506 prescribed Not Covered MEDICAID Documentation that the patient is on a statin medication or has documentation of a valid contraindication or exception to statin medications; contraindications/exceptions that can be defined by diagnosis codes include pregnancy during the measurement period, active liver disease, rhabdomyolysis, end stage renal disease on dialysis and heart failure; provider documented contraindications/exceptions include breastfeeding during the measurement period, woman of childbearing age not actively taking birth control, allergy to statin, drug interaction (hiv protease inhibitors, nefazodone, cyclosporine, gemfibrozil, and danazol) and intolerance (with supporting documentation of trying a statin at least once within the last 5 years or diagnosis codes for myostitis or toxic myopathy related to drugs)

G9507 Not Covered MEDICAID Documentation that the patient is not on a G9508 statin medication Not Covered MEDICAID Remission at twelve months as demonstrated by a twelve month (+/-30 G9509 days) phq-9 score of less than 5 Not Covered MEDICAID Remission at twelve months not demonstrated by a twelve month (+/-30 days) phq-9 score of less than five; either phq-9 score was not assessed or is greater than or equal to 5 G9510 Not Covered MEDICAID Index date phq-9 score greater than 9 documented during the twelve month G9511 denominator identification period Not Covered MEDICAID G9512 Individual had a pdc of 0.8 or greater Not Covered MEDICAID Individual did not have a pdc of 0.8 or G9513 greater Not Covered MEDICAID Patient required a return to the operating room within 90 days of surgery G9514 Not Covered MEDICAID Patient did not require a return to the operating room within 90 days of surgery G9515 Not Covered MEDICAID Patient achieved an improvement in visual acuity, from their preoperative level, within G9516 90 days of surgery Not Covered MEDICAID Patient did not achieve an improvement in visual acuity, from their preoperative level, within 90 days of surgery, reason not G9517 given Not Covered MEDICAID Documentation of active injection drug G9518 use Not Covered MEDICAID

520 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient achieves final refraction (spherical equivalent) +/- 1.0 diopters of their planned refraction within 90 days of G9519 surgery Not Covered MEDICAID Patient does not achieve final refraction (spherical equivalent) +/- 1.0 diopters of their planned refraction within 90 days of surgery, reason not given G9520 Not Covered MEDICAID Total number of emergency department visits and inpatient hospitalizations less than two in the past 12 months G9521 Not Covered MEDICAID Total number of emergency department visits and inpatient hospitalizations equal to or greater than two in the past 12 months or patient not screened, reason not given G9522 Not Covered MEDICAID Patient discontinued from hemodialysis or G9523 peritoneal dialysis Not Covered MEDICAID G9524 Patient was referred to hospice care Not Covered MEDICAID Documentation of patient reason(s) for not referring to hospice care (e.g., patient declined, other patient reasons) G9525 Not Covered MEDICAID Patient was not referred to hospice care, G9526 reason not given Not Covered MEDICAID Patient with minor blunt head trauma had an appropriate indication(s) for a head ct G9529 Not Covered MEDICAID Patient presented within 24 hours of a minor blunt head trauma with a gcs score of 15 and had a head ct ordered for trauma by an emergency care provider G9530 Not Covered MEDICAID Patient has a valid reason for a head ct for trauma being ordered, regardless of indications (i.e., ventricular shunt, brain tumor, multisystem trauma, pregnancy, or currently taking an antiplatelet medication including: asa/dipyridamole, clopidogrel, prasugrel, ticlopidine, ticagrelor or cilstazol)

G9531 Not Covered MEDICAID Patient's head injury occurred greater than 24 hours before presentation to the emergency department, or has a gcs score less than 15, or had a head ct for trauma ordered by someone other than an emergency care provider, or was ordered for a reason other than trauma G9532 Not Covered MEDICAID Patient with minor blunt head trauma did not have an appropriate indication(s) for a G9533 head ct Not Covered MEDICAID Advanced brain imaging (cta, ct, mra or G9534 mri) was not ordered Not Covered MEDICAID Patients with a normal neurological G9535 examination Not Covered MEDICAID

521 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation of medical reason(s) for ordering an advanced brain imaging study (i.e., patient has an abnormal neurological examination; patient has the coexistence of seizures, or both; recent onset of severe headache; change in the type of headache; signs of increased intracranial pressure (e.g., papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation); hiv-positive patients with a new type of headache; immunocompromised patient with unexplained headache symptoms; patient on coagulopathy/anticoagulation or anti-platelet therapy; very young patients with unexplained headache symptoms)

G9536 Not Covered MEDICAID Documentation of system reason(s) for ordering an advanced brain imaging study (i.e., needed as part of a clinical trial; other clinician ordered the study) G9537 Not Covered MEDICAID Advanced brain imaging (cta, ct, mra or G9538 mri) was ordered Not Covered MEDICAID Intent for potential removal at time of G9539 placement Not Covered MEDICAID Patient alive 3 months post procedure G9540 Not Covered MEDICAID Filter removed within 3 months of G9541 placement Not Covered MEDICAID Documented re-assessment for the appropriateness of filter removal within 3 G9542 months of placement Not Covered MEDICAID Documentation of at least two attempts to reach the patient to arrange a clinical reassessment for the appropriateness of filter removal within 3 months of G9543 placement Not Covered MEDICAID Patients that do not have the filter removed, documented re-assessment for the appropriateness of filter removal, or documentation of at least two attempts to reach the patient to arrange a clinical reassessment for the appropriateness of filter removal within 3 months of placement G9544 Not Covered MEDICAID Incidental ct finding: liver lesion = 0.5 cm, cystic kidney lesion < 1.0 cm or adrenal G9547 lesion = 1.0 cm Not Covered MEDICAID Final reports for abdominal imaging studies with follow-up imaging G9548 recommended Not Covered MEDICAID Documentation of medical reason(s) that follow-up imaging is not indicated (e.g., patient has a known malignancy that can metastasize, other medical reason(s) G9549 Not Covered MEDICAID Final reports for abdominal imaging studies with follow-up imaging not G9550 recommended Not Covered MEDICAID Final reports for abdominal imaging studies without a liver lesion < 0.5 cm, cystic kidney lesion < 1.0 cm or adrenal G9551 lesion < 1.0 cm noted Not Covered MEDICAID Incidental thyroid nodule < 1.0 cm noted G9552 in report Not Covered MEDICAID

522 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines G9553 Prior thyroid disease diagnosis Not Covered MEDICAID Final reports for ct or mri of the chest or neck or ultrasound of the neck with follow- G9554 up imaging recommended Not Covered MEDICAID Documentation of medical reason(s) for not including documentation that follow up imaging is not needed (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical reason(s)) G9555 Not Covered MEDICAID Final reports for ct or mri of the chest or neck or ultrasound of the neck with follow- G9556 up imaging not recommended Not Covered MEDICAID Final reports for ct or mri studies of the chest or neck or ultrasound of the neck without a thyroid nodule < 1.0 cm noted G9557 Not Covered MEDICAID Patient treated with a beta-lactam G9558 antibiotic as definitive therapy Not Covered MEDICAID Documentation of medical reason(s) for not prescribing a beta-lactam antibiotic (e.g., allergy, intolerance to beta -lactam G9559 antibiotics) Not Covered MEDICAID Patient not treated with a beta-lactam antibiotic as definitive therapy, reason not G9560 given Not Covered MEDICAID Patients prescribed opiates for longer G9561 than six weeks Not Covered MEDICAID Patients who had a follow-up evaluation conducted at least every three months G9562 during opioid therapy Not Covered MEDICAID Patients who did not have a follow-up evaluation conducted at least every three G9563 months during opioid therapy Not Covered MEDICAID Remission at six months as demonstrated by a six month (+/-30 days) phq-9 score G9573 of less than five Not Covered MEDICAID Remission at six months not demonstrated by a six month (+/-30 days) phq-9 score of less than five. either phq-9 score was not assessed or is greater than or equal to five G9574 Not Covered MEDICAID Patients prescribed opiates for longer G9577 than six weeks Not Covered MEDICAID Documentation of signed opioid treatment agreement at least once during opioid G9578 therapy Not Covered MEDICAID No documentation of signed an opioid treatment agreement at least once during G9579 opioid therapy Not Covered MEDICAID Door to puncture time of less than 2 hours G9580 Not Covered MEDICAID Door to puncture time of greater than 2 G9582 hours, no reason given Not Covered MEDICAID Patients prescribed opiates for longer G9583 than six weeks Not Covered MEDICAID Patient evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., opioid risk tool, soaap-r) or patient interviewed at least once during G9584 opioid therapy Not Covered MEDICAID Patient not evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., opioid risk tool, soaap-r) or patient not interviewed at least once during opioid therapy G9585 Not Covered MEDICAID

523 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Pediatric patient with minor blunt head trauma classified as low risk according to the pecarn prediction rules G9593 Not Covered MEDICAID Patient presented within 24 hours of a minor blunt head trauma with a gcs score of 15 and had a head ct ordered for trauma by an emergency care provider G9594 Not Covered MEDICAID Patient has a valid reason for a head ct for trauma being ordered, regardless of indications (ie, ventricular shunt, brain tumor, coagulopathy, including thrombocytopenia) G9595 Not Covered MEDICAID Pediatric patient's head injury occurred greater than 24 hours before presentation to the emergency department, or has a gcs score less than 15, or had a head ct for trauma ordered by someone other than an emergency care provider, or was ordered for a reason other than trauma

G9596 Not Covered MEDICAID Pediatric patient with minor blunt head trauma not classified as low risk according to the pecarn prediction rules G9597 Not Covered MEDICAID Aortic aneurysm 5.5 - 5.9 cm maximum diameter on centerline formatted ct or minor diameter on axial formatted ct G9598 Not Covered MEDICAID Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted ct or minor diameter on axial G9599 formatted ct Not Covered MEDICAID Symptomatic aaas that required G9600 urgent/emergent (non-elective) repair Not Covered MEDICAID Patient discharge to home no later than G9601 post-operative day #7 Not Covered MEDICAID Patient not discharged to home by post- G9602 operative day #7 Not Covered MEDICAID Patient survey score improved from G9603 baseline following treatment Not Covered MEDICAID G9604 Patient survey results not available Not Covered MEDICAID Patient survey score did not improve from G9605 baseline following treatment Not Covered MEDICAID Intraoperative cystoscopy performed to G9606 evaluate for lower tract injury Not Covered MEDICAID Patient is not eligible (e.g., patient death during procedure, absent urethra or an otherwise inaccessible bladder) G9607 Not Covered MEDICAID Intraoperative cystoscopy not performed to evaluate for lower tract injury G9608 Not Covered MEDICAID Documentation of an order for anti-platelet G9609 agents or p2y12 antagonists Not Covered MEDICAID Documentation of medical reason(s) for not ordering anti-platelet agents or p2y12 antagonists (e.g., patients with known intolerance to anti-platelet agents such as aspirin or aspirin-like agents, or p2y12 antagonists, or those on or other intravenous anti-coagulants; patients with active bleeding or undergoing urgent or emergent operations or endarterectomy combined with cardiac surgery, other medical reason(s))

G9610 Not Covered MEDICAID

524 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Order for anti-platelet agents or p2y12 antagonists was not documented, reason not otherwise specified G9611 Not Covered MEDICAID Photodocumentation of one or more cecal landmarks to establish a complete G9612 examination Not Covered MEDICAID Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal G9613 resection, etc.) Not Covered MEDICAID No photodocumentation of cecal landmarks to establish a complete G9614 examination Not Covered MEDICAID Preoperative assessment documented G9615 Not Covered MEDICAID Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery) G9616 Not Covered MEDICAID Preoperative assessment not G9617 documented, reason not given Not Covered MEDICAID Documentation of screening for uterine malignancy or those that had an ultrasound and/or endometrial sampling of G9618 any kind Not Covered MEDICAID Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given G9620 Not Covered MEDICAID Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling G9621 Not Covered MEDICAID Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening G9622 method Not Covered MEDICAID Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other G9623 medical reasons) Not Covered MEDICAID Patient not screened for unhealthy alcohol screening using a systematic screening method or patient did not receive brief counseling, reason not given G9624 Not Covered MEDICAID Patient sustained bladder injury at the time of surgery or subsequently up to 1 G9625 month post-surgery Not Covered MEDICAID Patient is not eligible (e.g., gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder neoplasia or otherwise to treat a bladder specific problem, patient death from other causes, etc.) G9626 Not Covered MEDICAID Patient did not sustained bladder injury at the time of surgery or subsequently up to 1 month post-surgery G9627 Not Covered MEDICAID Patient sustained major viscus injury at the time of surgery or subsequently up to 1 month post-surgery G9628 Not Covered MEDICAID

525 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient is not eligible (e.g., gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder neoplasia or otherwise to treat a bladder specific problem, patient death from other causes, etc.) G9629 Not Covered MEDICAID Patient did not sustain major viscus injury at the time of surgery or subsequently up to 1 month post-surgery G9630 Not Covered MEDICAID Patient sustained ureter injury at the time of surgery or discovered subsequently up to 1 month post-surgery G9631 Not Covered MEDICAID Patient is not eligible (e.g., gynecologic or other pelvic malignancy documented, concurrent surgery involving bladder neoplasia or otherwise to treat a bladder specific problem, patient death from other causes, etc.) G9632 Not Covered MEDICAID Patient did not sustain ureter injury at the time of surgery or subsequently up to 1 G9633 month post-surgery Not Covered MEDICAID Health-related quality of life assessed with tool during at least two visits and quality of life score remained the same or G9634 improved Not Covered MEDICAID Health-related quality of life not assessed with tool for documented reason(s) (e.g., patient has a cognitive or neuropsychiatric impairment that impairs his/her ability to complete the hrqol survey, patient has the inability to read and/or write in order to complete the hrqol questionnaire)

G9635 Not Covered MEDICAID Health-related quality of life not assessed with tool during at least two visits or quality of life score declined G9636 Not Covered MEDICAID Final reports with documentation of one or more dose reduction techniques (e.g., automated exposure control, adjustment of the ma and/or kv according to patient size, use of iterative reconstruction technique) G9637 Not Covered MEDICAID Final reports without documentation of one or more dose reduction techniques (e.g., automated exposure control, adjustment of the ma and/or kv according to patient size, use of iterative reconstruction technique) G9638 Not Covered MEDICAID Major amputation or open surgical bypass not required within 48 hours of the index endovascular lower extremity G9639 revascularization procedure Not Covered MEDICAID Documentation of planned hybrid or G9640 staged procedure Not Covered MEDICAID Major amputation or open surgical bypass required within 48 hours of the index endovascular lower extremity G9641 revascularization procedure Not Covered MEDICAID G9642 Current cigarette smokers Not Covered MEDICAID G9643 Elective surgery Not Covered MEDICAID Patients who abstained from smoking prior to anesthesia on the day of surgery G9644 or procedure Not Covered MEDICAID

526 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patients who did not abstain from smoking prior to anesthesia on the day of G9645 surgery or procedure Not Covered MEDICAID Patients with 90 day mrs score of 0 to 2 G9646 Not Covered MEDICAID Patients in whom mrs score could not be G9647 obtained at 90 day follow-up Not Covered MEDICAID Patients with 90 day mrs score greater G9648 than 2 Not Covered MEDICAID Psoriasis assessment tool documented meeting any one of the specified benchmarks (e.g., (pga; 6-point scale), body surface area (bsa), psoriasis area and severity index (pasi) and/or dermatology life quality index) (dlqi)) G9649 Not Covered MEDICAID Psoriasis assessment tool documented not meeting any one of the specified benchmarks (e.g., (pga; 6-point scale), body surface area (bsa), psoriasis area and severity index (pasi) and/or dermatology life quality index) (dlqi)) or psoriasis assessment tool not G9651 documented Not Covered MEDICAID G9654 Monitored anesthesia care (mac) Not Covered MEDICAID A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is used G9655 Not Covered MEDICAID Patient transferred directly from G9656 anesthetizing location to pacu Not Covered MEDICAID A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is not used G9658 Not Covered MEDICAID Patients greater than 85 years of age who did not have a history of colorectal cancer or valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, crohn's disease (i.e., regional enteritis), familial adenomatous polyposis, lynch syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits

G9659 Not Covered MEDICAID Documentation of medical reason(s) for a colonoscopy performed on a patient greater than 85 years of age (eg., last colonoscopy incomplete, last colonoscopy had inadequate prep, iron deficiency anemia, lower gastrointestinal bleeding, crohn's disease (i.e., regional enteritis), familial history of adenomatous polyposis, lynch syndrome (i.e., hereditary non- polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits)

G9660 Not Covered MEDICAID

527 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patients greater than 85 years of age who received a routine colonoscopy for a reason other than the following: an assessment of signs/symptoms of gi tract illness, and/or the patient is considered high risk, and/or to follow-up on previously diagnoses advance lesions G9661 Not Covered MEDICAID Previously diagnosed or have an active G9662 diagnosis of clinical ascvd Not Covered MEDICAID Any fasting or direct ldl-c laboratory test G9663 result = 190 mg/dl Not Covered MEDICAID Patients who are currently statin therapy users or received an order (prescription) G9664 for statin therapy Not Covered MEDICAID Patients who are not currently statin therapy users or did not receive an order G9665 (prescription) for statin therapy Not Covered MEDICAID The highest fasting or direct ldl-c laboratory test result of 70?189 mg/dl in the measurement period or two years prior to the beginning of the measurement G9666 period Not Covered MEDICAID G9674 Patients with clinical ascvd diagnosis Not Covered MEDICAID Patients who have ever had a fasting or direct laboratory result of ldl-c = 190 mg/dl G9675 Not Covered MEDICAID Patients aged 40 to 75 years at the beginning of the measurement period with type 1 or type 2 diabetes and with an ldl-c result of 70?189 mg/dl recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period G9676 Not Covered MEDICAID Onsite acute care treatment of a nursing facility resident with pneumonia. May only be billed oncper day per beneficiary. G9679 No MEDICAID Onsite acute care treatment of a nursing facility resident with CHF. May only be billed once per day per beneficiary. G9680 No MEDICAID Onsite acute care treatment of a resident with COPD or asthma. May only be billed once per day per beneficiary. G9681 No MEDICAID Onsite acute care treatment a nursing facility resident with a skin infection. May only be billed once per day per beneficiary G9682 No MEDICAID Onsite acute care treatment of a nursing facility resident with fluid or electrolyte disorder or dehydration (similar pattern). May only be billed once per day per G9683 beneficiary. No MEDICAID Onsite acute care treatment of a nursing facility resident for a UTI. May only be billed once per day per beneficiary. G9684 No MEDICAID Evaluation and management of a beneficiary’s acute change in condition in G9685 a nursing facility No MEDICAID Onsite nursing facility conference, that is separate and distinct from an Evaluation and Management visit, including qualified practitioner and at least one member of the nursing facility interdisciplinary care G9686 team No MEDICAID

528 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Hospice services provided to patient any time during the measurement period G9687 Not Covered INFO MEDICAID Patients using hospice services any time G9688 during the measurement period Not Covered INFO MEDICAID Patient admitted for performance of G9689 elective carotid intervention Not Covered INFO MEDICAID Patient receiving hospice services any time during the measurement period G9690 Not Covered INFO MEDICAID Patient had hospice services any time G9691 during the measurement period Not Covered INFO MEDICAID Hospice services received by patient any time during the measurement period G9692 Not Covered INFO MEDICAID Patient use of hospice services any time G9693 during the measurement period Not Covered INFO MEDICAID Hospice services utilized by patient any time during the measurement period G9694 Not Covered INFO MEDICAID Long-acting inhaled bronchodilator G9695 prescribed Not Covered INFO MEDICAID Documentation of medical reason(s) for not prescribing a long-acting inhaled G9696 bronchodilator Not Covered INFO MEDICAID Documentation of patient reason(s) for not prescribing a long-acting inhaled G9697 bronchodilator Not Covered INFO MEDICAID Documentation of system reason(s) for not prescribing a long-acting inhaled G9698 bronchodilator Not Covered INFO MEDICAID Long-acting inhaled bronchodilator not prescribed, reason not otherwise specified G9699 Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9700 Not Covered INFO MEDICAID Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was G9701 established Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9702 Not Covered INFO MEDICAID Children who are taking antibiotics in the 30 days prior to the diagnosis of G9703 pharyngitis Not Covered INFO MEDICAID Ajcc breast cancer stage i: t1 mic or t1a G9704 documented Not Covered INFO MEDICAID Ajcc breast cancer stage i: t1b (tumor > 0.5 cm but <= 1 cm in greatest dimension) G9705 documented Not Covered INFO MEDICAID Low (or very low) risk of recurrence, G9706 prostate cancer Not Covered INFO MEDICAID Patient received hospice services any time during the measurement period G9707 Not Covered INFO MEDICAID Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral G9708 mastectomy Not Covered INFO MEDICAID Hospice services used by patient any time G9709 during the measurement period Not Covered INFO MEDICAID Patient was provided hospice services any time during the measurement period G9710 Not Covered INFO MEDICAID Patients with a diagnosis or past history of total colectomy or colorectal cancer G9711 Not Covered INFO MEDICAID

529 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation of medical reason(s) for prescribing or dispensing antibiotic (e.g., intestinal infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis/ mastoiditis/bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections/venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis/uti, acne, hiv disease/asymptomatic hiv, cystic fibrosis, disorders of the immune system, malignancy neoplasms, chronic bronchitis, emphysema, bronchiectasis, extrinsic allergic alveolitis, chronic airway obstruction, chronic obstructive asthma, pneumoconiosis and other lung disease due to external agents, other diseases of the respiratory system, and tuberculosis

G9712 Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9713 Not Covered INFO MEDICAID Patient is using hospice services any time G9714 during the measurement period Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9715 Not Covered INFO MEDICAID Bmi is documented as being outside of normal limits, follow-up plan is not G9716 completed for documented reason Not Covered INFO MEDICAID Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required G9717 Not Covered INFO MEDICAID Hospice services for patient provided any time during the measurement period G9718 Not Covered INFO MEDICAID Patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair G9719 Not Covered INFO MEDICAID Hospice services for patient occurred any time during the measurement period G9720 Not Covered INFO MEDICAID Patient not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair G9721 Not Covered INFO MEDICAID Documented history of renal failure or baseline serum creatinine = 4.0 mg/dl; renal transplant recipients are not considered to have preoperative renal failure, unless, since transplantation the cr has been or is 4.0 or higher G9722 Not Covered INFO MEDICAID

530 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Hospice services for patient received any time during the measurement period G9723 Not Covered INFO MEDICAID Patients who had documentation of use of anticoagulant medications overlapping the G9724 measurement year Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9725 Not Covered INFO MEDICAID G9726 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto knee intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available G9727 Not Covered INFO MEDICAID G9728 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto hip intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available G9729 Not Covered INFO MEDICAID G9730 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto foot or ankle intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available G9731 Not Covered INFO MEDICAID G9732 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto lumbar intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is G9733 not available Not Covered INFO MEDICAID G9734 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto shoulder intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is G9735 not available Not Covered INFO MEDICAID G9736 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto elbow, wrist or hand intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available G9737 Not Covered INFO MEDICAID G9738 Patient refused to participate Not Covered INFO MEDICAID Patient unable to complete the foto general orthopedic intake prom at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available G9739 Not Covered INFO MEDICAID Hospice services given to patient any time G9740 during the measurement period Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9741 Not Covered INFO MEDICAID G9742 Psychiatric symptoms assessed Not Covered INFO MEDICAID Psychiatric symptoms not assessed, G9743 reason not otherwise specified Not Covered INFO MEDICAID Patient not eligible due to active diagnosis G9744 of hypertension Not Covered INFO MEDICAID

531 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documented reason for not screening or recommending a follow-up for high blood G9745 pressure Not Covered INFO MEDICAID Patient has mitral stenosis or prosthetic heart valves or patient has transient or reversible cause of af (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac G9746 surgery) Not Covered INFO MEDICAID Patient is undergoing palliative dialysis G9747 with a catheter Not Covered INFO MEDICAID Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant G9748 Not Covered INFO MEDICAID Patient is undergoing palliative dialysis G9749 with a catheter Not Covered INFO MEDICAID Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant G9750 Not Covered INFO MEDICAID Patient died at any time during the 24- G9751 month measurement period Not Covered INFO MEDICAID G9752 Emergency surgery Not Covered INFO MEDICAID Documentation of medical reason for not conducting a search for dicom format images for prior patient ct imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12 months that are available through a secure, authorized, media-free, shared archive (e.g., trauma, acute myocardial infarction, stroke, aortic aneurysm where time is of the essence)

G9753 Not Covered INFO MEDICAID A finding of an incidental pulmonary G9754 nodule Not Covered INFO MEDICAID Documentation of medical reason(s) that follow-up imaging is indicated (e.g., patient has a known malignancy that can metastasize, other medical reason(s) G9755 Not Covered INFO MEDICAID Surgical procedures that included the use G9756 of silicone oil Not Covered INFO MEDICAID Surgical procedures that included the use G9757 of silicone oil Not Covered INFO MEDICAID Patient in hospice and in terminal phase G9758 Not Covered INFO MEDICAID History of preoperative posterior capsule G9759 rupture Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9760 Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9761 Not Covered INFO MEDICAID Patient had at least three hpv vaccines on or between the patient's 9th and 13th G9762 birthdays Not Covered INFO MEDICAID Patient did not have at least three hpv vaccines on or between the patient's 9th G9763 and 13th birthdays Not Covered INFO MEDICAID Patient has been treated with an oral systemic or biologic medication for G9764 psoriasis Not Covered INFO MEDICAID

532 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation that the patient declined therapy change, has documented contraindications, or has not been treated with an oral systemic or biologic for at least six consecutive months (e.g., experienced adverse effects or lack of efficacy with all other therapy options) in order to achieve better disease control as measured by pga, bsa, pasi, or dlqi

G9765 Not Covered INFO MEDICAID Patients who are transferred from one institution to another with a known diagnosis of cva for endovascular stroke G9766 treatment Not Covered INFO MEDICAID Hospitalized patients with newly diagnosed cva considered for G9767 endovascular stroke treatment Not Covered INFO MEDICAID Patients who utilize hospice services any time during the measurement period G9768 Not Covered INFO MEDICAID Patient had a bone mineral density test in the past two years or received osteoporosis medication or therapy in the G9769 past 12 months Not Covered INFO MEDICAID G9770 Peripheral nerve block (pnb) Not Covered INFO MEDICAID At least 1 body temperature measurement equal to or greater than 35.5 degrees celsius (or 95.9 degrees fahrenheit) achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time G9771 Not Covered INFO MEDICAID Documentation of one of the following medical reason(s) for not achieving at least 1 body temperature measurement equal to or greater than 35.5 degrees celsius (or 95.9 degrees fahrenheit) achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (e.g., emergency cases, intentional hypothermia, etc.) G9772 Not Covered INFO MEDICAID At least 1 body temperature measurement equal to or greater than 35.5 degrees celsius (or 95.9 degrees fahrenheit) not achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time G9773 Not Covered INFO MEDICAID Patients who have had a hysterectomy G9774 Not Covered INFO MEDICAID Patient received at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or G9775 intraoperatively Not Covered INFO MEDICAID Documentation of medical reason for not receiving at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively (e.g., intolerance or other G9776 medical reason) Not Covered INFO MEDICAID Patient did not receive at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively G9777 and/or intraoperatively Not Covered INFO MEDICAID Patients who have a diagnosis of G9778 pregnancy Not Covered INFO MEDICAID G9779 Patients who are breastfeeding Not Covered INFO MEDICAID

533 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patients who have a diagnosis of G9780 rhabdomyolysis Not Covered INFO MEDICAID Documentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, and patients with end stage renal disease (esrd)) G9781 Not Covered INFO MEDICAID History of or active diagnosis of familial or G9782 pure hypercholesterolemia Not Covered INFO MEDICAID Documentation of patients with diabetes who have a most recent fasting or direct ldl- c laboratory test result < 70 mg/dl and are not taking statin therapy G9783 Not Covered INFO MEDICAID Pathologists/dermatopathologists providing a second opinion on a biopsy G9784 Not Covered INFO MEDICAID Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the pathologist/dermatopathologist to the biopsying clinician for review within 7 business days from the time when the tissue specimen was received by the pathologist G9785 Not Covered INFO MEDICAID Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) was not sent from the pathologist/dermatopathologist to the biopsying clinician for review within 7 business days from the time when the tissue specimen was received by the G9786 pathologist Not Covered INFO MEDICAID Patient alive as of the last day of the G9787 measurement year Not Covered INFO MEDICAID Most recent bp is less than or equal to G9788 140/90 mm hg Not Covered INFO MEDICAID Blood pressure recorded during inpatient stays, emergency room visits, urgent care visits, and patient self-reported bp's (home and health fair bp results) G9789 Not Covered INFO MEDICAID Most recent bp is greater than 140/90 mm hg, or blood pressure not documented G9790 Not Covered INFO MEDICAID Most recent tobacco status is tobacco G9791 free Not Covered INFO MEDICAID Most recent tobacco status is not tobacco G9792 free Not Covered INFO MEDICAID Patient is currently on a daily aspirin or G9793 other antiplatelet Not Covered INFO MEDICAID Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g. history of gastrointestinal bleed or intra-cranial bleed or documentation of active anticoagulant use during the measurement period G9794 Not Covered INFO MEDICAID Patient is not currently on a daily aspirin G9795 or other antiplatelet Not Covered INFO MEDICAID G9796 Patient is currently on a statin therapy Not Covered INFO MEDICAID G9797 Patient is not on a statin therapy Not Covered INFO MEDICAID

534 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Discharge(s) for ami between july 1 of the year prior measurement year to june 30 of G9798 the measurement period Not Covered INFO MEDICAID Patients with a medication dispensing event indicator of a history of asthma any time during the patient's history through the end of the measure period G9799 Not Covered INFO MEDICAID Patients who are identified as having an intolerance or allergy to beta-blocker G9800 therapy Not Covered INFO MEDICAID Hospitalizations in which the patient was transferred directly to a non-acute care G9801 facility for any diagnosis` Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9802 Not Covered INFO MEDICAID Patient prescribed a 180-day course of treatment with beta-blockers post G9803 discharge for ami Not Covered INFO MEDICAID Patient was not prescribed a 180-day course of treatment with beta-blockers G9804 post discharge for ami Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9805 Not Covered INFO MEDICAID Patients who received cervical cytology or G9806 an hpv test Not Covered INFO MEDICAID Patients who did not receive cervical G9807 cytology or an hpv test Not Covered INFO MEDICAID Any patients who had no asthma controller medications dispensed during G9808 the measurement year Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9809 Not Covered INFO MEDICAID Patient achieved a pdc of at least 75% for their asthma controller medication G9810 Not Covered INFO MEDICAID Patient did not achieve a pdc of at least 75% for their asthma controller medication G9811 Not Covered INFO MEDICAID Patient died including all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure G9812 Not Covered INFO MEDICAID Patient did not die within 30 days of the procedure or during the index G9813 hospitalization Not Covered INFO MEDICAID Death occurring during hospitalization G9814 Not Covered INFO MEDICAID Death did not occur during hospitalization G9815 Not Covered INFO MEDICAID Death occurring 30 days post procedure G9816 Not Covered INFO MEDICAID Death did not occur 30 days post G9817 procedure Not Covered INFO MEDICAID G9818 Documentation of sexual activity Not Covered INFO MEDICAID Patients who use hospice services any time during the measurement period G9819 Not Covered INFO MEDICAID Documentation of a chlamydia screening G9820 test with proper follow-up Not Covered INFO MEDICAID No documentation of a chlamydia G9821 screening test with proper follow-up Not Covered INFO MEDICAID

535 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Women who had an endometrial ablation procedure during the year prior to the index date (exclusive of the index date) G9822 Not Covered INFO MEDICAID Endometrial sampling or hysteroscopy with biopsy and results documented G9823 Not Covered INFO MEDICAID Endometrial sampling or hysteroscopy with biopsy and results not documented G9824 Not Covered INFO MEDICAID Her-2/neu negative or G9825 undocumented/unknown Not Covered INFO MEDICAID Patient transferred to practice after G9826 initiation of chemotherapy Not Covered INFO MEDICAID Her2-targeted therapies not administered during the initial course of treatment G9827 Not Covered INFO MEDICAID Her2-targeted therapies administered during the initial course of treatment G9828 Not Covered INFO MEDICAID Breast adjuvant chemotherapy G9829 administered Not Covered INFO MEDICAID G9830 Her-2/neu positive Not Covered INFO MEDICAID Ajcc stage at breast cancer diagnosis = ii G9831 or iii Not Covered INFO MEDICAID Ajcc stage at breast cancer diagnosis = i (ia or ib) and t-stage at breast cancer diagnosis does not equal = t1, t1a, t1b G9832 Not Covered INFO MEDICAID Patient transfer to practice after initiation G9833 of chemotherapy Not Covered INFO MEDICAID Patient has metastatic disease at G9834 diagnosis Not Covered INFO MEDICAID Trastuzumab administered within 12 G9835 months of diagnosis Not Covered INFO MEDICAID Reason for not administering trastuzumab documented (e.g. patient declined, patient died, patient transferred, contraindication or other clinical exclusion, neoadjuvant chemotherapy or radiation not complete)

G9836 Not Covered INFO MEDICAID Trastuzumab not administered within 12 G9837 months of diagnosis Not Covered INFO MEDICAID Patient has metastatic disease at G9838 diagnosis Not Covered INFO MEDICAID Anti-egfr monoclonal antibody therapy G9839 Not Covered INFO MEDICAID Kras gene mutation testing performed before initiation of anti-egfr moab G9840 Not Covered INFO MEDICAID Kras gene mutation testing not performed before initiation of anti-egfr moab G9841 Not Covered INFO MEDICAID Patient has metastatic disease at G9842 diagnosis Not Covered INFO MEDICAID G9843 Kras gene mutation Not Covered INFO MEDICAID Patient did not receive anti-egfr G9844 monoclonal antibody therapy Not Covered INFO MEDICAID Patient received anti-egfr monoclonal G9845 antibody therapy Not Covered INFO MEDICAID G9846 Patients who died from cancer Not Covered INFO MEDICAID Patient received chemotherapy in the last G9847 14 days of life Not Covered INFO MEDICAID Patient did not receive chemotherapy in G9848 the last 14 days of life Not Covered INFO MEDICAID G9849 Patients who died from cancer Not Covered INFO MEDICAID Patient had more than one emergency department visit in the last 30 days of life G9850 Not Covered INFO MEDICAID

536 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Patient had one or less emergency department visits in the last 30 days of life G9851 Not Covered INFO MEDICAID G9852 Patients who died from cancer Not Covered INFO MEDICAID Patient admitted to the icu in the last 30 G9853 days of life Not Covered INFO MEDICAID Patient was not admitted to the icu in the G9854 last 30 days of life Not Covered INFO MEDICAID G9855 Patients who died from cancer Not Covered INFO MEDICAID G9856 Patient was not admitted to hospice Not Covered INFO MEDICAID G9857 Patient admitted to hospice Not Covered INFO MEDICAID G9858 Patient enrolled in hospice Not Covered INFO MEDICAID G9859 Patients who died from cancer Not Covered INFO MEDICAID Patient spent less than three days in G9860 hospice care Not Covered INFO MEDICAID Patient spent greater than or equal to G9861 three days in hospice care Not Covered INFO MEDICAID Documentation of medical reason(s) for not recommending at least a 10 year follow-up interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is = 66 years old, or life expectancy < 10 years old, other medical reasons) G9862 Not Covered INFO MEDICAID Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use under the Next Generation ACO model, less than 10 minutes. G9868 No MEDICAID Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use under the Next Generation ACO model, 10‐ 20 minutes G9869 No MEDICAID Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use under the Next Generation ACO model, 20 or more minutes. G9870 No MEDICAID First Medicare Diabetes Prevention Program (MDPP) core session was attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: 1. is furnished by an MDPP supplier during months 1 thru 6 of the MDPP services period; 2. is approximately 1 hour in length; and 3. adheres to a CDC-approved DPP curriculum for core sessions G9873 Not Covered MEDICAID Four total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP servcie that: 1 is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period: 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for core sessions

G9874 Not Covered MEDICAID

537 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Nine total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: 1 is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; 2 is approxmately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for core sessions

G9875 Not Covered MEDICAID Two Medicare Diabetes Prevention Prgram (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7‐9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that; 1 is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; 2 is approximately 1 hour in lenght; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9876 Not Covered MEDICAID Two Medicare Diabetes Prevention Prgram (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10‐12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that; 1 is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9877 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7‐9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions G9878 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10‐12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions G9879 Not Covered MEDICAID The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight in months 1‐12 of the MDPP services period under the MDPP Expanded Model (EM). This is a one time payment available when a beneficiary first achieves at least 5% weight loss from baseline as measured by an in‐person weight measurement at a core session or core maintenance session.

G9880 Not Covered MEDICAID

538 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her baseline weight in months 1‐24 of the MDPP services period under the MDPP Expanded Model (EM). This is a one time payment available when a beneficiary first achieves at least 9% weight loss from baseline as measured by an in‐person weight measurement at a core session, core maintenance session, or ongoing maintenance sessions.

G9881 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficary in months (mo) 13-15 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: 1 is furnished by an MDPP supplier during months 13 through 24 of the MDPP supplier during months 13 through 24 of the MDPP services period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9882 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficary in months (mo) 16-18 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: 1 is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9883 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 19-21 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that; 1 is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9884 Not Covered MEDICAID Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP Model (EM). An ongoing maintenance sessions is an MDPP service that: 1 is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; 2 is approximately 1 hour in length; and 3 adheres to a CDC approved DPP curriculum for maintenance sessions.

G9885 Not Covered MEDICAID

539 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Bridge Payment: A one time payment for the first Medicare Diabetes Prevention Program (MDPP) core session, core maintenance session, or ongoint maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the MDPP Expanded Model. A supplier may only receive one bridge payment per MDPP beneficiary. G9890 Not Covered MEDICAID MDPP session reported as a line‐item on a claim for a payable MDPP Expanded Model (EM) HCPCS code for a session furnished by the billing supplier under the MDPP Expanded Model and counting toward achievement of the attendance performance goal for the payable MDPP Expanded Model HCPCS code. (This is for reporting purposes only)

G9891 Not Covered MEDICAID Dilated macular exam was not performed, reason not otherwise specified G9893 Not Covered INFO MEDICAID Androgen deprivation therapy prescribed/administered in combination with external beam radiotherapy to the G9894 prostate Not Covered INFO MEDICAID Documentation of medical reason(s) for not prescribing/administering androgen deprivation therapy in combination with external beam radiotherapy to the prostate (e.g., salvage therapy) G9895 Not Covered INFO MEDICAID Documentation of patient reason(s) for not prescribing/administering androgen deprivation therapy in combination with external beam radiotherapy to the G9896 prostate Not Covered INFO MEDICAID Patients who were not prescribed/administered androgen deprivation therapy in combination with external beam radiotherapy to the G9897 prostate, reason not given Not Covered INFO MEDICAID Patient age 65 or older in institutinal special needs plans (snp) or residing in long-term care with pos code 32, 33, 34, 54, or 56 any time during the G9898 measurement period Not Covered INFO MEDICAID Screening, diagnostic, film, digital or digital breast tomosynthesis (3d) mammography results documented and G9899 reviewed Not Covered INFO MEDICAID Screening, diagnostic, film, digital or digital breast tomosynthesis (3d) mammography results were not documented and reviewed, reason not G9900 otherwise specified Not Covered INFO MEDICAID Patient age 65 or older in institutional special needs plans (snp) or residing in long-term care with pos code 32, 33, 34, 54, or 56 any time during the G9901 measurement period Not Covered INFO MEDICAID Patient screened for tobacco use and G9902 identified as a tobacco user Not Covered INFO MEDICAID Patient screened for tobacco use and G9903 identified as a tobacco non-user Not Covered INFO MEDICAID

540 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical G9904 reason) Not Covered INFO MEDICAID Patient not screened for tobacco use, G9905 reason not given Not Covered INFO MEDICAID Patient identified as a tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy) G9906 Not Covered INFO MEDICAID Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, G9907 other medical reason) Not Covered INFO MEDICAID Patient identified as tobacco user did not receive tobacco cessation intervention (counseling and/or pharmacotherapy), G9908 reason not given Not Covered INFO MEDICAID Documentation of medical reason(s) for not providing tobacco cessation intervention if identified as a tobacco user (eg, limited life expectancy, other medical G9909 reason) Not Covered INFO MEDICAID Patients age 65 or older in institutional special needs plans (snp) or residing in long-term care with pos code 32, 33, 34, 54 or 56 anytime during the measurement period G9910 Not Covered INFO MEDICAID Clinically node negative (t1n0m0 or t2n0m0) invasive breast cancer before or after neoadjuvant systemic therapy G9911 Not Covered INFO MEDICAID Hepatitis b virus (hbv) status assessed and results interpreted prior to initiating anti-tnf (tumor necrosis factor) therapy G9912 Not Covered INFO MEDICAID Hepatitis b virus (hbv) status not assessed and results interpreted prior to initiating anti-tnf (tumor necrosis factor) therapy, reason not given G9913 Not Covered INFO MEDICAID G9914 Patient receiving an anti-tnf agent Not Covered INFO MEDICAID G9915 No record of hbv results documented Not Covered INFO MEDICAID Functional status performed once in the G9916 last 12 months Not Covered INFO MEDICAID Documentation of medical reason(s) for not performing functional status (e.g., patient is severely impaired and caregiver knowledge is limited, other medical G9917 reason) Not Covered INFO MEDICAID Functional status not performed, reason G9918 not otherwise specified Not Covered INFO MEDICAID Screening performed and positive and G9919 provision of recommendations Not Covered INFO MEDICAID G9920 Screening performed and negative Not Covered INFO MEDICAID No screening performed, partial screening performed or positive screen without recommendations and reason is not given or otherwise specified G9921 Not Covered INFO MEDICAID Safety concerns screen provided and if positive then documented mitigation G9922 recommendations Not Covered INFO MEDICAID Safety concerns screen provided and G9923 negative Not Covered INFO MEDICAID

541 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Documentation of medical reason(s) for not providing safety concerns screen or for not providing recommendations, orders or referrals for positive screen (e.g., patient in palliative care, other medical reason) G9924 Not Covered INFO MEDICAID Safety concerns screening not provided, reason not otherwise specified G9925 Not Covered INFO MEDICAID Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources G9926 Not Covered INFO MEDICAID Documentation of system reason(s) for not prescribing warfarin or another fda- approved anticoagulation due to patient being currently enrolled in a clinical trial related to af/atrial flutter treatment G9927 Not Covered INFO MEDICAID Warfarin or another fda-approved anticoagulant not prescribed, reason not G9928 given Not Covered INFO MEDICAID Patient with transient or reversible cause of af (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery) G9929 Not Covered INFO MEDICAID Patients who are receiving comfort care G9930 only Not Covered INFO MEDICAID Documentation of cha2ds2-vasc risk G9931 score of 0 or 1 Not Covered INFO MEDICAID Documentation of patient reason(s) for not having records of negative or managed positive tb screen (e.g., patient does not return for mantoux (ppd) skin test G9932 evaluation) Not Covered INFO MEDICAID Adenoma(s) or colorectal cancer detected during screening colonoscopy G9933 Not Covered INFO MEDICAID Documentation that neoplasm detected is only diagnosed as traditional serrated adenoma, sessile serrated polyp, or sessile serrated adenoma G9934 Not Covered INFO MEDICAID Adenoma(s) or colorectal cancer not detected during screening colonoscopy G9935 Not Covered INFO MEDICAID Surveillance colonoscopy - personal history of colonic polyps, colon cancer, or other malignant neoplasm of rectum, rectosigmoid junction, and anus G9936 Not Covered INFO MEDICAID G9937 Diagnostic colonoscopy Not Covered INFO MEDICAID Patients age 65 or older in institutional special needs plans (snp) or residing in long-term care with pos code 32, 33, 34, 54, or 56 any time during the measurement period G9938 Not Covered INFO MEDICAID Pathologists/dermatopathologists is the same clinician who performed the biopsy G9939 Not Covered INFO MEDICAID Documentation of medical reason(s) for not on a statin (e.g., pregnancy, in vitro fertilization, clomiphene rx, esrd, cirrhosis, muscular pain and disease during the measurement period or prior year) G9940 Not Covered INFO MEDICAID

542 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Back pain was measured by the visual analog scale (vas) within three months preoperatively and at three months (6 - 20 weeks) postoperatively G9941 Not Covered INFO MEDICAID Patient had any additional spine procedures performed on the same date as the lumbar discectomy/laminotomy G9942 Not Covered INFO MEDICAID Back pain was not measured by the visual analog scale (vas) within three months preoperatively and at three months ( 6 - 20 weeks) postoperatively G9943 Not Covered INFO MEDICAID Back pain was measured by the visual analog scale (vas) within three months preoperatively and at one year (9 to 15 G9944 months) postoperatively Not Covered INFO MEDICAID Patient had cancer, fracture or infection related to the lumbar spine or patient had idiopathic or congenital scoliosis G9945 Not Covered INFO MEDICAID Back pain was not measured by the visual analog scale (vas) within three months preoperatively and at one year (9 to 15 G9946 months) postoperatively Not Covered INFO MEDICAID Leg pain was measured by the visual analog scale (vas) within three months preoperatively and at three months (6 to 20 weeks) postoperatively G9947 Not Covered INFO MEDICAID Patient had any additional spine procedures performed on the same date as the lumbar discectomy/laminotomy G9948 Not Covered INFO MEDICAID Leg pain was not measured by the visual analog scale (vas) within three months preoperatively and at three months (6 to 20 weeks) postoperatively G9949 Not Covered INFO MEDICAID Patient exhibits 2 or more risk factors for G9954 post-operative vomiting Not Covered INFO MEDICAID Cases in which an inhalational anesthetic G9955 is used only for induction Not Covered INFO MEDICAID Patient received combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or G9956 intraoperatively Not Covered INFO MEDICAID Documentation of medical reason for not receiving combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively (e.g., intolerance or other medical reason) G9957 Not Covered INFO MEDICAID Patient did not receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively G9958 and/or intraoperatively Not Covered INFO MEDICAID Systemic antimicrobials not prescribed G9959 Not Covered INFO MEDICAID Documentation of medical reason(s) for prescribing systemic antimicrobials G9960 Not Covered INFO MEDICAID G9961 Systemic antimicrobials prescribed Not Covered INFO MEDICAID

543 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Embolization endpoints are documented separately for each embolized vessel and ovarian artery angiography or embolization performed in the presence of variant uterine artery anatomy G9962 Not Covered INFO MEDICAID Embolization endpoints are not documented separately for each embolized vessel or ovarian artery angiography or embolization not performed in the presence of variant G9963 uterine artery anatomy Not Covered INFO MEDICAID Patient received at least one well-child visit with a pcp during the performance G9964 period Not Covered INFO MEDICAID Patient did not receive at least one well- child visit with a pcp during the G9965 performance period Not Covered INFO MEDICAID Children who were screened for risk of developmental, behavioral and social delays using a standardized tool with G9966 interpretation and report Not Covered INFO MEDICAID Children who were not screened for risk of developmental, behavioral and social delays using a standardized tool with G9967 interpretation and report Not Covered INFO MEDICAID Patient was referred to another provider or specialist during the performance G9968 period Not Covered INFO MEDICAID Provider who referred the patient to another provider received a report from the provider to whom the patient was G9969 referred Not Covered INFO MEDICAID Provider who referred the patient to another provider did not receive a report from the provider to whom the patient was G9970 referred Not Covered INFO MEDICAID Dilated macular exam performed, including documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage and the level of macular degeneration severity G9974 Not Covered INFO MEDICAID Documentation of medical reason(s) for not performing a dilated macular G9975 examination Not Covered INFO MEDICAID Documentation of patient reason(s) for not performing a dilated macular examination G9976 Not Covered INFO MEDICAID Dilated macular exam was not performed, reason not otherwise specified G9977 Not Covered INFO MEDICAID G9978 Remote in-home visit for the evaluation and Not Covered INFO MEDICAID G9979 Remote in-home visit for the evaluation and Not Covered INFO MEDICAID G9980 Remote in-home visit for the evaluation and Not Covered INFO MEDICAID G9981 Remote E/M new pt 45mins Not Covered INFO MEDICAID G9982 Remote E/M new pt 60mins Not Covered INFO MEDICAID G9983 Remote E/M est. pt 10mins Not Covered INFO MEDICAID G9984 Remote E/M est. pt 15mins Not Covered INFO MEDICAID G9985 Remote E/M est. pt 25mins Not Covered INFO MEDICAID G9986 Remote E/M est. pt 40mins Not Covered INFO MEDICAID G9987 Bundled Payments for Care Improvement A Not Covered INFO MEDICAID H1000 Prenatal care, at-risk assessment No MEDICAID Prenatal care, at-risk enhanced service; H1001 antepartum management Not Covered MEDICAID Prenatal care, at risk enhanced service; H1002 care coordination Not Covered MEDICAID Prenatal care, at-risk enhanced service; H1003 education Not Covered MEDICAID Prenatal care, at-risk enhanced service; H1004 follow-up home visit Not Covered MEDICAID

544 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Prenatal care, at-risk enhanced service package (includes H1001-H1004) H1005 Not Covered MEDICAID NON-MEDICAL FAMILY PLANNING H1010 EDUCATION, PER SESSION Not Covered MEDICAID Comprehensive multidisciplinary H2000 evaluation No MEDICAID H2001 Rehabilitation program, per 1/2 day Yes MEDICAID INJECTION, TETRACYCLINE, UP TO J0120 250 MG No MEDICAID INJECTION, ABATACEPT, PER 10 MG J0129 Yes ExGEN MEDICAID J0130 INJECTION ABCIXIMAB, 10 MG No MEDICAID INJECTION, ACETAMINOPHEN, 10 MG J0131 Yes MEDICAID INJECTION, ACETYLCYSTEINE, 100 J0132 MG No MEDICAID J0133 INJECTION, ACYCLOVIR, 5 MG No MEDICAID J0135 INJECTION, ADALIMUMAB, 20 MG No MEDICAID Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate J0153 compounds) No MEDICAID INJECTION, ADRENALIN, J0171 EPINEPHRINE, 0.1 MG No MEDICAID J0178 INJECTION, AFLIBERCEPT, 1 mg No MEDICAID INJECTION, AGALSIDASE BETA, 1 MG J0180 No MEDICAID INJECTION, BIPERIDEN LACTATE, PER J0190 5 MG No MEDICAID INJECTION, ALATROFLOXACIN J0200 MESYLATE, 100 MG No MEDICAID J0202 Injection, alemtuzumab, 1 mg No MEDICAID INJECTION, ALGLUCERASE, PER 10 J0205 UNITS Yes ExGEN MEDICAID J0207 INJECTION, AMIFOSTINE, 500 MG No MEDICAID INJECTION, METHYLDOPATE HCL, UP J0210 TO 250 MG No MEDICAID J0215 INJECTION, ALEFACEPT, 0.5 MG No MEDICAID INJECTION, AGLUCOSIDASE ALFA, 10 J0220 MG No MEDICAID INJECTION, ALGLUCOSIDASE ALFA, J0221 (LUMIZYME), 10 MG No MEDICAID INJECTION, ALPHA 1 - PROTEINASE J0256 INHIBITOR - HUMAN, 10 MG No MEDICAID INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 J0257 MG No MEDICAID INJECTION, ALPROSTADIL, 1.25 MCG J0270 No MEDICAID ALPROSTADIL URETHRAL J0275 SUPPOSITORY No MEDICAID INJECTION, AMIKACIN SULFATE, 100 J0278 MG No MEDICAID INJECTION, AMINOPHYLLIN, UP TO J0280 250 MG No MEDICAID INJECTION, AMIODARONE J0282 HYDROCHLORIDE, 30 MG No MEDICAID INJECTION, AMPHOTERICIN B, 50 MG J0285 No MEDICAID INJECTION, AMPHOTERICIN B LIPID J0287 COMPLEX, 10 MG No MEDICAID INJECTION, AMPHOTERICIN B J0288 CHOLESTERYL SULFATE COMPLEX, Yes 10 MG MEDICAID INJECTION, AMPHOTERICIN B J0289 LIPOSOME, 10 MG No MEDICAID INJECTION, AMPICILLIN SODIUM, 500 J0290 MG No MEDICAID INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER J0295 1.5 GM No MEDICAID

545 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, AMOBARBITAL, UP TO 125 J0300 MG No MEDICAID INJECTION, SUCCINYLCHOLINE J0330 CHLORIDE, UP TO 20 MG No MEDICAID J0348 INJECTION, ANADULAFUNGIN, 1 MG No MEDICAID INJECTION, ANISTREPLASE, PER 30 J0350 UNITS No MEDICAID INJECTION, HYDRALAZINE HCL, UP J0360 TO 20 MG No MEDICAID INJECTION, APOMORPHINE J0364 HYDROCHLORIDE, 1 MG No MEDICAID INJECTION, APROTONIN, 10,000 KIU J0365 No MEDICAID INJECTION, METARAMINOL J0380 Yes BITARTRATE, PER 10 MG MEDICAID INJECTION, CHLOROQUINE J0390 HYDROCHLORIDE, UP TO 250 MG No MEDICAID INJECTION, ARBUTAMINE HCL, 1 MG J0395 No MEDICAID INJECTION, ARIPIPRAZOLE, J0400 INTRAMUSCULAR, 0.25 MG No MEDICAID Injection, aripiprazole, extended release, 1 J0401 mg No MEDICAID INJECTION, AZITHROMYCIN, 500 MG J0456 No MEDICAID J0461 INJECTION, ATROPINE SULFATE, 0.01 MG No MEDICAID INJECTION, DIMERCAPROL, PER 100 J0470 MG No MEDICAID J0475 INJECTION, BACLOFEN, 10 MG No MEDICAID INJECTION, BACLOFEN, 50 MCG FOR J0476 INTRATHECAL TRIAL No MEDICAID J0480 INJECTION, BASILIXIMAB, 20 MG No MEDICAID J0485 Injection, belatacept, 1 mg No MEDICAID J0490 INJECTION, BELIMUMAB, 10 MG No MEDICAID INJECTION, DICYCLOMINE HCL, UP TO J0500 20 MG No MEDICAID INJECTION, BENZTROPINE J0515 MESYLATE, PER 1 MG No MEDICAID INJECTION, BETHANECHOL J0520 CHLORIDE, MYOTONACHOL OR Yes URECHOLINE, UP TO 5 MG MEDICAID INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G J0558 PROCAINE, 100,000 UNITS No MEDICAID INJECTION, PENICILLIN G J0561 BENZATHINE, 100,000 UNITS No MEDICAID J0565 Injection, bezlotoxumab, 10 mg No MEDICAID J0570 Buprenorphine implant, 74.2 mg No MEDICAID J0571 Buprenorphine, oral, 1 mg No MEDICAID Buprenorphine/naloxone, oral, less than J0572 or equal to 3 mg No MEDICAID Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg J0573 No MEDICAID Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg J0574 No MEDICAID Buprenorphine/naloxone, oral, greater J0575 than 10 mg No MEDICAID J0583 INJECTION, BIVALIRUDIN, 1 MG No MEDICAID BOTULINUM TOXIN TYPE A, PER UNIT J0585 Yes RMT/* MEDICAID J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS Yes RMT MEDICAID BOTULINUM TOXIN TYPE B, PER 100 J0587 UNITS No MEDICAID INJECTION, INCOBOTULINUMTOXIN A, J0588 1 UNIT No MEDICAID INJECTION, BUPRENORPHINE J0592 HYDROCHLORIDE, 0.1 MG No MEDICAID

546 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines J0594 INJECTION, BUSULFAN, 1 MG No MEDICAID INJECTION, BUTORPHANOL J0595 TARTRATE, 1 MG No MEDICAID Injection, c1 esterase inhibitor J0596 (recombinant), ruconest, 10 units No MEDICAID INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS J0597 No MEDICAID INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS J0598 No MEDICAID INJECTION, EDETATE CALCIUM J0600 DISODIUM, UP TO 1000 MG No MEDICAID Cinacalcet, oral, 1 mg, (for esrd on J0604 dialysis) No MEDICAID J0606 Injection, etelcalcetide, 0.1 mg No MEDICAID INJECTION, CALCIUM GLUCONATE, J0610 PER 10 ML No MEDICAID INJECTION, CALCIUM J0620 GLYCEROPHOSPHATE AND CALCIUM Yes LACTATE, PER 10 ML MEDICAID INJECTION, CALCITONIN SALMON, UP J0630 TO 400 UNITS No MEDICAID J0636 INJECTION, CALCITRIOL, 0.1 MCG No MEDICAID INJECTION, CASPOFUNGIN ACETATE, J0637 5 MG No MEDICAID J0638 INJECTION, CANAKINUMAB, 1 MG No MEDICAID INJECTION, LEUCOVORIN CALCIUM, J0640 PER 50 MG No MEDICAID INJECTION, LEVOLEUCOVORIN J0641 CALCIUM, 0.5 MG No MEDICAID INJECTION, MEPIVACAINE J0670 HYDROCHLORIDE, PER 10 ML No MEDICAID INJECTION, CEFAZOLIN SODIUM, 500 J0690 MG No MEDICAID INJECTION, CEFEPIME J0692 HYDROCHLORIDE, 500 MG No MEDICAID INJECTION, CEFOXITIN SODIUM, 1 GM J0694 No MEDICAID Injection, ceftolozane 50 mg and tazobactam 25 J0695 Yes mg MEDICAID INJECTION, CEFTRIAXONE SODIUM, J0696 PER 250 MG No MEDICAID INJECTION, STERILE CEFUROXIME J0697 SODIUM, PER 750 MG No MEDICAID INJECTION, CEFOTAXIME SODIUM, J0698 PER GM No MEDICAID INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIUM J0702 PHOSPHATE 3MG No MEDICAID INJECTION, CAFFEINE CITRATE, 5MG J0706 No MEDICAID INJECTION, CEPHAPIRIN SODIUM, UP J0710 Yes TO 1 GM MEDICAID INJECTION, CEFTAROLINE FOSAMIL, J0712 10 MG No MEDICAID INJECTION, CEFTAZIDIME, PER 500 J0713 MG No MEDICAID Injection, ceftazidime and avibactam, 0.5 J0714 Yes g/0.125 g MEDICAID INJECTION, CEFTIZOXIME SODIUM, J0715 Yes PER 500 MG MEDICAID J0716 Injection, centruroides immune f(ab)2, up to 120 milligrams No MEDICAID Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) J0717 No MEDICAID

547 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, CHLORAMPHENICOL J0720 SODIUM SUCCINATE, UP TO 1 GM No MEDICAID INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP J0725 UNITS No MEDICAID INJECTION, CLONIDINE J0735 HYDROCHLORIDE, 1 MG No MEDICAID J0740 INJECTION, CIDOFOVIR, 375 MG No MEDICAID INJECTION, CILASTATIN SODIUM; J0743 IMIPENEM, PER 250 MG No MEDICAID INJECTION, CIPROFLOXACIN FOR J0744 Yes INTRAVENOUS INFUSION, 200 MG MEDICAID INJECTION, CODEINE PHOSPHATE, J0745 Yes PER 30 MG MEDICAID INJECTION, COLISTIMETHATE J0770 SODIUM, UP TO 150 MG No MEDICAID INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 J0775 MG No MEDICAID INJECTION, PROCHLORPERAZINE, UP J0780 TO 10 MG No MEDICAID INJECTION, CORTICORELIN OVINE J0795 TRIFLUTATE, 1 MICROGRAM No MEDICAID INJECTION, CORTICOTROPIN, UP TO J0800 40 UNITS No MEDICAID J0833 INJECTION, COSYNTROPIN, NOT OTHERWISE SPECIFIED, 0.25 MG No MEDICAID J0834 INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG No MEDICAID INJECTION, CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), J0840 UP TO 1 GRAM No MEDICAID INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS J0850 (HUMAN), PER VIAL Yes ExGEN MEDICAID INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS J0850 (HUMAN), PER VIAL No MEDICAID J0875 Injection, dalbavancin, 5mg No MEDICAID J0878 INJECTION, DAPTOMYCIN, 1 MG No MEDICAID INJECTION, DARBEPOETIN ALFA, 1 J0881 MICROGRAM (NON-ESRD USE) No MEDICAID INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD OM J0882 DIALYSIS) No MEDICAID Injection, argatroban, 1 mg (for non-esrd J0883 Yes use) MEDICAID Injection, argatroban, 1 mg (for esrd on J0884 Yes dialysis) MEDICAID INJECTION, EPOETIN ALFA, (FOR NON- J0885 ESRD USE), 1000 UNITS No MEDICAID INJECTION, EPOETIN ALFA, 1000 J0886 UNITS (FOR ESRD ON DIALYSIS) No MEDICAID Injection, epoetin beta, 1 microgram, (for J0887 esrd on dialysis) No MEDICAID Injectin, epoetin beta, 1 microgram, (for J0888 non esrd use) No MEDICAID J0890 Injection, peginesatide, 0. 1 mg (for esrd on dialysis) No MEDICAID J0894 INJECTION, DECITABINE, 1 MG No MEDICAID INJECTION, DEFEROXAMINE J0895 MESYLATE, 500 MG No MEDICAID J0897 INJECTION, DENOSUMAB, 1 MG No MEDICAID INJECTION, BROMPHENIRAMINE J0945 Yes MALEATE, PER 10 MG MEDICAID INJECTION, DEPO-ESTRADIOL J1000 CYPIONATE, UP TO 5 MG No MEDICAID INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG J1020 No MEDICAID

548 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG J1030 No MEDICAID INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG J1040 No MEDICAID J1050 Injection, medroxyprogesterone acetate, 1 mg No MEDICAID Injection, testosterone cypionate, 1mg J1071 No MEDICAID INJECTION, DEXAMETHASONE J1094 ACETATE, 1 MG No MEDICAID INJECTION, DEXAMETHASONE J1100 SODIUM PHOSPHATE, 1MG No MEDICAID INJECTION, DIHYDROERGOTAMINE J1110 MESYLATE, PER 1 MG No MEDICAID INJECTION, ACETAZOLAMIDE J1120 SODIUM, UP TO 500 MG No MEDICAID J1130 Injection, diclofenac sodium, 0.5 mg Yes MEDICAID J1160 INJECTION, DIGOXIN, UP TO 0.5 MG No MEDICAID INJECTION, DIGOXIN IMMUNE FAB J1162 (OVINE), PER VIAL No MEDICAID INJECTION, PHENYTOIN SODIUM, PER J1165 50 MG No MEDICAID INJECTION, HYDROMORPHONE, UP J1170 TO 4 MG No MEDICAID INJECTION, DYPHYLLINE, UP TO 500 J1180 MG No MEDICAID INJECTION, DEXRAZOXANE J1190 HYDROCHLORIDE, PER 250 MG No MEDICAID INJECTION, DIPHENHYDRAMINE HCL, J1200 UP TO 50 MG No MEDICAID INJECTION, CHLOROTHIAZIDE J1205 SODIUM, PER 500 MG No MEDICAID INJECTION, DMSO, DIMETHYL J1212 SULFOXIDE, 50%, 50 ML No MEDICAID INJECTION, METHADONE HCL, UP TO J1230 10 MG Not Covered MEDICAID INJECTION, DIMENHYDRINATE, UP TO J1240 50 MG No MEDICAID INJECTION, DIPYRIDAMOLE, PER 10 J1245 MG No MEDICAID INJECTION, DOBUTAMINE J1250 HYDROCHLORIDE, PER 250 MG No MEDICAID INJECTION, DOLASETRON MESYLATE, J1260 10 MG No MEDICAID J1265 INJECTION, DOPAMINE HCL, 40 MG No MEDICAID J1267 INJECTION, DORIPENEM, 10 MG No MEDICAID INJECTION, DOXERCALCIFEROL, 1 J1270 MCG No MEDICAID J1290 INJECTION, ECALLANTIDE, 1 MG No MEDICAID J1300 INJECTION, ECULIZUMAB, 10 MG No MEDICAID INJECTION, AMITRIPTYLINE HCL, UP J1320 Yes TO 20 MG MEDICAID J1322 Injection, elosulfase alfa, 1mg Yes ExGEN MEDICAID J1324 INJECTION, ENFUVIRTIDE, 1 MG No MEDICAID INJECTION, EPOPROSTENOL, 0.5 MG J1325 No MEDICAID J1327 INJECTION, EPTIFIBATIDE, 5 MG No MEDICAID INJECTION, ERGONOVINE MALEATE, J1330 Yes UP TO 0.2 MG MEDICAID INJECTION, ERTAPENEM SODIUM, 500 J1335 MG No MEDICAID INJECTION, ERYTHROMYCIN J1364 LACTOBIONATE, PER 500 MG No MEDICAID INJECTION, ESTRADIOL VALERATE, J1380 UP TO 10 MG No MEDICAID INJECTION, ESTROGEN J1410 CONJUGATED, PER 25 MG No MEDICAID J1428 Injection, eteplirsen, 10 mg Yes MEDICAID

549 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, ETHANOLAMINE OLEATE, J1430 100 MG No MEDICAID J1435 INJECTION, ESTRONE, PER 1 MG Yes MEDICAID INJECTION, ETIDRONATE DISODIUM, J1436 Yes PER 300 MG MEDICAID INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMIN UNDER DIRECT SUPERVI OF A PHYSICIAN, NOT SELF J1438 ADMINIS No MEDICAID J1439 Injection, ferric carboxymaltose, 1mg No MEDICAID Injection, filgrastim (g-csf), 1 microgram J1442 No MEDICAID Injection, ferric pyrophosphate citrate solution, J1443 0.1 mg of iron No MEDICAID J1447 Injection, tbo-filgrastim, 1 microgram No MEDICAID J1450 INJECTION FLUCONAZOLE, 200 MG No MEDICAID J1451 INJECTION, FOMEPIZOLE, 15 MG No MEDICAID INJECTION, FOMIVIRSEN SODIUM, J1452 Yes INTRAOCULAR, 1.65 MG MEDICAID J1453 INJECTION, FOSAPREPITANT, 1 MG No MEDICAID INJECTION, FOSCARNET SODIUM, J1455 PER 1000 MG No MEDICAID INJECTION, GALLIUM NITRATE, 1 MG J1457 Yes MEDICAID J1458 NJECTION, GALSULFASE, 1 MG No MEDICAID INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON- J1459 LYOPHILIZED (E.G. LIQUID), 500 MG No MEDICAID INJECTION, GAMMA GLOBULIN, J1460 INTRAMUSCULAR, 1 CC No MEDICAID Injection, immune globulin (cuvitru), 100 J1555 mg No MEDICAID Injection, immune globulin (bivigam), 500 J1556 mg No MEDICAID INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON- J1557 LYOPHILIZED (E.G. LIQUID), 500 MG No MEDICAID

INJECTION, IMMUNE GLOBULIN J1559 (HIZENTRA), 100 MG No MEDICAID INJECTION, GAMMA GLOBULIN, J1560 INTRAMUSCULAR, OVER 10 CC No MEDICAID INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON- J1561 LYOPHILIZED (E.G. LIQUID), 500 MG No MEDICAID INJECTION, IMMUNE GLOBULIN J1562 (VIVAGLOBIN), 100 MG Yes ExGEN MEDICAID INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT OTHERWISE J1566 SPECIFIED, 500 MG Yes ExGEN MEDICAID INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON- J1568 LYOPHILIZED (E.G. LIQUID), 500 MG No MEDICAID INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED, J1569 (E.G. LIQUID), 500 MG No MEDICAID INJECTION, GANCICLOVIR SODIUM, J1570 500 MG No MEDICAID INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), J1571 INTRAMUSCULAR, 0.5 ML No MEDICAID INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON- LYOPHILIZED (E.G. LIQUID), 500 MG J1572 No MEDICAID INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), J1573 INTRAVENOUS, 0.5 ML No MEDICAID

550 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin J1575 No MEDICAID INJECTION, GARAMYCIN, J1580 GENTAMICIN, UP TO 80 MG No MEDICAID INJECTION, GLATIRAMER ACETATE, J1595 20 MG Yes ExGEN MEDICAID INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), NOT OTHERWISE J1599 SPECIFIED, 500 MG Yes ExGEN MEDICAID INJECTION, GOLD SODIUM J1600 THIOMALATE, UP TO 50 MG No MEDICAID Injection, golimumab, 1 mg, for J1602 intravenous use No MEDICAID INJECTION, GLUCAGON J1610 HYDROCHLORIDE, PER 1 MG No MEDICAID INJECTION, GONADORELIN J1620 Yes HYDROCHLORIDE, PER 100 MCG MEDICAID INJECTION, GRANISETRON J1626 HYDROCHLORIDE, 100 MCG No MEDICAID Injection, granisetron, extended-release, J1627 0.1 mg No MEDICAID INJECTION, HALOPERIDOL, UP TO 5 J1630 MG No MEDICAID INJECTION, HALOPERIDOL J1631 DECANOATE, PER 50 MG No MEDICAID J1640 INJECTION, HEMIN, 1 MG No MEDICAID INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 J1642 UNITS No MEDICAID J1644 HEPARIN SODIUM, PER 1000U IN No MEDICAID INJECTION, DALTEPARIN SODIUM, J1645 PER 2500 IU No MEDICAID INJECTION, ENOXAPARIN SODIUM, 10 J1650 MG No MEDICAID INJECTION, FONDAPARINUX SODIUM, J1652 0.5 MG No MEDICAID INJECTION, TINZAPARIN SODIUM, J1655 Yes 1000 IU MEDICAID INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS J1670 No MEDICAID INJECTION, HISTRELIN ACETATE, 10 J1675 Yes MICROGRAMS MEDICAID INJECTION, HYDROCORTISONE J1700 Yes ACETATE, UP TO 25 MG MEDICAID INJECTION, HYDROCORTISONE J1710 SODIUM PHOSPHATE, UP TO 50 MG Yes MEDICAID INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG J1720 No MEDICAID Injection, hydroxyprogesterone caproate, J1726 (makena), 10 mg No MEDICAID Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg J1729 Yes MEDICAID INJECTION, DIAZOXIDE, UP TO 300 MG J1730 No MEDICAID INJECTION, IBANDRONATE SODIUM, 1 J1740 MG No MEDICAID J1741 Injection, ibuprofen, 100 mg Yes MEDICAID INJECTION, IBUTILIDE FUMARATE, 1 J1742 MG No MEDICAID J1743 INJECTION, IDURSULFASE, 1 MG No MEDICAID J1744 Injection, icatibant, 1 mg Yes ExGEN MEDICAID J1745 INJECTION, INFLIXIMAB, 10 MG No MEDICAID J1750 INJECTION, IRON DEXTRAN, 50 MG No MEDICAID J1756 INJECTION, IRON SUCROSE, 1 MG No MEDICAID

551 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, IMIGLUCERASE, 10 UNITS J1786 No MEDICAID INJECTION, DROPERIDOL, UP TO 5 J1790 MG No MEDICAID INJECTION, PROPRANOLOL HCL, UP J1800 TO 1 MG No MEDICAID INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML J1810 AMPULE No MEDICAID J1815 INJECTION, INSULIN, PER 5 UNITS No MEDICAID INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) J1817 PER 50 UNITS No MEDICAID INJECTION, INTERFERON BETA-1A, 30 J1826 MCG Yes ExGEN MEDICAID INJECTION, INTERFERON BETA-LB, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMIN UNDER DIRECT SUPERV OF PHYS, J1830 NOT SELF ADMIN No MEDICAID J1833 Injection, isavuconazonium, 1 mg Yes MEDICAID J1835 INJECTION, ITRACONAZOLE, 50 MG No MEDICAID INJECTION, KANAMYCIN SULFATE, UP J1840 TO 500 MG No MEDICAID INJECTION, KANAMYCIN SULFATE, UP J1850 TO 75 MG No MEDICAID INJECTION, KETOROLAC J1885 TROMETHAMINE, PER 15 MG No MEDICAID INJECTION, CEPHALOTHIN SODIUM, J1890 Yes UP TO 1 GRAM MEDICAID J1930 INJECTION, LANREOTIDE, 1 MG No MEDICAID J1931 INJECTION, LARONIDASE, 0.1 MG No MEDICAID INJECTION, FUROSEMIDE, UP TO 20 J1940 MG No MEDICAID J1942 Injection, aripiprazole lauroxil, 1 mg No MEDICAID J1945 INJECTION, LEPIRUDIN, 50 MG No MEDICAID INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 J1950 MG No * MEDICAID INJECTION, LEVETIRACETAM, 10 MG J1953 No MEDICAID INJECTION, LEVOCARNITINE, PER 1 J1955 GM No MEDICAID INJECTION, LEVOFLOXACIN, 250 MG J1956 No MEDICAID INJECTION, LEVORPHANOL J1960 Yes TARTRATE, UP TO 2 MG MEDICAID INJECTION, HYOSCYAMINE SULFATE, J1980 UP TO 0.25 MG No MEDICAID INJECTION, CHLORDIAZEPOXIDE HCL, J1990 Yes UP TO 100 MG MEDICAID INJECTION, LIDOCAINE HCL FOR J2001 INTRAVENOUS INFUSION, 10 MG No MEDICAID INJECTION, LINCOMYCIN HCL, UP TO J2010 300 MG No MEDICAID J2020 INJECTION, LINEZOLID, 200MG No MEDICAID J2060 INJECTION, LORAZEPAM, 2 MG No MEDICAID INJECTION, MANNITOL, 25% IN 50 ML J2150 No MEDICAID J2170 INJECTION, MECASERMIN, 1 MG No MEDICAID INJECTION, MEPERIDINE J2175 HYDROCHLORIDE, PER 100 MG No MEDICAID INJECTION, MEPERIDINE AND J2180 Yes PROMETHAZINE HCL, UP TO 50 MG MEDICAID J2182 Injection, mepolizumab, 1 mg No MEDICAID J2185 INJECTION, MEROPENEM, 100 MG No MEDICAID INJECTION, METHYLERGONOVINE J2210 MALEATE, UP TO 0.2 MG No MEDICAID J2212 Injection, methylnaltrexone, 0. 1 mg Yes MEDICAID INJECTION, MICAFUNGIN SODIUM, 1 J2248 MG No MEDICAID

552 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, MIDAZOLAM J2250 HYDROCHLORIDE, PER 1 MG No MEDICAID INJECTION, MILRINONE LACTATE, 5 J2260 MG No MEDICAID INJECTION, MINOCYCLINE J2265 Yes HYDROCHLORIDE, 1 MG MEDICAID INJECTION, MORPHINE SULFATE, UP J2270 TO 10 MG No MEDICAID Injection, morphine sulfate, preservative- free for epidural or intrathecal use, 10mg J2274 No MEDICAID INJECTION, ZICONOTIDE, 1 J2278 MICROGRAM No MEDICAID J2280 INJECTION, MOXIFLOXACIN, 100 MG No MEDICAID INJECTION, NALBUPHINE J2300 HYDROCHLORIDE, PER 10 MG No MEDICAID INJECTION, NALOXONE J2310 HYDROCHLORIDE, PER 1 MG No MEDICAID INJECTION, NALTREXONE, DEPOT J2315 FORM, 1 MG No MEDICAID INJECTION, NANDROLONE J2320 Yes DECANOATE, UP TO 50 MG MEDICAID J2323 INJECTION, NATALIZUMAB, 1 MG No MEDICAID J2325 INJECTION, NESIRITIDE, 0.1 MG No MEDICAID J2326 Injection, nusinersen, 0.1 mg Yes MEDICAID J2350 Injection, ocrelizumab, 1 mg No MEDICAID INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR J2353 INJECTION, 1 MG No MEDICAID INJECTION, OCTREOTIDE, NON- DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS J2354 No MEDICAID J2355 INJECTION, OPRELVEKIN, 5 MG No MEDICAID J2357 INJECTION, OMALIZUMAB, 5 MG No MEDICAID INJECTION, OLANZAPINE, LONG- J2358 ACTING, 1 MG No MEDICAID INJECTION, ORPHENADRINE J2360 CITRATE, UP TO 60 MG No MEDICAID INJECTION, PHENYLEPHRINE HCL, UP J2370 TO 1 ML No MEDICAID INJECTION, CHLOROPROCAINE J2400 HYDROCHLORIDE, PER 30 ML No MEDICAID INJECTION, ONDANSETRON J2405 HYDROCHLORIDE, PER 1 MG No MEDICAID J2407 Injection, oritavancin, 10 mg No MEDICAID INJECTION, OXYMORPHONE HCL, UP J2410 TO 1 MG No MEDICAID INJECTION, PALIFERMIN, 50 J2425 MICROGRAMS No MEDICAID INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 J2426 MG No MEDICAID INJECTION, PAMIDRONATE J2430 DISODIUM, PER 30 MG No MEDICAID INJECTION, PAPAVERINE HCL, UP TO J2440 60 MG No MEDICAID INJECTION, OXYTETRACYCLINE HCL, J2460 UP TO 50 MG No MEDICAID INJECTION, PALONOSETRON HCL, 25 J2469 MCG No MEDICAID J2501 INJECTION, PARICALCITOL, 1 MCG No MEDICAID Injection, pasireotide long acting, 1 mg J2502 Yes ExGEN MEDICAID INJECTION, PEGAPTANIB SODIUM, 0.3 J2503 MG No MEDICAID INJECTION, PEGADEMASE BOVINE, 25 J2504 IU No MEDICAID J2505 INJECTION, PEGFILGRASTIM, 6 MG No MEDICAID J2507 INJECTION, PEGLOTICASE, 1 MG No MEDICAID

553 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS J2510 No MEDICAID INJECTION, PENTASTARCH, 10% J2513 Yes SOLUTION, 100 ML MEDICAID INJECTION, PENTOBARBITAL J2515 SODIUM, PER 50 MG No MEDICAID INJECTION, PENICILLIN G J2540 POTASSIUM, UP TO 600,000 UNITS No MEDICAID INJECTION, PIPERACILLIN J2543 SODIUM/TAZOBACTAM SODIUM, 1 Yes GRAM/0.125 GRAMS MEDICAID PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA- APPROVED FINAL PRODUCT, NON- COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, J2545 PER 300 MG No MEDICAID J2547 Injection, peramivir, 1 mg Yes MEDICAID INJECTION, PROMETHAZINE HCL, UP J2550 TO 50 MG No MEDICAID INJECTION, PHENOBARBITAL J2560 SODIUM, UP TO 120 MG No MEDICAID J2562 INJECTION, PLERIXAFOR, 1 MG No MEDICAID INJECTION, OXYTOCIN, UP TO 10 J2590 UNITS No MEDICAID INJECTION, DESMOPRESSIN J2597 ACETATE, PER 1 MCG No MEDICAID INJECTION, PREDNISOLONE J2650 Yes ACETATE, UP TO 1 ML MEDICAID INJECTION, TOLAZOLINE HCL, UP TO J2670 25 MG No MEDICAID INJECTION, PROGESTERONE, PER 50 J2675 MG No MEDICAID INJECTION, FLUPHENAZINE J2680 DECANOATE, UP TO 25 MG No MEDICAID INJECTION, PROCAINAMIDE HCL, UP J2690 TO 1 GM No MEDICAID INJECTION, OXACILLIN SODIUM, UP J2700 TO 250 MG No MEDICAID J2704 Injection, propofol, 10 mg No MEDICAID INJECTION, NEOSTIGMINE J2710 METHYLSULFATE, UP TO 0.5 MG No MEDICAID INJECTION, PROTAMINE SULFATE, J2720 PER 10 MG No MEDICAID INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, J2724 HUMAN, 10 IU No MEDICAID INJECTION, PROTIRELIN, PER 250 J2725 MCG No MEDICAID INJECTION, PRALIDOXIME CHLORIDE, J2730 UP TO 1 GM No MEDICAID INJECTION, PHENTOLAMINE J2760 MESYLATE, UP TO 5 MG No MEDICAID INJECTION, METOCLOPRAMIDE HCL, J2765 UP TO 10 MG No MEDICAID INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 J2770 MG (150/350) No MEDICAID J2778 INJECTION, RANIBIZUMAB, 0.1 MG No MEDICAID INJECTION, RANITIDINE J2780 HYDROCHLORIDE, 25 MG No MEDICAID J2783 INJECTION, RASBURICASE, 0.5 MG No MEDICAID INJECTION, LEVETIRACETAM, 10 MG J2785 No MEDICAID J2786 Injection, reslizumab, 1 mg Yes ExGEN MEDICAID INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 J2788 MCG No MEDICAID

554 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, ONE DOSE J2790 PACKAGE No MEDICAID INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS, J2791 100 IU No MEDICAID INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, J2792 SOLVENT DETERGENT, No MEDICAID J2793 INJECTION, RILONACEPT, 1 MG No MEDICAID INJECTION, RISPERIDONE, LONG J2794 ACTING, 0.5 MG No MEDICAID INJECTION, ROPIVACAINE J2795 HYDROCHLORIDE, 1 MG No MEDICAID J2796 INJECTION, ROMIPLOSTIM, 10 MICROGRAMS No MEDICAID INJECTION, METHOCARBAMOL, UP J2800 TO 10 ML No MEDICAID INJECTION, SINCALIDE, 5 J2805 MICROGRAMS No MEDICAID INJECTION, THEOPHYLLINE, PER 40 J2810 MG No MEDICAID INJECTION, SARGRAMOSTIM (GM- J2820 CSF), 50 MCG No * MEDICAID J2840 Injection, sebelipase alfa, 1 mg Yes ExGEN MEDICAID INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM J2850 No MEDICAID J2860 Injection, siltuximab, 10 mg Yes ExGEN MEDICAID INJECTION, AUROTHIOGLUCOSE, UP J2910 Yes TO 50 MG MEDICAID INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE J2916 INJECTION, 12.5 MG No MEDICAID INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG J2920 No MEDICAID INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG J2930 No MEDICAID J2940 INJECTION, SOMATREM, 1 MG No MEDICAID J2941 INJECTION, SOMATROPIN, 1 MG No MEDICAID INJECTION, PROMAZINE HCL, UP TO J2950 Yes 25 MG MEDICAID J2993 INJECTION, RETEPLASE, 18.1 MG No MEDICAID INJECTION, STREPTOKINASE, PER J2995 Yes 250,000 IU MEDICAID INJECTION, ALTEPLASE J2997 RECOMBINANT, 1 MG No MEDICAID INJECTION, STREPTOMYCIN, UP TO 1 J3000 GM No MEDICAID INJECTION, FENTANYL CITRATE, 0.1 J3010 MG No MEDICAID INJECTION, SUMATRIPTAN J3030 SUCCINATE, 6 MG No MEDICAID J3060 Injection, taliglucerace alfa, 10 units No MEDICAID J3070 INJECTION, PENTAZOCINE, 30 MG No MEDICAID J3090 Injection, tedizolid phosphate, 1 mg No MEDICAID J3095 INJECTION, TELAVANCIN, 10 MG No MEDICAID INJECTION, REGADENOSON, 0.1 MG J3101 No MEDICAID INJECTION, TERBUTALINE SULFATE, J3105 UP TO 1 MG No MEDICAID J3110 INJECTION, TERIPARATIDE, 10 MCG No MEDICAID Injection, testosterone enanthate, 1mg J3121 No MEDICAID Injection, testosterone undecanoate, 1 mg J3145 Yes ExGEN MEDICAID INJECTION, CHLORPROMAZINE HCL, J3230 UP TO 50 MG No MEDICAID

555 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, THYROTROPIN ALPHA, 0.9 J3240 MG, PROVIDED IN 1.1 MG VIAL No MEDICAID J3243 INJECTION, TIGECYCLINE, 1 MG No MEDICAID INJECTION, TIROFIBAN HCL, 0.25MG J3246 No MEDICAID INJECTION, TRIMETHOBENZAMIDE J3250 HCL, UP TO 200 MG No MEDICAID INJECTION, TOBRAMYCIN SULFATE, J3260 UP TO 80 MG No MEDICAID J3262 INJECTION, TOCILIZUMAB, 1 MG No MEDICAID J3265 INJECTION, TORSEMIDE, 10 MG/ML Yes MEDICAID INJECTION, THIETHYLPERAZINE J3280 Yes MALEATE, UP TO 10 MG MEDICAID J3285 INJECTION, TREPROSTINIL, 1 MG No MEDICAID J3300 INJECTION, TENECTEPLASE, 1 MG No MEDICAID INJECTION, TRIAMCINOLONE J3301 ACETONIDE, PER 10MG No MEDICAID INJECTION, TRIAMCINOLONE J3302 Yes DIACETATE, PER 5MG MEDICAID INJECTION, TRIAMCINOLONE J3303 HEXACETONIDE, PER 5MG No MEDICAID INJECTION, TRIMETREXATE J3305 Yes GLUCURONATE, PER 25 MG MEDICAID INJECTION, PERPHENAZINE, UP TO 5 J3310 Yes MG MEDICAID INJECTION, TRIPTORELIN PAMOATE, J3315 3.75 MG No MEDICAID INJECTION, SPECTINOMYCIN J3320 Yes DIHYDROCHLORIDE, UP TO 2 GM MEDICAID J3350 INJECTION, UREA, UP TO 40 GM No MEDICAID INJECTION, UROFOLLITROPIN, 75 IU J3355 Yes ExGEN MEDICAID J3357 INJECTION, USTEKINUMAB, 1 MG No MEDICAID Ustekinumab, for intravenous injection, 1 J3358 mg No MEDICAID J3360 INJECTION, DIAZEPAM, UP TO 5 MG No MEDICAID INJECTION, UROKINASE, 5000 IU VIAL J3364 Yes MEDICAID INJECTION, IV, UROKINASE, 250,000 J3365 I.U. VIAL No MEDICAID INJECTION, VANCOMYCIN HCL, 500 J3370 Yes MG MEDICAID J3380 Injection, vedolizumab, 1 mg No MEDICAID INJECTION, VELAGLUCERASE ALFA, J3385 100 UNITS Yes ExGEN MEDICAID J3396 INJECTION, VERTEPORFIN, 0.1 MG No MEDICAID INJECTION, TRIFLUPROMAZINE HCL, J3400 UP TO 20 MG No MEDICAID INJECTION, HYDROXYZINE HCL, UP J3410 TO 25 MG No MEDICAID J3411 INJECTION, THIAMINE HCL, 100 MG No MEDICAID INJECTION, PYRIDOXINE HCL, 100 MG J3415 No MEDICAID INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG J3420 No MEDICAID INJECTION, PHYTONADIONE (VITAMIN J3430 K), PER 1 MG No MEDICAID J3465 INJECTION, VORICONAZOLE, 10 MG No MEDICAID INJECTION, HYALURONIDASE, UP TO J3470 150 UNITS No MEDICAID INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 USP J3471 UNIT (UP TO 999 No MEDICAID INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 USP J3472 UNITS No MEDICAID INJECTION, HYALURONIDASE, J3473 RECOMBINANT, 1 USP UNIT No MEDICAID INJECTION, MAGNESIUM SULFATE, J3475 PER 500 MG No MEDICAID

556 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INJECTION, POTASSIUM CHLORIDE, J3480 PER 2 MEQ No MEDICAID J3485 INJECTION, ZIDOVUDINE, 10 MG No MEDICAID INJECTION, ZIPRASIDONE MESYLATE, J3486 10 MG No MEDICAID J3489 Injection, zoledronic acid, 1 mg No MEDICAID J3490 UNCLASSIFIED DRUGS Yes MEDICAID J3520 EDETATE DISODIUM, PER 150 MG No MEDICAID J3530 NASAL VACCINE INHALATION No MEDICAID DRUG ADMINISTERED THROUGH A J3535 METERED DOSE INHALER No MEDICAID LAETRILE, AMYGDALIN, VITAMIN B17 J3570 Not covered MEDICAID J3590 UNCLASSIFIED BIOLOGICS Yes ExGEN MEDICAID INFUSION, NORMAL SALINE J7030 SOLUTION , 1000 CC No MEDICAID INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) J7040 No MEDICAID 5% DEXTROSE/NORMAL SALINE (500 J7042 ML = 1 UNIT) No MEDICAID INFUSION, NORMAL SALINE J7050 SOLUTION , 250 CC No MEDICAID 5% DEXTROSE/WATER (500 ML = 1 J7060 UNIT) No MEDICAID J7070 INFUSION, D5W, 1000 CC No MEDICAID J7100 INFUSION, DEXTRAN 40, 500 ML No MEDICAID J7110 INFUSION, DEXTRAN 75, 500 ML Yes MEDICAID RINGERS LACTATE INFUSION, UP TO J7120 1000 CC No MEDICAID 5% dextrose in lactated ringers infusion, up to J7121 Yes 1000 cc MEDICAID HYPERTONIC SALINE SOLUTION, 1 ML J7131 Yes MEDICAID J7175 Injection, factor x, (human), 1 i.u. Yes ExGEN MEDICAID J7178 Injection, human fibrinogen concentrate, 1 mg No MEDICAID Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco J7179 Yes ExGEN MEDICAID INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), J7180 1 I.U. No MEDICAID Injection, factor xiii a-subunit, J7181 (recombinant), per iu Yes ExGEN MEDICAID Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu J7182 No MEDICAID INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, J7183 1 I.U. VWF:RCO No MEDICAID J7185 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U. No MEDICAID Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per J7186 factor VIII i.u. No MEDICAID INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER J7187 IU VWF:RCO No MEDICAID Injection, factor viii (antihemophilic factor, J7188 recombinant), (obizur), per i.u. Yes ExGEN MEDICAID FACTOR VIIA (ANTIHEMOPHILIC J7189 FACTOR, RECOMBINANT), No MEDICAID FACTOR VIII, (ANTI-HEMOPHILIC J7190 FACTOR (HUMAN)), PER I.U. No MEDICAID FACTOR VIII (ANTIHEMOPHILIC J7191 FACTOR (PORCINE)), PER I.U. Yes ExGEN MEDICAID FACTOR VIII (ANTIHEMOPHILIC J7192 FACTOR (RECOMBINANT)), PER I.U. No MEDICAID

557 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON- J7193 RECOMBINANT) PER IU No MEDICAID J7194 FACTOR IX, COMPLEX, PER I.U. No MEDICAID FACTOR IX (ANTIHEMOPHILIC J7195 FACTOR, RECOMBINANT) PER IU No MEDICAID INJECTION, ANTITHROMBIN J7196 Yes RECOMBINANT, 50 I.U. MEDICAID ANTITHROMBIN III (HUMAN), PER I.U. J7197 No MEDICAID J7198 ANTI INHIBITOR, PER I.U. No MEDICAID HEMOPHILIA CLOTTING FACTOR, NOT J7199 OTHERWISE CLASSIFIED Yes ExGEN MEDICAID Injection, factor ix, (antihemophilic factor, J7200 recombinant), rixubis, per iu No MEDICAID Injection, factor ix, fc fusion protein J7201 (recombinant), per iu No MEDICAID Injection, factor ix, albumin fusion protein, J7202 (recombinant), idelvion, 1 i.u. Yes ExGEN MEDICAID Injection, factor viii fc fusion J7205 (recombinant), per iu No MEDICAID Injection, factor viii, (antihemophilic factor, J7207 recombinant), pegylated, 1 i.u. Yes ExGEN MEDICAID Injection, factor viii, (antihemophilic factor, J7209 recombinant), (nuwiq), 1 i.u. Yes ExGEN MEDICAID Injection, factor viii, (antihemophilic factor, J7210 recombinant), (afstyla), 1 i.u. Yes ExGEN MEDICAID Injection, factor viii, (antihemophilic factor, J7211 recombinant), (kovaltry), 1 i.u. Yes ExGEN MEDICAID Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg J7296 No MEDICAID Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year J7297 duration No MEDICAID Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year J7298 duration No MEDICAID INTRAUTERINE COPPER J7300 CONTRACEPTIVE No MEDICAID Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg J7301 No MEDICAID CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH J7303 No MEDICAID CONTRACEPTIVE SUPPLY, HORMONE CONTAINING PATCH, EACH J7304 No MEDICAID LEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANTS AND J7306 No MEDICAID ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES J7307 No MEDICAID AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%. SINGLE UNIT DOSAGE FORM (354 MG) J7308 No MEDICAID METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, J7309 16.8%, 1 GRAM No MEDICAID GANCICLOVIR, 4.5 MG, LONG-ACTING J7310 IMPLANT No MEDICAID FLUOCINOLONE ACETONIDE, J7311 INTRAVITREAL IMPLANT No MEDICAID INJECTION, DEXAMETHASONE, J7312 INTRAVITREAL IMPLANT, 0.1 MG No MEDICAID

558 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Injection, fluocinolone acetonide, intravitreal J7313 implant, 0.01 mg No MEDICAID J7315 Mitomycin, opthalmic, 0. 2 mg Yes MEDICAID J7316 Injection, ocriplasmin, 0.125 mg No MEDICAID Hyaluronan or derivative, GenVisc 850, J7320 for intra-articular injection, 1 mg No MEDICAID HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA- J7321 ARTICULAR INJECTION, PER DOSE No MEDICAID Hyaluronan or derivative, Hymovis, for J7322 Yes intra-articular injection, 1 mg MEDICAID HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR J7323 INJECTION, PER DOSE No MEDICAID HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR J7324 INJECTION, PER DOSE No MEDICAID J7325 HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULAR INJECTION, 1 MG No MEDICAID HYALURONAN OR DERIVATIVE, GEL- ONE, FOR INTRA-ARTICULAR J7326 INJECTION, PER DOSE No MEDICAID Hyaluronan or derivative, monovisc, for J7327 intra-articular injection, per dose No MEDICAID Hyaluronan or derivative, gel-syn, for intra- J7328 Yes articular injection, 0.1 mg MEDICAID AUTOLOGOUS CULTURED J7330 CHONDROCYTES, IMPLANT Yes RMT MEDICAID Capsaicin 8% patch, per square J7336 centimeter Yes ExGEN MEDICAID Carbidopa 5 mg/levodopa 20 mg enteral J7340 suspension Yes ExGEN MEDICAID Installation, ciprofloxacin otic suspension, J7342 Yes 6 mg MEDICAID Aminolevulinic acid hcl for topical J7345 administration, 10% gel, 10 mg No MEDICAID J7500 AZATHIOPRINE, ORAL, 50 MG No MEDICAID AZATHIOPRINE, PARENTERAL, 100 J7501 MG No MEDICAID J7502 CYCLOSPORINE, ORAL, 100 MG No MEDICAID Tacrolimus, extended release, (envarsus xr), J7503 oral, 0.25 mg No MEDICAID LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, J7504 PARENTERAL, No MEDICAID MUROMONAB-CD3, PARENTERAL, 5 J7505 MG No MEDICAID J7507 TACROLIMUS, ORAL, PER 1 MG No MEDICAID Tacrolimus, extended release, oral, 0.1 J7508 mg No MEDICAID METHYLPREDNISOLONE ORAL, PER 4 J7509 MG No MEDICAID J7510 PREDNISOLONE ORAL, PER 5 MG No MEDICAID LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, J7511 PARENTERAL, No MEDICAID Prednisone, immediate release or delayed J7512 release, oral, 1 mg No MEDICAID J7513 DACLIZUMAB, PARENTERAL, 25 MG Yes MEDICAID J7515 CYCLOSPORINE, ORAL, 25 MG No MEDICAID CYCLOSPORIN, PARENTERAL, 250 MG J7516 No MEDICAID MYCOPHENOLATE MOFETIL, ORAL, J7517 250 MG No MEDICAID MYCOPHENOLIC ACID, ORAL, 180 MG J7518 No MEDICAID J7520 SIROLIMUS, ORAL, 1 MG No MEDICAID J7525 TACROLIMUS, PARENTERAL, 5 MG No MEDICAID J7527 Everolimus, oral, 0. 25 mg Yes ExGEN MEDICAID

559 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines IMMUNOSUPPRESSIVE DRUG, NOT J7599 OTHERWISE CLASSIFIED No MEDICAID ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM J7604 No MEDICAID ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS J7605 No MEDICAID INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN), PER J7606 FACTOR VIII I.U. No MEDICAID LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7607 ADMINISTERED No MEDICAID ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT J7608 DOSE FORM, PER GRAM No MEDICAID ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7609 ADMINISTERED No MEDICAID ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7610 ADMINISTERED No MEDICAID ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMIN'ED THRU DME, CONCENTRATED FORM, 1 MG (REINSTATED J7611 No MEDICAID LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMIN THRU DME, CONCENTRATED FORM 0.5MG (REINSTATED J7612 No MEDICAID ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 1MG J7613 (REINSTATED) No MEDICAID LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMIN'ED THRU DME, UNIT DOSE 0.5 J7614 MG (REINSTATED) No MEDICAID LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7615 ADMINISTERED No MEDICAID ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 J7620 MG, NON No MEDICAID BECLOMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH J7622 DME, UNIT DOSE No MEDICAID BETAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH J7624 DME, UNIT DOSE No MEDICAID BUDESONIDE INHALATION SOLUTION, NON-COMPOUNDED, ADMINISTERED J7626 THROUGH No MEDICAID BUDESONIDE, POWDER, COMPOUNDED FOR INHALATION J7627 SOLUTION, ADMINISTERED No MEDICAID

560 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BITOLTEROL MESYLATE, INHALATION SOLUTION ADMINISTERED THROUGH J7628 DME, No MEDICAID BITOLTEROL MESYLATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT J7629 No MEDICAID CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS J7631 No MEDICAID CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS J7632 No MEDICAID BUDESONIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, J7633 CONCENTRATED No MEDICAID BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7634 ADMINISTERED No MEDICAID ATROPINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, J7635 CONCENTRATED No MEDICAID ATROPINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT J7636 DOSE FORM, No MEDICAID DEXAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH J7637 DME, No MEDICAID DEXAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH J7638 DME, UNIT DOSE No MEDICAID DORNASE ALPHA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT J7639 DOSE FORM, PER MILLIGRAM No MEDICAID FORMOTEROL, INHALATION SOLUTION ADMINISTERED THROUGH J7640 DME, UNIT DOSE No MEDICAID FLUNISOLIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT J7641 DOSE, No MEDICAID GLYCOPYRROLATE, INHALATION SOLUTION ADMINISTERED THROUGH J7642 DME, No MEDICAID GLYCOPYRROLATE, INHALATION SOLUTION ADMINISTERED THROUGH J7643 DME, UNIT DOSE No MEDICAID IPRATROPIUM BROMIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT J7644 No MEDICAID IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7645 No MEDICAID ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7647 ADMINISTERED No MEDICAID ISOETHARINE HCL, INHALATION J7648 SOLUTION ADMINISTERED THROUGH Yes DME, MEDICAID ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH J7649 DME, UNIT DOSE No MEDICAID

561 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, J7650 ADMINISTERED No MEDICAID ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTER J7657 No MEDICAID ISOPROTERENOL HCL, INHALATION J7658 SOLUTION ADMINISTERED THROUGH Yes DME, MEDICAID ISOPROTERENOL HCL, INHALATION SOLUTION ADMINISTERED THROUGH J7659 Yes DME, UNIT MEDICAID ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTER J7660 No MEDICAID MANNITOL, ADMINISTERED THROUGH J7665 AN INHALER, 5 MG No MEDICAID METAPROTERENOL SULFATE, INHALATION SOLUTION, J7667 COMPOUNDED PRODUCT, No MEDICAID METAPROTERENOL SULFATE, INHALATION SOLUTION J7668 ADMINISTERED THROUGH DME, No MEDICAID METAPROTERENOL SULFATE, INHALATION SOLUTION J7669 ADMINISTERED THROUGH DME, No MEDICAID METAPROTERENOL SULFATE, INHALATION SOLUTION, J7670 COMPOUNDED PRODUCT, No MEDICAID METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION J7674 SOLUTION THROUGH A No MEDICAID PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT J7676 DOSE FORM, PER 300 MG No MEDICAID TERBUTALINE SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH J7680 DME, No MEDICAID TERBUTALINE SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT J7681 No MEDICAID TOBRAMYCIN, UNIT DOSE FORM, 300 MG, INHALATION SOLUTION, J7682 ADMINISTERED No MEDICAID TRIAMCINOLONE, INHALATION SOLUTION ADMINISTERED THROUGH J7683 DME, CONCEN No MEDICAID TRIAMCINOLONE, INHALATION SOLUTION ADMINISTERED THROUGH J7684 DME, UNIT DOSE No MEDICAID TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS J7685 No MEDICAID TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT J7686 DOSE FORM, 1.74 MG Yes ExGEN MEDICAID NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME J7699 No MEDICAID

562 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED J7799 THROUGH DME No MEDICAID Compounded drug, not otherwise classified J7999 Yes MEDICAID ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT J8498 OTHERWISE No MEDICAID PRESCRIPTION DRUG, ORAL, NON J8499 CHEMOTHERAPEUTIC, NOS No MEDICAID J8501 APREPITANT, ORAL, 5 MG No MEDICAID J8510 BULSULFAN; ORAL, 2 MG No MEDICAID J8515 CABERGOLINE, ORAL, 0.25 MG No MEDICAID J8520 CAPECITABINE, ORAL, 150 MG No MEDICAID J8521 CAPECITABINE, ORAL, 500 MG No MEDICAID CYCLOPHOSPHAMIDE; ORAL, 25 MG J8530 No MEDICAID J8540 DEXAMETHASONE, ORAL, 0.25 MG No MEDICAID J8560 ETOPOSIDE; ORAL, 50 MG No MEDICAID FLUDARABINE PHOSPHATE, ORAL, 10 J8562 MG No MEDICAID J8565 GEFITINIB, ORAL, 250 MG No MEDICAID ANTIEMETIC DRUG, ORAL, NOT J8597 OTHERWISE SPECIFIED No MEDICAID J8600 MELPHALAN; ORAL, 2 MG No MEDICAID J8610 METHOTREXATE; ORAL, 2.5 MG No MEDICAID J8650 NABILONE, ORAL, 1 MG No MEDICAID Netupitant 300 mg and palonosetron 0.5 J8655 mg No MEDICAID J8670 Rolapitant, oral, 1 mg No ExGEN MEDICAID J8700 TEMOZOLOMIDE, ORAL, 5MG No MEDICAID J8705 TOPOTECAN, ORAL, 0.25 MG Yes ExGEN MEDICAID PRESCRIPTION DRUG, ORAL, J8999 CHEMOTHERAPEUTIC, NOS Yes ExGEN MEDICAID J9000 DOXORUBICIN HCL, 10 MG No MEDICAID ALDESLEUKIN, PER SINGLE USE VIAL J9015 No MEDICAID J9017 ARSENIC TRIOXIDE, 1MG No MEDICAID J9019 Injection, asparaginase (erwinaze), 1,000 iu No MEDICAID J9020 ASPARAGINASE, 10,000 UNITS No MEDICAID J9022 Injection, atezolizumab, 10 mg No MEDICAID J9023 Injection, avelumab, 10 mg No MEDICAID J9025 INJECTION, AZACITIDINE, 1 MG No MEDICAID J9027 INJECTION, CLOFARABINE, 1 MG No MEDICAID BCG (INTRAVESICAL) PER J9031 INSTILLATION No MEDICAID J9032 Injection, belinostat, 10 mg No MEDICAID J9033 INJECTION, BENDAMUSTINE, 1MG No MEDICAID Injection, bendamustine hcl (bendeka), 1 J9034 mg No MEDICAID J9035 INJECTION, BEVACIZUMAB, 10 MG No MEDICAID J9039 Injection, blinatumomab, 1 microgram No MEDICAID J9040 BLEOMYCIN SULFATE, 15 UNITS No MEDICAID J9041 INJECTION, BORTEZOMIB, 0.1 MG No MEDICAID J9042 Injection, brentuximab vedotin, 1 mg No MEDICAID J9043 INJECTION, CABAZITAXEL, 1 MG No MEDICAID J9045 CARBOPLATIN, 50 MG No MEDICAID J9047 Injection, carfilzomib, 1 mg No MEDICAID J9050 CARMUSTINE, 100 MG No MEDICAID J9055 INJECTION, CETUXIMAB, 10 MG No MEDICAID INJECTION, CISPLATIN, POWDER OR J9060 S0LUTION, 10 MG No MEDICAID J9065 INJECTION, CLADRIBINE, PER 1 MG No MEDICAID J9070 CYCLOPHOSPHAMIDE, 100 MG No MEDICAID J9098 CYTARABINE LIPOSOME, 10 MG No MEDICAID J9100 CYTARABINE, 100 MG No MEDICAID J9120 DACTINOMYCIN, 0.5 MG No MEDICAID J9130 DACARBAZINE, 100 MG No MEDICAID

563 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines J9145 Injection, daratumumab, 10 mg No MEDICAID J9150 DAUNORUBICIN, 10 MG No MEDICAID DAUNORUBICIN CITRATE, LIPOSOMAL J9151 Yes FORMULATION, 10 MG MEDICAID J9155 INJECTION, DEGARELIX, 1 MG No MEDICAID J9160 DENILEUKIN DIFTITOX, 300 MCG No MEDICAID DIETHYLSTILBESTROL J9165 Yes DIPHOSPHATE, 250 MG MEDICAID J9171 INJECTION, DOCETAXEL, 1 MG No MEDICAID INJECTION, ELLIOTTS' B SOLUTION, 1 J9175 ML No MEDICAID J9176 Injection, elotuzumab, 1 mg No MEDICAID J9178 INJECTION, EPIRUBICIN HCL, 2 MG No MEDICAID INJECTION, ERIBULIN MESYLATE, 0.1 J9179 MG No MEDICAID J9181 ETOPOSIDE, 10 MG No MEDICAID J9185 FLUDARABINE PHOSPHATE, 50 MG No MEDICAID J9190 FLUOROURACIL, 500 MG No MEDICAID J9200 FLOXURIDINE, 500 MG No MEDICAID J9201 GEMCITABINE HCL, 200 MG No MEDICAID GOSERELIN ACETATE IMPLANT, PER J9202 3.6 MG No * MEDICAID Injection, gemtuzumab ozogamicin, 0.1 J9203 mg No MEDICAID J9205 Injection, irinotecan liposome, 1 mg No MEDICAID J9206 IRINOTECAN, 20 MG No MEDICAID J9207 INJECTION, IXABEPILONE, 1 MG No MEDICAID J9208 IFOSFAMIDE, 1 GM No MEDICAID J9209 MESNA, 200 MG No MEDICAID IDARUBICIN HYDROCHLORIDE, 5 MG J9211 No MEDICAID INJECTION, INTERFERON ALFACON-1, J9212 RECOMBINANT, 1 MCG Yes ExGEN MEDICAID INTERFERON, ALFA-2A, J9213 RECOMBINANT, 3 MILLION UNITS Yes ExGEN MEDICAID INTERFERON, ALFA-2B, J9214 RECOMBINANT, 1 MILLION UNITS No MEDICAID INTERFERON, ALFA-N3, (HUMAN J9215 LEUKOCYTE DERIVED), 250,000 IU No MEDICAID INTERFERON, GAMMA 1-B, 3 MILLION J9216 UNITS Yes ExGEN MEDICAID LEUPROLIDE ACETATE (FOR DEPOT J9217 SUSPENSION), 7.5 MG No * MEDICAID J9218 LEUPROLIDE ACETATE, PER 1 MG No MEDICAID LEUPROLIDE ACETATE IMPLANT, 65 J9219 Yes MG MEDICAID HISTRELIN IMPLANT (VANTAS), 50 MG J9225 No MEDICAID HISTRELIN IMPLANT (SUPPRELIN LA), J9226 50 MG No MEDICAID J9228 INJECTION, IPILIMUMAB, 1 MG No MEDICAID MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN J9230 MUSTARD), 10 MG No MEDICAID INJECTION, MELPHALAN J9245 HYDROCHLORIDE, 50 MG No MEDICAID J9250 METHOTREXATE SODIUM, 5 MG No MEDICAID J9260 METHOTREXATE SODIUM, 50 MG No MEDICAID J9261 INJECTION, NELARABINE, 50 MG No MEDICAID Injection, omacetaxine mepesuccinate, J9262 0.01 mg No MEDICAID J9263 INJECTION, OXALIPLATIN, 0.5 MG No MEDICAID INJECTION, PACLITAXEL PROTEIN- J9264 BOUND PARTICLES, 1 MG No MEDICAID PEGASPARGASE, PER SINGLE DOSE J9266 VIAL No MEDICAID J9267 Injection, paclitaxel, 1 mg No MEDICAID J9268 PENTOSTATIN, PER 10 MG No MEDICAID J9270 PLICAMYCIN, 2.5 MG No MEDICAID J9271 Injection, pembrolizumab, 1 mg No MEDICAID

564 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines J9280 MITOMYCIN, 5 MG No MEDICAID J9285 Injection, olaratumab, 10 mg No MEDICAID INJECTION, MITOXANTRONE J9293 HYDROCHLORIDE, PER 5 MG No MEDICAID J9295 Injection, necitumumab, 1 mg No MEDICAID J9299 Injection, nivolumab, 1 mg No MEDICAID J9301 Injection, obinutuzumab, 10 mg No MEDICAID J9302 INJECTION, OFATUMUMAB, 10 MG No MEDICAID J9303 INJECTION, PANITUMUMAB, 10 MG No MEDICAID J9305 INJECTION, PEMETREXED, 10 MG No MEDICAID J9306 Injection, pertuzumab, 1 mg No MEDICAID J9307 INJECTION, PRALATREXATE, 1 MG No MEDICAID J9308 Injection, ramucirumab, 5 mg No MEDICAID J9310 RITUXIMAB, 100 MG No MEDICAID J9315 INJECTION, ROMIDEPSIN, 1 MG No MEDICAID J9320 STREPTOZOCIN, 1 GM No MEDICAID Injection, talimogene laherparepvec, per 1 J9325 million plaque forming units Yes ExGEN MEDICAID J9328 INJECTION, TEMOZOLOMIDE, 1 MG No MEDICAID J9330 INJECTION, TEMSIROLIMUS, 1 MG No MEDICAID J9340 THIOTEPA, 15 MG No MEDICAID J9351 INJECTION, TOPOTECAN, 0.1 MG No MEDICAID J9352 Injection, trabectedin, 0.1 mg No MEDICAID Injection, ado-trastuzumab emtansine, 1 J9354 mg No MEDICAID J9355 TRASTUZUMAB, 10 MG No MEDICAID VALRUBICIN, INTRAVESICAL, 200 MG J9357 No MEDICAID J9360 VINBLASTINE SULFATE, 1 MG No MEDICAID J9370 VINCRISTINE SULFATE, 1 MG No MEDICAID Injection, vincristine sulfate liposome, 1 J9371 mg No MEDICAID VINORELBINE TARTRATE, PER 10 MG J9390 No MEDICAID J9395 INJECTION, FULVESTRANT, 25 MG No MEDICAID J9400 Injection, ziv-aflibercept, 1 mg No MEDICAID J9600 PORFIMER SODIUM, 75 MG Yes MEDICAID NOT OTHERWISE CLASSIFIED, J9999 Yes ANTINEOPLASTIC DRUGS MEDICAID For Diabetics Only, Multiple Density Insert, Made By Direct Carving With CAM Technology From A Rectified CAD Model Created From A Digitized Scan Of The Patient, Total Contact With Patient's Foot, Including Arch, Base Layer Minimum Of 3/16 Inch Material Of Shore A 35 Durometer (Or Higher), Includes Arch Filler And Other Shaping Material, Custom Fabricated, Each K0903 Yes MEDICAID IMPLANTABLE BREAST PROSTHESIS, L8600 SILICONE OR EQUAL No MEDICAID COLLAGEN IMPLANT, URINARY TRACT, PER 2.5 CC SYRINGE, INCLUDES SHIPPING AND L8603 NECESSARY SUPPLIES No MEDICAID L8604 INJECTION, TEMSIROLIMUS, 1 MG No MEDICAID L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies Not Covered MEDICAID INJECTABLE BULKING AGENT, SYNTHETIC IMPLANT, URINARY TRACT, 1ML SYRINGE, INCLUDES SHIPPING AND NECESSARY L8606 SUPPLIES No MEDICAID Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and L8607 necessary supplies No MEDICAID

565 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines L8609 ARTIFICIAL CORNEA No MEDICAID L8610 OCULAR IMPLANT No MEDICAID L8612 AQUEOUS SHUNT No MEDICAID L8613 OSSICULA IMPLANT No MEDICAID COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL L8614 COMPONENTS No MEDICAID HEADSET/HEADPIECE FOR USE L8615 W/COCHLEAR IMPLANT DEVICE, Yes REPLACEMENT MEDICAID MICROPHONE FOR USE L8616 W/COCHLEAR IMPLANT DEVICE, Yes REPLACEMENT MEDICAID TRANSMITTING COIL FOR USW L8617 W/COCHLEAR IMPLANT DEVICE, Yes REPLACEMENT MEDICAID TRANSMITTER CABLE FOR USE L8618 WCOCHLEAR IMPLANT DEVICE, Yes REPLACEMENT MEDICAID COCHLEAR IMPLANT EXTERNAL L8619 SPEECH PROCESSOR, Yes REPLACEMENT MEDICAID ZINC AIR BATTERY FOR USE W/COCHLEAR IMPLANT DECIVE, L8621 Yes REPLACEMENT, EACH (reactivated from being term'ed as of 3/31/98) MEDICAID ALKALINE BATTERY FOR USE W/COCHLEAR IMPLANT DEVICE, ANY L8622 SIZE, REPLACEMENT (reactivated from Yes being term'ed as of 3/31/98) MEDICAID LITHIUM ION BATTERY FOR USE WITH L8623 Yes COCHLEAR IMPLANT MEDICAID LITHIUM ION BATTERY FOR USE WITH L8624 Yes COCHLEAR IMPLANT MEDICAID COCHLEAR IMPLANT, EXTERNAL L8627 SPEECH PROCESSOR, COMPONENT, Yes REPLACEMENT MEDICAID COCHLEAR IMPLANT, EXTERNAL L8628 CONTROLLER COMPONENT, Yes REPLACEMENT MEDICAID TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH L8629 Yes COCHLEAR IMPLANT DEVICE, REPLACEMENT MEDICAID METACARPOPHALANGEAL JOINT L8630 IMPLANT No MEDICAID METACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE L8631 PIECES, METAL No MEDICAID L8641 METATARSAL JOINT IMPLANT No MEDICAID L8642 HALLUX IMPLANT No MEDICAID INTERPHALANGEAL JOINT SPACER, SILICONE OR EQUAL, EACH L8658 No MEDICAID INTERPHALANGEAL FINGER JOINT REPLACEMENT, 2 OR MORE , METAL, L8659 CERAMIC No MEDICAID VASCULAR GRAFT MATERIAL, L8670 SYNTHETIC, IMPLANT No MEDICAID IMPLANTABLE NEUROSTIMULATOR L8680 ELECTRODE, EACH No MEDICAID PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE L8681 PROGRAMMABLE No MEDICAID IMPLANTABLE NEUROSTIMULATOR L8682 RADIOFREQUENCY RECEIVER No MEDICAID RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH L8683 IMPLANTABLE No MEDICAID

566 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH L8684 IMPLANTABLE SACRAL No MEDICAID IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, L8685 RECHARGE No MEDICAID IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, L8686 NON No MEDICAID IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, L8687 RECHARGEABLE No MEDICAID IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, L8688 NON-RECHARGE No MEDICAID EXTERNAL RECHARGING SYSTEM FOR IMPLANTED NEUROSTIMULATOR, REPLACEMENT L8689 ONLY No MEDICAID AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL L8690 AND EXTERNAL COMPONENTS No MEDICAID AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND L8691 PROCESSOR, REPLACEMENT No MEDICAID AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUT L8692 OSSEOINTEGRATION, BODY WORN, Yes INCLUDES HEADBAND OR OTHER MEANS OF EXTERNAL ATTACHMENT MEDICAID AUDITORY OSSEOINTEGRATED L8693 DEVICE ABUTMENT, ANY LENGTH, Yes REPLACEMENT ONLY MEDICAID EXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLE L8695 NEUROSTIMULATOR No MEDICAID PROSTHETIC IMPLANT, NOT L8699 OTHERWISE SPECIFIED Yes MEDICAID ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER L9900 HCPCS L CODE No MEDICAID M0075 CELLULAR THERAPY Not Covered MEDICAID M0076 PROLOTHERAPY Not Covered MEDICAID INTRAGASTRIC HYPOTHERMIA USING M0100 GASTRIC FREEZING No MEDICAID IV CHELATION THERAPY (CHEMICAL M0300 ENDARTERECTOMY) Not Covered MEDICAID FABRIC WRAPPING OF ABDOMINAL M0301 ANEURYSM (MNP) Not Covered MEDICAID P2028 CEPHALIN FLOCULATION, BLOOD No MEDICAID P2029 CONGO RED, BLOOD No MEDICAID HAIR ANALYSIS (EXCLUDING P2031 ARSENIC) Not Covered MEDICAID P2033 THYMOL TURBIDITY, BLOOD No MEDICAID MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY P2038 PROCEDURE) No MEDICAID SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO P3000 THREE SMEARS No MEDICAID SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO P3001 THREE SMEARS, No MEDICAID CULTURE, BACTERIAL, URINE; P7001 QUANTITATIVE, SENSITIVITY STUDY No MEDICAID BLOOD (WHOLE), FOR TRANSFUSION, P9010 PER UNIT No MEDICAID

567 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BLOOD (SPLIT UNIT), SPECIFY P9011 AMOUNT No MEDICAID P9012 CRYOPRECIPITATE, EACH UNIT No MEDICAID RED BLOOD CELLS, LEUKOCYTES P9016 REDUCED, EACH UNIT No MEDICAID FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS P9017 OF COLLECTION, No MEDICAID P9019 PLATELETS, EACH UNIT No MEDICAID PLATELET RICH PLASMA, EACH UNIT P9020 Not Covered MEDICAID P9021 RED BLOOD CELLS, EACH UNIT No MEDICAID RED BLOOD CELLS, WASHED, EACH P9022 UNIT No MEDICAID PLASMA, POOLED MULTIPLE DONOR, SOLVENT/DETERGENT TREATED, P9023 FROZEN, EACH No MEDICAID PLATELETS, LEUKOCYTES REDUCED, P9031 EACH UNIT No MEDICAID PLATELETS, IRRADIATED, EACH UNIT P9032 No MEDICAID PLATELETS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT P9033 No MEDICAID P9034 PLATELETS, PHERESIS, EACH UNIT No MEDICAID PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT P9035 No MEDICAID PLATELETS, PHERESIS, IRRADIATED, P9036 EACH UNIT No MEDICAID PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT P9037 No MEDICAID RED BLOOD CELLS, IRRADIATED, P9038 EACH UNIT No MEDICAID RED BLOOD CELLS, P9039 DEGLYCEROLIZED, EACH UNIT No MEDICAID RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT P9040 No MEDICAID INFUSION, ALBUMIN (HUMAN), 5%, 50 P9041 ML No MEDICAID INFUSION, PLASMA PROTEIN P9043 FRACTION (HUMAN), 5%, 50 ML No MEDICAID PLASMA, CRYOPRECIPITATE P9044 REDUCED, EACH UNIT No MEDICAID INFUSION, ALBUMIN (HUMAN), 5%, 250 P9045 ML No MEDICAID INFUSION, ALBUMIN (HUMAN), 25%, 20 P9046 ML No MEDICAID INFUSION, ALBUMIN (HUMAN), 25%, 50 P9047 ML No MEDICAID INFUSION, PLASMA PROTEIN P9048 FRACTION (HUMAN), 5%, 250ML No MEDICAID GRANULOCYTES, PHERESIS, EACH P9050 UNIT No MEDICAID WHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV- P9051 NEGATIVE, EACH No MEDICAID PLATELETS, HLA-MATCHED LEUKOCYTES REDUCED, P9052 APHERESIS/PHERESIS, EACH No MEDICAID PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, P9053 IRRADIATED, EACH No MEDICAID WHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, P9054 FROZEN, No MEDICAID PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, P9055 APHERESIS/PHERESIS, EACH No MEDICAID

568 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines WHOLE BLOOD, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT P9056 No MEDICAID RED BLOOD CELLS, FROZEN/DEGLYCEROLIZED/WASHED, P9057 LEUKOCYTES REDUCED, No MEDICAID RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, P9058 IRRADIATED, EACH UNIT No MEDICAID FRESH FROZEN PLASMA BETWEEN 8- 24 HOURS OF COLLECTION, EACH P9059 UNIT No MEDICAID FRESH FROZEN PLASMA, DONOR P9060 RETESTED, EACH UNIT No MEDICAID Plasma, pooled multiple donor, pathogen P9070 reduced, frozen, each unit No MEDICAID Plasma (single donor), pathogen reduced, P9071 frozen, each unit No MEDICAID Platelets, pheresis, pathogen-reduced, P9073 each unit No MEDICAID P9100 Pathogen(s) test for platelets No MEDICAID TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED. P9603 No MEDICAID TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED P9604 TRIP CHARGE. No MEDICAID CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, ALL P9612 PLACES No MEDICAID CATHETERIZATION FOR COLLECTION OF SPECIMEN (S) (MULTIPLE P9615 PATIENTS) No MEDICAID Q0035 CARDIOKYMOGRAPHY No MEDICAID INFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC DRUGS, Q0081 PER VISIT No MEDICAID CHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION TECHNIQUE ONLY (EG SUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISIT Q0083 No MEDICAID CHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE ONLY, PER Q0084 VISIT No MEDICAID CHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE AND OTHER TECHIQUE(S) (EG SUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISIT Q0085 No MEDICAID SCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND Q0091 CONVEYANCE OF No MEDICAID WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, Q0111 CERVICAL OR SKIN SPECIMENS No MEDICAID ALL POTASSIUM HYDROXIDE (KOH) Q0112 PREPARATIONS No MEDICAID Q0113 PINWORM EXAMINATIONS No MEDICAID Q0114 FERN TEST No MEDICAID

569 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines POST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR Q0115 CERVICAL MUCOUS No MEDICAID Q0138 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE) No MEDICAID Q0139 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRD ON DIALYSIS) No MEDICAID AZITHROMYCIN DIHYDRATE, ORAL, Q0144 CAPSULES/POWDER, 1 GRAM No MEDICAID Chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0161 No MEDICAID ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE Q0162 REGIMEN No MEDICAID DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA Q0163 APPROVED PRESCRIPTION No MEDICAID PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED Q0164 PRESCRIPTION No MEDICAID GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED Q0166 PRESCRIPTION No MEDICAID DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE Q0167 REGIMEN No MEDICAID PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED Q0169 PRESCRIPTION No MEDICAID TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, Q0173 FDA APPROVED No MEDICAID THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED Q0174 PRESCRIPTION ANTI-EMET No MEDICAID PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI- Q0175 EMETIC, No MEDICAID HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED Q0177 PRESCRIPTION ANTI-EMETIC, No MEDICAID DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED Q0180 PRESCRIPTION ANTI-EMETIC, No MEDICAID UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN Q0181 No MEDICAID

570 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Power module patient cable for use with electric or electric/pneumatic ventricular Q0477 Yes assist device, replacement only MEDICAID POWER ADAPTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE, VEHICLE TYPE Q0478 No MEDICAID POWER MODULE FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY Q0479 No MEDICAID DRIVER FOR USE WITH PNEUMATIC VENTRICULAR ASSIST DEVICE, Q0480 REPLACEMENT No MEDICAID MICROPROCESSOR CONTROL UNIT FOR USE WITH ELECTRIC Q0481 VENTRICULAR ASSIST No MEDICAID MICROPROCESSOR CONTROL UNIT FOR USE WITH Q0482 ELECTRIC/PNEUMATIC COMBINA No MEDICAID MONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC VENTRICULAR Q0483 ASSIST DEVICE, No MEDICAID MONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC OR Q0484 ELECTRIC/PNEUMATIC No MEDICAID MONITOR CONTROL CABLE FOR USE WITH ELECTRIC VENTRICULAR Q0485 ASSIST DEVICE No MEDICAID MONITOR CONTROL CABLE FOR USE WITH ELECTRIC/PNEUMATIC Q0486 VENTRICULAR No MEDICAID LEADS (PNEUMATIC/ELECTRICAL) FOR USE WITH ANY TYPE Q0487 ELECTRIC/PNEUMATIC No MEDICAID POWER PACK BASE FOR USE WITH ELECTRIC VENTRICULAR ASSIST Q0488 DEVICE, No MEDICAID POWER PACK BASE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR Q0489 ASSIST No MEDICAID EMERGENCY POWER SOURCE FOR USE WITH ELECTRIC VENTRICULAR Q0490 ASSIST DEVICE No MEDICAID EMERGENCY POWER SOURCE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR Q0491 No MEDICAID EMERGENCY POWER SUPPLY CABLE FOR USE WITH ELECTRIC Q0492 VENTRICULAR ASSIST No MEDICAID EMERGENCY POWER SUPPLY CABLE FOR USE WITH Q0493 ELECTRIC/PNEUMATIC VENTRIC No MEDICAID EMERGENCY HAND PUMP FOR USE WITH ELECTRIC OR Q0494 ELECTRIC/PNEUMATIC No MEDICAID BATTERY/POWER PACK CHARGER FOR USE WITH ELECTRIC OR Q0495 ELECTRIC/PNEUMATIC No MEDICAID BATTERY FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VAD, REPLACEMENT Q0496 No MEDICAID BATTERY CLIPS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VAD, REPLACE Q0497 No MEDICAID

571 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOLSTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VAD, REPLACEMENT Q0498 No MEDICAID BELT/VEST/BAG FOR USE TO CARRY EXTERNAL PERIPHERAL COMPONENTS OF ANY TYPE VENTRICULAR ASSIST DEVICE, Q0499 REPLACEMENT ONLY No MEDICAID FILTERS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VAD, Q0500 REPLACEMENT No MEDICAID SHOWER COVER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VAD, REPLACE Q0501 No MEDICAID MOBILITY CART FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, Q0502 REPLACEMENT ONLY No MEDICAID BATTERY FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, Q0503 REPLACEMENT ONLY, EACH No MEDICAID POWER ADAPTER FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, Q0504 REPLACEMENT No MEDICAID Q0506 BATTERY, LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY No MEDICAID Miscellaneous supply or accessory for use Q0507 with ventricular assist device Yes MEDICAID Miscellaneous supply or accessory for use Q0508 with an implanted venticular assist device Yes MEDICAID Miscellaneous supply or accessory for use any implanted ventricular assist device for Q0509 which payment was not made under Medicare Part A Yes MEDICAID PHARMACY SUPPLY FEE FOR INITIAL Q0510 IMMUNOSUPPRESSIVE No MEDICAID PHARMACY SUPPLY FEE FOR ORAL Q0511 ANTI-CANCER, ORAL ANT No MEDICAID PHARMACY SUPPLY FEE FOR ORAL Q0512 ANTI-CANCER, ORAL ANT No MEDICAID PHARMACY DISPENSING FEE FOR Q0513 INHALATION DRUG(S); PE No MEDICAID PHARMACY DISPENSING FEE FOR Q0514 INHALATION DRUG(S); PE No MEDICAID INJECTION, SERMORELIN ACETATE, 1 Q0515 MICROGRAM No MEDICAID NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 4 AS DEFINED IN Q1004 FEDERAL REGISTER NOTICE No MEDICAID NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 5 AS DEFINED IN Q1005 FEDERAL REGISTER NOTICE No MEDICAID IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, Q2004 No MEDICAID Q2009 INJECTION, FOSPHENYTOIN, 50 MG No MEDICAID Q2017 INJECTION, TENIPOSIDE, 50 MG No MEDICAID Q2026 Injection, Radiesse, 0.1 ml Yes RMT MEDICAID Q2028 Injection, sculptra, 0.5 mg No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR INTRAMUSCULAR USE Q2034 (AGRIFLU) No MEDICAID

572 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE Q2035 (AFLURIA) No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE Q2036 (FLULAVAL) No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE Q2037 (FLUVIRIN) No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE Q2038 (FLUZONE) No MEDICAID INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO Q2039 INDIVIDUALS 3 YEARS OF AGE AND Yes OLDER, FOR INTRAMUSCULAR USE (NOT OTHERWISE SPECIFIED) MEDICAID Tisagenlecleucel, up to 250 million car- positive viable t cells, including leukapheresis and dose preparation Q2040 procedures, per infusion Yes MEDICAID Axicabtagene Ciloleucel, up to 200 Million Autologous Anti-CD19 CAR T Cells, Including Leukapheresis And Dose Preparation Procedures, Per Infusion Q2041 Yes MEDICAID SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY Q2043 PROCEDURES, PER INFUSION No MEDICAID INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, Q2049 IMPORTED LIPODOX, 10 MG No MEDICAID Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, Q2050 10mg No MEDICAID Services, supplies and accessories used in the home under the medicare intravenous immune globulin (ivig) Q2052 demonstration No MEDICAID RADIOELEMENTS FOR BRACHYTHERAPY, ANY TYPE, EACH Q3001 No MEDICAID TELEHEALTH ORIGINATING SITE Q3014 FACILITY FEE No MEDICAID Injection, interferon beta-1a, 1 mcg for Q3027 intramuscular use No MEDICAID Injection, interferon beta-1a, 1 mcg for Q3028 subcutaneous use No MEDICAID Q3031 COLLAGEN SKIN TEST No MEDICAID CASTING SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, Q4001 PLASTER No MEDICAID CAST SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, Q4002 FIBERGLASS No MEDICAID CAST SUPPLIES, SHOULDER CAST, Q4003 ADULT (11 YEARS +), PLASTER No MEDICAID CAST SUPPLIES, SHOULDER CAST, Q4004 ADULT (11 YEARS +), FIBERGLASS No MEDICAID

573 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CAST SUPPLIES, LONG ARM CAST, Q4005 ADULT (11 YEARS +), PLASTER No MEDICAID CAST SUPPLIES, LONG ARM CAST, Q4006 ADULT (11 YEARS +), FIBERGLASS No MEDICAID CAST SUPPLIES, LONG ARM CAST, Q4007 PEDIATRIC (0-10 YEARS), PLASTER No MEDICAID CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), Q4008 FIBERGLASS No MEDICAID CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), PLASTER Q4009 No MEDICAID CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), FIBERGLASS Q4010 No MEDICAID CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), PLASTER Q4011 No MEDICAID CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), Q4012 FIBERGLASS No MEDICAID CAST SUPPLIES, GAUNTLET CAST, Q4013 ADULT (11 YEARS +), PLASTER No MEDICAID CAST SUPPLIES, GAUNTLET CAST, Q4014 ADULT (11 YEARS +), FIBERGLASS No MEDICAID CAST SUPPLIES, GAUNTLET CAST , Q4015 PEDIATRIC (0-10 YEARS), PLASTER No MEDICAID CAST SUPPLIES, GAUNTLET CAST, PEDIATRIC (0-10 YEARS), Q4016 FIBERGLASS No MEDICAID CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), PLASTER Q4017 No MEDICAID CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS Q4018 No MEDICAID CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTER Q4019 No MEDICAID CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4020 FIBERGLASS No MEDICAID CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), PLASTER Q4021 No MEDICAID CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS Q4022 No MEDICAID CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTER Q4023 No MEDICAID CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4024 FIBERGLASS No MEDICAID CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), Q4025 PLASTER No MEDICAID CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), Q4026 FIBERGLASS No MEDICAID CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 Q4027 YEARS), PLASTER No MEDICAID CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YRS), Q4028 FIBERGLASS No MEDICAID CAST SUPPLIES, LONG LEG CAST, Q4029 ADULT (11 YEARS +), PLASTER No MEDICAID CAST SUPPLIES, LONG LEG CAST, Q4030 ADULT (11 YEARS +), FIBERGLASS No MEDICAID

574 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CAST SUPPLIES, LONG LEG CAST, Q4031 PEDIATRIC (0-10 YEARS), PLASTER No MEDICAID CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), Q4032 FIBERGLASS No MEDICAID CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS Q4033 +), PLASTER No MEDICAID CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS Q4034 +), FIBERGLASS No MEDICAID CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 Q4035 YEARS), PLASTER No MEDICAID CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 Q4036 YEARS), FIBERGLASS No MEDICAID CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), PLASTER Q4037 No MEDICAID CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), FIBERGLASS Q4038 No MEDICAID CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), PLASTER Q4039 No MEDICAID CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), Q4040 FIBERGLASS No MEDICAID CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), PLASTER Q4041 No MEDICAID CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), FIBERGLASS Q4042 No MEDICAID CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTER Q4043 No MEDICAID CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4044 FIBERGLASS No MEDICAID CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), PLASTER Q4045 No MEDICAID CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), FIBERGLASS Q4046 No MEDICAID CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTER Q4047 No MEDICAID CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4048 FIBERGLASS No MEDICAID Q4049 FINGER SPLINT, STATIC No MEDICAID CAST SUPPLIES, FOR UNLISTED Q4050 Yes TYPES AND MATERIALS OF CASTS MEDICAID SPLINT SUPPLIES, MISCELLANEOUS (INCLUDES THERMOPLASTICS, Q4051 STRAPPING, FASTENERS, PADDING Yes AND OTHER SUPPLIES) MEDICAID Q4074 ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS Yes ExGEN MEDICAID INJECTION, EPOETIN ALFA, 100 UNITS Q4081 (FOR ESRD ON DIALYSIS) No MEDICAID

575 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B DRUG COMPETITIVE ACQUISITION Q4082 PROGRAM (CAP) No MEDICAID SKIN SUBSTITUTE, NOT OTHERWISE Q4100 SPECIFIED Yes MEDICAID APLIGRAF, PER SQUARE Q4101 CENTIMETER No MEDICAID OASIS WOUND MATRIX, PER SQUARE Q4102 CENTIMETER No MEDICAID OASIS BURN MATRIX, PER SQUARE Q4103 CENTIMETER Not Covered MEDICAID INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE Q4104 CENTIMETER No MEDICAID INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE Q4105 CENTIMETER No MEDICAID DERMAGRAFT, PER SQUARE Q4106 CENTIMETER No MEDICAID GRAFTJACKET, PER SQUARE Q4107 CENTIMETER No MEDICAID INTEGRA MATRIX, PER SQUARE Q4108 CENTIMETER No MEDICAID PRIMATRIX, PER SQUARE Q4110 No CENTIMETER MEDICAID GAMMAGRAFT, PER SQUARE Q4111 CENTIMETER Not Covered MEDICAID Q4112 CYMETRA, INJECTABLE, 1CC Not Covered MEDICAID GRAFTJACKET XPRESS, INJECTABLE, Q4113 1CC Not Covered MEDICAID INTEGRA FLOWABLE WOUND Q4114 MATRIX, INJECTABLE, 1CC No MEDICAID ALLOSKIN, PER SQUARE Q4115 CENTIMETER Not Covered MEDICAID ALLODERM, PER SQUARE Q4116 CENTIMETER No MEDICAID HYALOMATRIX, PER SQUARE Q4117 CENTIMETER Not Covered MEDICAID Q4118 MATRISTEM MICROMATRIX, 1 MG Not Covered MEDICAID THERASKIN, PER SQUARE Q4121 CENTIMETER No MEDICAID DERMACELL, PER SQUARE Q4122 CENTIMETER No * MEDICAID ALLOSKIN RT, PER SQUARE Q4123 CENTIMETER Not Covered MEDICAID OASIS ULTRA TRI-LAYER WOUND MATRIX, PER SQUARE CENTIMETER Q4124 No MEDICAID ARTHROFLEX, PER SQUARE Q4125 CENTIMETER Not Covered MEDICAID MEMODERM, PER SQUARE Q4126 CENTIMETER Not Covered MEDICAID TALYMED, PER SQUARE CENTIMETER Q4127 No MEDICAID FLEXHD OR ALLOPATCH HD, PER Q4128 SQUARE CENTIMETER No MEDICAID STRATTICE TM, PER SQUARE Q4130 CENTIMETER Not Covered MEDICAID Q4131 Epifix, per square centimeter No MEDICAID Q4132 Grafix core, per square centimeter No MEDICAID Q4133 Grafix prime, per square centimeter No MEDICAID Q4134 Hmatrix, per square centimeter Not Covered MEDICAID Q4135 Mediskin, per square centimeter Not Covered MEDICAID Q4136 Ez-derm, per square centimeter Not Covered MEDICAID Amnioexcel or biodexcel, per square Q4137 centimeter Not Covered MEDICAID Biodfence dryflex, per square centimeter Q4138 Not Covered MEDICAID Amniomatrix or biodmatrix, injectable, 1 Q4139 cc Not Covered MEDICAID

576 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Q4140 Biodfence, per square centimeter Not Covered MEDICAID Q4141 Alloskin ac, per square centimeter Not Covered MEDICAID Xcm biologic tissue matrix, per square Q4142 centimeter Not Covered MEDICAID Q4143 Repriza, per square centimeter Not Covered MEDICAID Q4145 Epifix, injectable, 1 mg Not Covered MEDICAID Q4146 Tensix, per square centimeter Not Covered MEDICAID Architect extracellular matrix, per square Q4147 centimeter Not Covered MEDICAID Q4148 Neox 1k, per square centimeter Not Covered MEDICAID Q4149 Excellagen, 0.1 cc Not Covered MEDICAID Allowrap ds or dry, per square centimeter Q4150 Not Covered MEDICAID Amnioband or guardian, per square Q4151 centimeter Not Covered MEDICAID Q4152 Dermapure, per square centimeter Not Covered MEDICAID Q4153 Dermavest, per square centimeter Not Covered MEDICAID Q4154 Biovance, per square centimeter Not Covered MEDICAID Q4155 Neoxflo or clarixflo, 1 mg Not Covered MEDICAID Q4156 Neox 100, per square centimeter Not Covered MEDICAID Q4157 Revitalon, per square centimeter Not Covered MEDICAID Q4158 Marigen, per square centimeter Not Covered MEDICAID Q4159 Affinity, per square centimeter Not Covered MEDICAID Q4160 Nushield, per square centimeter Not Covered MEDICAID Bio-connekt wound matrix, per square Q4161 centimeter Not Covered MEDICAID Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5 cc Q4162 Not Covered MEDICAID Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square Q4163 centimeter Not Covered MEDICAID Q4164 Helicoll, per square centimeter Not Covered MEDICAID Q4165 Keramatrix, per square centimeter Not Covered MEDICAID Q4166 Cytal, per square centimeter Not Covered MEDICAID Q4167 Truskin, per square centimeter Not Covered MEDICAID Q4168 Amnioband, 1 mg Not Covered MEDICAID Artacent wound, per square centimeter Q4169 Not Covered MEDICAID Q4170 Cygnus, per square centimeter Not Covered MEDICAID Q4171 Interfyl, 1 mg Not Covered MEDICAID Puraply or puraply am, per square Q4172 centimeter Not Covered MEDICAID Palingen or palingen xplus, per square Q4173 centimeter Not Covered MEDICAID Palingen or promatrx, 0.36 mg per 0.25 cc Q4174 Not Covered MEDICAID Q4175 Miroderm, per square centimeter Not Covered MEDICAID Q4176 Neopatch, per square centimeter Not Covered MEDICAID Q4177 Floweramnioflo, 0.1 cc Not Covered MEDICAID Floweramniopatch, per square centimeter Q4178 Not Covered MEDICAID Q4179 Flowerderm, per square centimeter Not Covered MEDICAID Q4180 Revita, per square centimeter Not Covered MEDICAID Q4181 Amnio wound, per square centimeter Not Covered MEDICAID Q4182 Transcyte, per square centimeter Not Covered MEDICAID HOSPICE CARE PROVIDED IN Q5001 PATIENT'S HOME/RESIDENCE No ExGEN MEDICAID HOSPICE CARE PROVIDED IN Q5002 ASSISTED LIVING FACILITY No ExGEN MEDICAID HOSPICE CARE PROVIDED IN NURSING LTC OR NON-SKILLED Q5003 NUSRING No ExGEN MEDICAID HOSPICE CARE PROVIDED IN SKILLED Q5004 NURSING FACILITY (SNF) No ExGEN MEDICAID HOSPICE CARE PROVIDED IN Q5005 INPATIENT HOSPITAL No ExGEN MEDICAID HOSPICE CARE PROVIDED IN Q5006 INPATIENT HOSPICE FACILITY No ExGEN MEDICAID

577 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOSPICE CARE PROVIDED IN Q5006 INPATIENT HOSPICE FACILITY No ExGEN MEDICAID HOSPICE CARE PROVIDED IN LONG- Q5007 TERM CARE FACILITY (LTCH) No ExGEN MEDICAID HOSPICE CARE PROVIDED IN Q5008 INPATIENT PSYCHIATRIC FACILITY No ExGEN MEDICAID HOSPICE CARE PROVIDED IN A APLACE NOT OTHERWISE SPECIFIED Q5009 (NOS) No ExGEN MEDICAID HOSPICE HOME CARE PROVIDED IN A Q5010 HOSPICE FACILITY No ExGEN MEDICAID Injection, filgrastim-sndz, biosimilar, Q5101 (zarxio), 1 microgram No MEDICAID Injection, infliximab-dyyb, biosimilar, Q5103 (inflectra), 10 mg No MEDICAID Injection, infliximab-abda, biosimilar, Q5104 (renflexis), 10 mg No MEDICAID Injection, epoetin alfa, biosimilar (Retacrit) Q5105 (for ESRD on dialysis) No MEDICAID Injection, epoetin alfa, biosimilar (Retacrit) Q5106 (for non-esrd use) No MEDICAID Q5108 on, pegfilgrastim-jmdb, biosimilar, (fulphila), No MEDICAID Q5110 n, filgrastim-aafi, biosimilar, (nivestym), 1 mi No MEDICAID Injection, sulfur hexafluoride lipid Q9950 microspheres, per ml No MEDICAID LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML Q9951 Yes IODINE CONCENTRATION, PER ML MEDICAID INJECTION, IRON-BASED MAGNETIC RESONANCE CONTRAST AGENT, PER Q9953 ML No MEDICAID ORAL MAGNETIC RESONANCE Q9954 CONTRAST AGENT, PER ML No MEDICAID INJECTION, PERFLEXANE LIPID Q9955 Yes MICROSPHERES, PER ML MEDICAID INJECTION, OCTAFLUOROPROPANCE MICROSPHERES, PER ML Q9956 No MEDICAID INJECTION, PERFLUTREN LIPID Q9957 MICROSPHERES, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE Q9958 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE Q9959 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE Q9960 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE Q9961 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE Q9962 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE Q9963 CONCENTRATION, PER ML No MEDICAID HIGH OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER ML Q9964 No MEDICAID LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE Q9965 CONCENTRATION, PER ML No MEDICAID LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE Q9966 CONCENTRATION, PER ML No MEDICAID

578 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE Q9967 CONCENTRATION, PER ML No MEDICAID Q9968 INJECTION, NON-RADIOACTIVE, NON- CONTRAST, VISUALIZATION ADJUNCT (E.G., METHYLENE BLUE, ISOSULFAN BLUE), 1 MG No MEDICAID Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose No MEDICAID Injection, Ferric Pyrophosphate Citrate Q9976 Solution, 0.01 mg of iron No MEDICAID Flutemetamol F18, diagnostic, per study Q9982 dose, up to 5 millicuries No MEDICAID Florbetaben f18, diagnostic, per study Q9983 dose, up to 8.1 millicuries No MEDICAID Injection, buprenorphine extended-release Q9991 (sublocade), less than or equal to 100 mg No MEDICAID Injection, buprenorphine extended-release Q9992 (sublocade), greater than 100 mg No MEDICAID Injection, triamcinolone acetonide, preservative- Q9993 free, extended-release, microsphere formulation, 1 mg No MEDICAID In-line cartridge containing digestive enzyme(s) Q9994 for enteral feeding, each No MEDICAID Q9995 Injection, emicizumab-kxwh, 0.5 mg No MEDICAID TRANSPORTATION OF PORTABLE X- RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSING HOME, PER TRIP TO FACILITY OR LOCATION, ONE R0070 PATIENT SEEN No MEDICAID TRANSPORTATION OF PORTABLE X- RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSING HOME, PER TRIP TO FACILITY OR LOCATION, R0075 MORE THAN ONE PATIENT SEEN No MEDICAID BUTORPHANOL TARTRATE, NASAL S0012 SPRAY, 25 MG No MEDICAID S0014 TACRINE HYDROCHLORIDE, 10 MG No MEDICAID INJECTION, AMINOCAPROIC ACID, 5 S0017 GRAMS No MEDICAID INJECTION, BUPIVICAINE S0020 HYDROCHLORIDE, 30 ML No MEDICAID INJECTION, CEFOPERAZONE SODIUM, S0021 1 GRAM No MEDICAID INJECTION, CIMETIDINE S0023 HYDROCHLORIDE, 300 MG No MEDICAID S0028 INJECTION, FAMOTIDINE, 20 MG No MEDICAID INJECTION, METRONIDAZOLE, 500 MG S0030 No MEDICAID INJECTION, NAFCILLIN SODIUM, 2 S0032 Yes GRAMS MEDICAID S0034 INJECTION, OFLOXACIN, 400 MG No MEDICAID INJECTION, SULFAMETHOXAZOLE S0039 AND TRIMETHOPRIM, 10 ML No MEDICAID INJECTION, TICARCILLIN DISODIUM AND CLAVULANATE POTASSIUM, 3.1 S0040 GRAMS No MEDICAID S0073 INJECTION, AZTREONAM, 500 MG No MEDICAID INJECTION, CEFOTETAN DISODIUM, S0074 Yes 500 MG MEDICAID INJECTION, CLINDAMYCIN S0077 PHOSPHATE, 300 MG No MEDICAID INJECTION, FOSPHENYTOIN SODIUM, S0078 750 MG No MEDICAID INJECTION, PENTAMIDINE S0080 ISETHIONATE, 300 MG No MEDICAID INJECTION, PIPERACILLIN SODIUM, S0081 500 MG No MEDICAID S0088 IMATINIB INJECTION, 100 MG No MEDICAID S0090 SILDENAFIL CITRATE, 25 MG No MEDICAID

579 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TEST, GRANISETRON HYDROCHLORIDE, 1MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE S0091 STATUTE, USE Q0166) No MEDICAID INJECTION, HYDROMORPHONE S0092 HYDROCHLORIDE, 250 MG No MEDICAID INJECTION, MORPHINE SULFATE, 500 MG (LOADING DOSE FOR INFUSION S0093 PUMP) No MEDICAID S0104 ZIDOVUDINE, ORAL, 100 MG No MEDICAID BUPROPION HCL SUSTAINED RELEASE TABLET, 150 MG, PER S0106 BOTTLE OF 60 TABLETS No MEDICAID S0108 MERCAPTOPURINE, ORAL, 50 MG No MEDICAID S0109 METHADONE, ORAL, 5 MG No MEDICAID S0117 TRETINOIN, TOPICAL, 5 GRAMS No MEDICAID ONDANSETRON, ORAL, 4 MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE S0119 HCPCS Q CODE) No MEDICAID S0122 INJECTION, MENOTROPINS 75 IU Yes ExGEN MEDICAID INJECTION FOLLITROPIN ALFA, 75 IU S0126 Yes ExGEN MEDICAID INJECTION FOLLITROPIN BETA, 75 IU S0128 Yes ExGEN MEDICAID INJECTION, GANIRELIX ACETATE 250 S0132 MG Yes ExGEN MEDICAID S0136 CLOZAPINE, 25 MG No MEDICAID S0137 DIDANOSINE (DDL), 25 MG No MEDICAID S0138 FINASTERIDE, 5 MG No MEDICAID S0139 MINOXIDIL, 10 MG Not Covered MEDICAID S0140 SAQUINAVIR, 200 MG No MEDICAID COLISTIMETHATE SODIUM, INHALATION SOLUTION S0142 ADMINISTERED THROUGH DME No MEDICAID INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML S0145 Yes ExGEN MEDICAID INJECTION, PEGYLATED INTERFERON S0148 ALFA-2B, 10 MCG Yes ExGEN MEDICAID STERILE DILUTANT FOR S0155 EPOPROSTENOL, 50ML No MEDICAID S0156 EXEMESTANE, 25 MG No MEDICAID S0157 BECAPLERMIN GEL 0.01%, 0.5 GM No MEDICAID DEXTROAMPHETAMINE SULFATE, 5 S0160 MG No MEDICAID S0161 CALCITROL, 0.25 MG No MEDICAID INJECTION, PANTOPRAZOLE SODIUM, S0164 40 MG No MEDICAID S0166 INJECTION, OLANZAPINE, 2.5 MG No MEDICAID S0169 CALCITROL, 0.25 MICROGRAM No MEDICAID S0170 ANASTROZOLE, ORAL, 1MG No MEDICAID S0171 INJECTION, BUMETANIDE, 0.5MG No MEDICAID S0172 CHLORAMBUCIL, ORAL, 2MG No MEDICAID DOLASETRON MESYLATE, ORAL S0174 50MG No MEDICAID S0175 FLUTAMIDE, ORAL, 125MG No MEDICAID S0176 HYDROXYUREA, ORAL, 500MG No MEDICAID LEVAMISOLE HYDROCHLORIDE, S0177 ORAL, 50MG No MEDICAID S0178 LOMUSTINE, ORAL, 10MG No MEDICAID MEGESTROL ACETATE, ORAL, 20MG S0179 No MEDICAID PROCARBAZINE HYDROCHLORIDE, S0182 ORAL, 50MG No MEDICAID PROCHLORPERAZINE MALEATE, S0183 ORAL, 5MG No MEDICAID S0187 TAMOXIFEN CITRATE, ORAL, 10MG No MEDICAID S0189 TESTOSTERONE PELLET, 75MG No MEDICAID

580 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines S0190 MIFEPRISTON, ORAL, 200 MG Yes * MEDICAID S0191 MISOPROSTOL, ORAL, 200 MCG Yes * MEDICAID DIALYSIS/STRESS VITAMIN SUPPLEMENT, ORAL, 100 CAPSULES S0194 Not Covered MEDICAID INJECTABLE POLY-L-LACTIC ACID, RESTORATIVE IMPLANT, 1 ML, FACE (DEEP DERMIS, SUBCUTANEOUS S0196 LAYERS) Not Covered MEDICAID PRENATAL VITAMINS, 30-DAY SUPPLY S0197 Not Covered MEDICAID MEDICALLY INDUCED ABORTION BY ORAL INGESTION OF MEDICATION INCLUD ALL ASSOC SRVCS/SUPP (PT COUNS, OFFICE VISIT, ETC.) NOT S0199 DRUGS Yes * MEDICAID PARTIAL HOSPITALIZATION SERVICES. LESS THAN 24 HRS, PER S0201 DIEM No MEDICAID PARAMEDIC INTERCEPT, NON- HOSPITAL BASED ALS SERVICE (NON- VOLUNTARY), NON-TRANSPORT S0207 Not Covered MEDICAID PARAMEDIC INTERCEPT, HOSPITAL- BASED ALS SERVICE (NON- S0208 VOLUNTARY), NON-TRANSPORT Not Covered MEDICAID WHEELCHAIR VAN, MILEAGE, PER S0209 MILE Not Covered ExGEN MEDICAID NON-EMERGENCY S0215 Yes TRANSPORTATION; MILEAGE MEDICAID MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH PROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO S0220 Not Covered MEDICAID MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH PROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO S0221 Not Covered MEDICAID COMPREHENSIVE GERIATRIC ASSESSMENT AND TREATMENT S0250 PLANNING No MEDICAID HOSPICE REFERRAL VISIT (ADVISING PATIENT AND FAMILY OF CARE S0255 OPTIONS) No MEDICAID COUNSELING AND DISCUSSION REGARDING ADVANCE DIRECTIVES S0257 OR END OF LIFE No MEDICAID HISTORY AND PHYSICAL (OUTPATIENT OR OFFICE) RELATED TO SURGICAL PROCEDURE (LIST SEPARATE IN ADDITION TO CODE FOR S0260 APPROPRIATE EVAL Not Covered MEDICAID GENETIC COUNSELING, UNDER PHYSICIAN SUPERVISION, EACH 15 S0265 MINUTES No MEDICAID PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, STANDARD MONTHLY CASE RATE (PER 30 DAYS) S0270 No MEDICAID PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, HOSPICE MONTHLY CASE RATE (PER 30 DAYS) S0271 No MEDICAID

581 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, EPISODIC CARE MONTHLY CASE RATE (PER 30 S0272 DAYS) No MEDICAID PHYSICIAN VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION S0273 ARRANGEMENT No MEDICAID NURSE PRACTIONER VISIT AT MEMBER'S HOME, OUTSIDE OF A S0274 CAPITATION ARRANGEMENT No MEDICAID S0280 MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, INITIAL PLAN No MEDICAID S0281 MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, MAINTENANCE OF PLAN No MEDICAID Colonoscopy consultation performed prior to a screening colonoscopy procedure S0285 Not Covered MEDICAID COMPLETED EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICE (LIST IN ADDITION TO CODE FOR APPROPRIATE EVALUATION AND S0302 MANAGEMENT SERVICE) No MEDICAID HOSPITALIST SERVICES (LIST SEPARATELY IN ADDITION TO CODE S0310 FOR APPROPRIATE No MEDICAID Comprehensive management and care coordination for advanced illness, per S0311 calendar month Yes MEDICAID DISEASE MANAGEMENT PROGRAM; INITIAL ASSESSMENT AND INITIATION S0315 OF THE PROGRAM No MEDICAID DISEASE MANAGEMENT PROGRAM; S0316 FOLLOWUP/REASSESSMENT No MEDICAID DISEASE MANAGEMENT PROGRAM; S0317 PER DIEM Not Covered MEDICAID TELEPHONE CALLS BY A REGISTERED NURSE TO A DISEASE MANAGEMENT PROGRAM MEMBER FOR MONITORING PURPOSES; PER S0320 MONTH Not Covered MEDICAID LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE, INCLUDING ALL SUPPORTIVE SERVICES; FIRST QUARTER / STAGE S0340 No MEDICAID LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE, INCLUDING ALL SUPPORTIVE SERVICES; SECOND OR THIRD QUARTER / STAGE S0341 No MEDICAID LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE, INCLUDING ALL SUPPORTIVE SERVICES; FOURTH QUARTER / STAGE S0342 No MEDICAID Treatment planning and care coordination management for cancer initial treatment S0353 Not Covered INFO MEDICAID Treatment planning and care coordination management for cancer established patient with a change of regimen S0354 Not Covered INFO MEDICAID

582 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines ROUTINE FOOT CARE; REMOVAL AND/OR TRIMMING OF CORN, CALLUSES AND/OR NAILD AND PREVENTIVE MAINTANENCE IN S0390 SPECIFIC MEDICAL CONDITION No * MEDICAID IMPRESSION CASTING OF A FOOT PERFORMED BY A PRACTITIONER OTHER THAN THE MANUFACTURER OF THE ORTHOTIC S0395 No MEDICAID GLOBAL FEE FOR EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY TREATMENT OF KIDNEY STONE(S) S0400 No MEDICAID DISPOSABLE CONTACT LENS, PER S0500 LENS No * MEDICAID SINGLE VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), S0504 PER LENS Not Covered MEDICAID BIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), S0506 PER LENS Not Covered MEDICAID TRIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR S0508 SUNGLASS), PER LENS Not Covered MEDICAID NON-PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER S0510 LENS Not Covered MEDICAID DAILY WEAR SPECIALTY CONTACT S0512 LENS, PER LENS No * MEDICAID S0514 COLOR CONTACT LENS, PER LENS Not Covered MEDICAID SCLERAL LENS, LIQUID BANDAGE S0515 DEVICE, PER LENS No * MEDICAID S0516 SAFETY EYEGLASS FRAMES Not Covered MEDICAID S0518 SUNGLASSES FRAMES Not Covered MEDICAID POLYCARBONATE LENS (LIST THIS CODE IN ADDITION TO THE BASIC S0580 CODE FOR THE LENS) Not Covered MEDICAID NONSTANDARD LENS (LIST THIS S0581 CODE IN ADDITION TO THE BASIC No CODE FOR THE LENS) MEDICAID INTEGRAL LENS SERVICE, MISCELLANEOUS SERVICES S0590 REPORTED SEPARATELY Not Covered MEDICAID COMPREHENSIVE CONTACT LENS S0592 No EVALUATION MEDICAID DISPENSING NEW SPECTACLE LENSES FOR PATIENT SUPPLIED S0595 FRAME Not Covered MEDICAID Phakic intraocular lens for correction of S0596 refractive error Not Covered MEDICAID S0601 SCREENING PROCTOSCOPY No MEDICAID ANNUAL GYNECOLOGICAL S0610 EXAMINATION, NEW PATIENT No MEDICAID ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED S0612 PATIENT No MEDICAID ANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST S0613 EXAMINATION W/O PELVIC No MEDICAID AUDIOMETRY FOR HEARING AID EVALUATION TO DETERMINE THE S0618 LEVEL AND DEGREE No MEDICAID ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING S0620 REFRACTION; NEW PATIENT No MEDICAID ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING S0621 REFRACTION; ESTABLISHED No MEDICAID PHYSICAL EXAM FOR COLLEGE, NEW S0622 OR ESTABLISHED PATIENT No MEDICAID

583 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines REMOVAL OF SUTURES; BY A PHYSICIAN OTHER THAN THE S0630 PHYSICIAN WHO ORIGINALLY No MEDICAID LASER IN SITU KERATOMILEUSIS S0800 (LASIK) No MEDICAID PHOTOREFRACTIVE KERATECTOMY S0810 (PRK) No MEDICAID PHOTOTHERAPEUTIC KERATECTOMY S0812 (PTK) No MEDICAID S1015 IV TUBING EXTENSION SET No MEDICAID NON-PVC (POLYVINYL CHLORIDE) INTRAVENOUS ADMINISTRATION SET, FOR USE WITH DRUGS THAT ARE NOT STABLE IN PVC EG, PACLITAXEL S1016 No MEDICAID CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE (FOR PHYSICIAN INTERPRETATION OF DATA, USE CPT S1030 CODE) Not Covered MEDICAID CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, RENTAL, INCLUDING SENSOR, SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR (FOR PHYSI S1031 Not Covered MEDICAID Artificial Pancreas Device System (eg, Low Glucose Suspend [LGS] Feature) Including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump And Computer Algorithm That Communicates With All Of The Devices S1034 Not Covered MEDICAID Sensor; Invasive (eg, Subcutaneous), Disposable, For Use With Artificial S1035 Pancreas Device System Not Covered MEDICAID Transmitter; External, For Use With S1036 Artificial Pancreas Device System Not Covered MEDICAID Receiver (Monitor); External, For Use With Artificial Pancreas Device System S1037 Not Covered MEDICAID TRANSPLANTATION OF SMALL INTESTINE AND LIVER ALLOGRAFTS S2053 No ExGEN MEDICAID TRANSPLANTATION OF S2054 MULTIVISCERAL ORGANS No ExGEN MEDICAID HARVESTING OF DONOR MULTIVISCERAL ORGANS, WITH PREPARATION AND MAINTENANCE OF ALLOGRAFTS; FROM CADAVER S2055 DONOR No ExGEN MEDICAID S2060 LOBAR LUNG TRANSPLANTATION Yes MEDICAID DONOR LOBECTOMY (LUNG) FOR S2061 TRANSPLANTATION, LIVING DONOR Yes MEDICAID SIMULTANEOUS PANCREAS KIDNEY S2065 TRANSPLANTATION No ExGEN MEDICAID BREAST RECONSTRUCTION WITH GLUTEAL ARTERY PERFORATOR S2066 (GAP) FLAP, INCLUDING No MEDICAID BREAST RECONSTRUCTION OF A SINGLE BREAST WITH "STACKED" S2067 DEPP INFERIOR No MEDICAID

584 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP OR SUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP, INCLUDING HARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO A BREAST, S2068 UNILATERA No MEDICAID CYSTOURETHROSCOPY W/ URETEROSCOPY AND/OR PYELOSCOPY; W/ ENDOSCOPIC LASER TREATMENT OF URETERAL CALCULI (INC URETERAL S2070 CATHERIZATION No MEDICAID LAPAROSCOPIC ESOPHAGOMYOTOMY (HELLER TYPE) S2079 No MEDICAID LASER-ASSISTED S2080 UVULOPALATOPLASTY (LAUP) Not Covered MEDICAID ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS S2083 PORT BY INJECTION OR No MEDICAID TRANSCATHETER OCCLUSION OR EMOLIZATION FOR TUMOR S2095 DESTRUCTION, PERCUTANEOUS No MEDICAID ISLET CELL TISSUE TRANSPLANT S2102 Yes FROM PANCREAS; ALLOGENEIC MEDICAID ADRENAL TISSUE TRANSPLANT TO S2103 Yes BRAIN MEDICAID ADOPTTIVE IMMUNOTHERAPY I.E. DEVELOPEMENT OF SPECIFIC ANTI- TUMOR REACTIVITY (E.G., TUMOR- INFILTRATING LYMPHOCYTE S2107 THERAPY) PER COUR Not Covered MEDICAID ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE S2112 (CHONDROCYTE CELLS) No MEDICAID OSTEOTOMY, PERIACETABULAR, S2115 WITH INTERNAL FIXATION No MEDICAID S2117 ARTHROEREISIS, SUBTALAR Not Covered MEDICAID METAL-ON-METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORAL S2118 COMPONENTS No MEDICAID LOW DENSITY LIPOPROTEIN (LDL) APHERESIS USING HEPARIN- INDUCED EXTRACORPOREAL LDL S2120 PRECIPITATION No MEDICAID CORD BLOOD HARVESTING FOR S2140 TRANSPLANTATION ALLOGENEIC No MEDICAID CORD BLOOD DERIVED STEM CELL FOR TRANSPLANTATION S2142 ALLOGENEIC No MEDICAID BONE MARROW OR BLOOD-DERIVED PERIPHERIAL STEM CELL HARVESTING AND TRANSPLANTATION, ALLOGENIC OR AUTOLOGOUS, & RELATED S2150 COMPLICATION No ExGEN MEDICAID SOLID ORGAN(S), COMPLETE OR S2152 SEGMENTAL, SINGLE ORGAN OR Yes COMBINATION OF ORGANS; MEDICAID S2202 ECHOSCLEROTHERAPY Yes MEDICAID

585 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI- THORACOTOMY OR MINI- STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFT S2205 No MEDICAID MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI- THORACOTOMY OR MINI- STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTS S2206 No MEDICAID MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI- THORACOTOMY OR MINI- STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING VENOUS GRAFT ONLY, SINGLE CORONARY VENOUS GRAFT S2207 No MEDICAID MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI- THORACOTOMY OR MINI- STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS S2208 GRAFT No MEDICAID MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI- THORACOTOMY OR MINI- STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT S2209 No MEDICAID S2225 MYRINGOTOMY, LASER-ASSISTED No MEDICAID IMPLANTATION OF MAGNETIC COMPONENT OF SEMI-IMPLANTABLE S2230 HEARING DEVICE No MEDICAID IMPLANTATION OF AUDITORY BRAIN S2235 STEM IMPLANT No MEDICAID INDUCED ABORTION, 17 TO 24 S2260 WEEKS (DESC REVISED 010107) Not Covered MEDICAID INDUCED ABORTION, 25 TO 28 S2265 WEEKS Not Covered MEDICAID INDUSCED ABORTION, 29 TO 31 S2266 WEEKS Not Covered MEDICAID INDUCED ABORTION, 32 WEEKS OR S2267 GREATER Not Covered MEDICAID ARTHROSCOPY, SHOULDER, SURGICAL; WITH THERMALLY- S2300 INDUCED CAPSULORRHAPHY Not Covered MEDICAID S2325 HIP CORE DECOMPRESSION No MEDICAID CHEMODENERVATION OF ABDUCTOR MUSCLE(S) OF VOCAL CORD S2340 No MEDICAID CHEMODENERVATION OF ADDUCTOR MUSCLE(S) OF VOCAL CORD S2341 No MEDICAID

586 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines NASAL ENDOSCOPY FOR POST- OPERATIVE DEBRIDEMENT FOLLOWING FUNCTIONAL ENDOSCOPIC SINUS SURGERY, NASAL AND/OR SINUS CAVITY(S), S2342 UNILATERAL OR BILATERAL No MEDICAID DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL S2348 DISC, USING RADIOFREQUENCY Yes ENERGY, SINGLE OR MULTIPLE LEVELS, LUMBAR MEDICAID DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; LUMBAR, S2350 SINGLE INTERSPACE No MEDICAID DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; LUMBAR, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) S2351 No MEDICAID REPAIR, CONGENITAL DIAPHRAGMATIC HERNIA IN THE FETUS USING TEMPORARY TRACHEAL OCCLUSION, PROCEDURE PERFORMED IN UTERO S2400 Not Covered MEDICAID REPAIR, URINARY TRACT OBSTRUCTION IN THE FETUS, PROCEDURE PERFORMED IN UTERO S2401 No MEDICAID REPAIR, CONGENITAL CYSTIC ADENOMATOID MALFORMATION IN THE FETUS, PROCEDURE S2402 PERFORMED IN UTERO No MEDICAID REPAIR, EXTRALOBAR PULMONARY SEQUESTRATION IN THE FETUS, PROCEDURE PERFORMED IN UTERO S2403 No MEDICAID REPAIR, MYELOMENINGOCELE IN THE FETUS, PROCEDURE S2404 PERFORMED IN UTERO No MEDICAID REPAIR OF SACROCOCCYGEAL TERATOMA IN THE FETUS, PROCEDURE PERFORMED IN UTERO S2405 No MEDICAID REPAIR, CONGENITAL MALFORMATION OF FETUS, PROCEDURE PERFORMED IN UTERO, NOT OTHERWISE CLASSIFIED S2409 Yes MEDICAID FETOSCOPIC LASER THERAPY FOR TREATMENT OF TWIN-TO-TWIN S2411 TRANSFUSION SYNDROME No MEDICAID SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) S2900 Not Covered MEDICAID DIABETIC INDICATOR; RETINAL EYE S3000 EXAM, DILATED, BILATERAL No MEDICAID PERFORMANCE MEASUREMENT, EVALUATION OF PATIENT SELF S3005 ASSESSMENT, DEPRESSION Not Covered MEDICAID STAT LABORATORY REQUEST S3600 (SITUATIONS OTHER THAN S3601) Not Covered MEDICAID

587 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines EMERGENCY STAT LABORATORY CHARGE FOR PATIENT WHO IS HOMEBOUND OR RESIDING IN A S3601 NURSING FACILITY Not Covered MEDICAID NEWBORN METABOLIC SCREENING PANEL, INCLUDES TEST KIT, POSTAGE AND THE LABORATORY TESTS SPECIFIED BY THE STATE FOR INCLUSION IN THIS PANEL (E.G. GALACTOSE; HEMOGLOBIN, ELECTROPHORESIS; HYDROXYPROGESTERONE, 17-D; PHENYLANINE (PKU); AND THYROXINE, TOTAL) S3620 No MEDICAID EOSINOPHIL COUNT, BLOOD, DIRECT S3630 No MEDICAID HIV-1 ANTIBODY TESTING OF ORAL S3645 MUCOSAL TRANSUDATE No MEDICAID SALIVA TEST, HORMONE LEVEL; S3650 DURING MENOPAUSE No MEDICAID SALIVA TEST, HORMONE LEVEL; TO S3652 ASSESS PRETERM LABOR RISK No MEDICAID ANTISPERM ANTIBODIES TEST S3655 (IMMUNOBEAD) No * MEDICAID GASTROINTESTINAL FAT S3708 ABSORPTION STUDY No MEDICAID KRAS MUTATION ANALYSIS TESTING S3713 No MEDICAID DOSE OPTIMIZATION BY AREA UNDER THE CURVE (AUC) ANALYSIS, FOR INFUSIONAL 5-FLUOROURACIL S3722 No MEDICAID GENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS S3800 (ALS) Not Covered MEDICAID COMPLETE GENE SEQUENCE S3818 ANALYSIS; BRCA1 GENE Yes MEDICAID COMPLETE GENE SEQUENCE S3819 ANALYSIS; BRCA2 GENE Yes MEDICAID COMPLETE GENE SEQUENCE ANALYSIS; BRCA1/BRCA2 FOR SUSCEPTIBILITY TO BREAST AND S3820 OVARIAN CANCER Yes MEDICAID SINGLE-MUTATION ANALYSIS (IN INDIVIDUAL W/ KNOWN BRCA1/BRCA2 MUTATION IN FAMILY) FOR SUSCEPTIBILITY TO S3822 BREAST/OVARIAN CANCER Yes MEDICAID THREE-MUTATION ANALYSIS; BRCA1/BRCA2 FOR SUSCEPTIBILITY TO BREAST/OVARIAN CANCER IN ASHKENAZI INDIVIDUALS S3823 Yes MEDICAID DNA ANALYSIS FOR APOE EPSILON 4 ALLELE FOR SUSCEPTIBILITY TO S3852 ALZHEIMER'S DISEASE Not Covered MEDICAID SURFACE ELECTROMYOGRAPHY S3900 (EMG) No MEDICAID S3902 BALLISTOCARDIOGRAM No MEDICAID S3904 MASTERS TWO STEP Not Covered MEDICAID INTERIM LABOR FACILITY GLOBAL (LABOR OCCURRING BUT NOT S4005 RESULTING IN DELIVERY) No MEDICAID IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION AND INCUBATION OF MATURE OOCYTES, FERTILIZATION WITH S4011 SPERM, IN Not Covered MEDICAID

588 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMPLETE CYCLE, GAMETE INTRAFALLOPIAN TRANSFER (GIFT), S4013 CASE RATE Not Covered MEDICAID COMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT) S4014 CASE RATE Not Covered MEDICAID COMPLETE IN VITRO FERTILIZATION S4015 CYCLE, CASE RATE Not Covered MEDICAID FROZEN IN VITRO FERTILIZATION S4016 CYCLE, CASE RATE Not Covered MEDICAID INCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO STIMULATION, S4017 CASE RATE Not Covered MEDICAID FROZEN EMBRYO TRANSFERPROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE S4018 Not Covered MEDICAID IN VITRO FERTILIZATION PROCEDURE CANCELLED BRFORE S4020 ASPIRATION, CASE RATE Not Covered MEDICAID IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER S4021 ASPIRATION, CASE RATE Not Covered MEDICAID ASSISTED OOCYTE FERTILIZATION, S4022 CASE RATE Not Covered MEDICAID DONOR CYCLE, INCOMPLETE, CASE S4023 RATE Not Covered MEDICAID DONOR SERVICES FOR IN VETRO FERTILIZATION (SPERM OR EMBRYO), S4025 CASE RATE Not Covered MEDICAID PROCUREMENT OF DONOR SPERM S4026 FROM SPERM BANK Not Covered MEDICAID STORAGE OF PREVIOUSLY FROZEN S4027 EMBRYOS Not Covered MEDICAID MICROSURGICAL EPIDIDYMAL SPERM S4028 ASPIRATION (MESA) Not Covered MEDICAID SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES, S4030 INITIAL VISIT Not Covered MEDICAID SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES, S4031 SUBSEQUENT VISIT Not Covered MEDICAID STIMULATED INTRAUTERINE S4035 INSEMINATION (IUI), CASE RATE Not Covered MEDICAID CRYOPRESERVED EMBRYO S4037 TRANSFER, CASE RATE Not Covered MEDICAID MONITORING AND STORAGE OF CRYOPRESERVED EMBRYOS, PER 30 S4040 DAYS Not Covered MEDICAID MANAGEMENT OF OVULATION INDUCTION (INTERPRETATION OF DIAGNOSTIC TESTS AND STUDIES, NON-FACE-TO-FACE MEDICAL MANAGEMENT OF THE PATIENT), PER S4042 CYCLE Not Covered MEDICAID INSERTION OF LEVONORGESTREL- RELEASING INTRAUTERINE SYSTEM S4981 No MEDICAID CONTRACEPTIVE INTRAUTERINE DEVICE (E.G. PROGESTACERT IUD), S4989 No MEDICAID CONTRACEPTIVE PILLS FOR BIRTH S4993 CONTROL No MEDICAID S5000 PRESCRIPTION DRUG, GENERIC Yes ExGEN MEDICAID PRESCRIPTION DRUG, BRAND NAME S5001 Yes ExGEN MEDICAID 5% DEXTROSE AND 0.45% NORMAL S5010 SALINE, 1000 ML No MEDICAID 5% DEXTROSE WITH POTASSIUM S5012 CHLORIDE, 1000 ML No MEDICAID

589 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines 5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE S5013 AND MAG SULFATE No MEDICAID 5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE S5014 AND MAG SULFATE No MEDICAID HOME INFUSION THERAPY, ROUTINE SERVICE OF INFUSION DEVICE (E.G. S5035 PUMP MAINTENANCE) No ExGEN MEDICAID HOME INFUSION THERAPY, REPAIR OF INFUSION DEVICE (E.G. PUMP S5036 REPAIR) No ExGEN MEDICAID DAY CARE SERVICES, ADULT; PER 15 S5100 MINUTES Not Covered MEDICAID DAY CARE SERVICES, ADULT; PER S5101 HALF DAY Not Covered MEDICAID DAY CARE SERVICES, ADULT; PER S5102 DIEM Not Covered MEDICAID DAY CARE SERVICES, CENTER- BASED; SERVICES NOT INCLUDED IN S5105 PROGRAM FEE, PER DIEM Not Covered MEDICAID HOME CARE TRAINING TO HOME S5108 CARE CLIENT, PER 15 MINUTES No MEDICAID HOME CARE TRAINING TO HOME S5109 CARE CLIENT, PER DIEM No MEDICAID HOME CARE TRAINING, FAMILY; PER S5110 15 MINUTES Not Covered MEDICAID HOME CARE TRAINING, FAMILY; PER S5111 SESSION No MEDICAID HOME CARE TRAINING, NON-FAMILY; S5115 PER 15 MINUTES Not Covered MEDICAID HOME CARE TRAINING, NON-FAMILY; S5116 PER SESSION No MEDICAID CHORE SERVICES; PER 15 MINUTES S5120 Not Covered MEDICAID S5121 CHORE SERVICES; PER DIEM Not Covered MEDICAID ATTENDANT CARE SERVICES; PER 15 S5125 MINUTES Not Covered MEDICAID ATTENDANT CARE SERVICES; PER S5126 DIEM Not Covered MEDICAID HOMEMAKER SERVICE, NOS; PER 15 S5130 MINUTES Not Covered MEDICAID HOMEMAKER SERVICE, NOS; PER S5131 DIEM Not Covered MEDICAID COMPANION CARE, ADULT (E.G. S5135 IADL/ADL); PER 15 MINUTES Not Covered MEDICAID COMPANION CARE, ADULT (E.G. S5136 IADL/ADL); PER DIEM Not Covered MEDICAID S5140 FOSTER CARE, ADULT; PER DIEM Not Covered MEDICAID FOSTER CARE, ADULT; PER MONTH S5141 Not Covered MEDICAID FOSTER CARE, THERAPEUTIC, CHILD; S5145 PER DIEM Not Covered MEDICAID FOSTER CARE, THERAPEUTIC, CHILD; S5146 PER MONTH Not Covered MEDICAID UNSKILLED RESPITE CARE, NOT S5150 HOSPICE; PER 15 MINUTES Not Covered MEDICAID UNSKILLED RESPITE CARE, NOT S5151 HOSPICE; PER DIEM Not Covered MEDICAID EMERGENCY RESPONSE SYSTEM; S5160 No INSTALLATION AND TESTING MEDICAID EMERGENCY RESPONSE SYSTEM; SERVICE FEE, PER MONTH S5161 No (EXCLUDES INSTALLATION AND TESTING) MEDICAID EMERGENCY RESPONSE SYSTEM; S5162 PURCHASE ONLY Not Covered MEDICAID HOME MODIFICATIONS; PER SERVICE S5165 Not Covered MEDICAID

590 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME DELIVERED MEALS, INCLUDING PREPARATION; PER MEAL S5170 Not Covered MEDICAID LAUNDRY SERVICE, EXTERNAL, S5175 PROFESSIONAL; PER ORDER Not Covered MEDICAID HOME HEALTH RESPIRATORY S5180 THERAPY, INITIAL EVALUATION No MEDICAID HOME HEALTH RESPIRATORY S5181 THERAPY, NOS, PER DIEM No MEDICAID MEDICATION REMINDER SERVICE, S5185 NON-FACE-TO-FACE; PER MONTH Not Covered MEDICAID WELLNESS ASSESSMENT, S5190 PERFORMED BY NON-PHYSICIAN Not Covered MEDICAID S5199 PERSONAL CARE ITEM, NOS EACH Yes MEDICAID HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, NOT OTHERWISE CLASSIFIED; INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S5497 Not Covered MEDICAID HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, SIMPLE (SINGLE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S5498 SERVICES, CARE COORDINATION Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL S5501 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, IMPLANTED ACCESS DEVICE, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY S5502 SUPPLIES AND EQUIPMENT, (DRUGS Yes AND NURSING VISITS CODED SEPARATELY), PER DIEM (USE THIS CODE FOR INTERIM MAINTENANCE OF VASCULAR ACCESS NOT CURRENTLY IN USE) MEDICAID HOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR RESTORATION OF CATHETER S5517 PATENCY OR DECLOTTING No MEDICAID HOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR S5518 CATHETER REPAIR No MEDICAID

591 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) S5520 NECESSARY FOR A PERIPHERALLY Yes INSERTED CENTRAL VENOUS CATHETER (PICC) LINE INSERTION MEDICAID HOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) S5521 Yes NECESSARY FOR A MIDLINE CATHETER INSERTION MEDICAID HOME INFUSION THERAPY, INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), NURSING SERVICES ONLY (NO SUPPLIES OR S5522 CATHETER INCLUDED) No MEDICAID HOME INFUSION THERAPY, INSERT MIDLINE VENOUS CATHETER, NURSING SERVICES ONLY (NO SUPPLIES OR CATHETER INCLUDED) S5523 No MEDICAID S5550 INSULIN, RAPID ONSET; 5 UNITS Not Covered MEDICAID INSULIN, MOST RAPID ONSET S5551 (LISPRO OR ASPART); 5 UNITS Not Covered MEDICAID INSULIN, INTERMEDIATE ACTING S5552 (NPH OR LENTE); 5 UNITS Not Covered MEDICAID S5553 INSULIN, LONG ACTING; 5 UNITS Not Covered MEDICAID SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR S8030 PROTON BEAM THERAPY Yes MEDICAID S8035 MAGNETIC SOURCE IMAGING No MEDICAID MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY S8037 (MRCP) Yes MEDICAID S8040 TOPOGRAPHIC BRAIN MAPPING No MEDICAID MAGNETIC RESONANCE IMAGING S8042 (MRI), LOW-FIELD Yes MEDICAID INTRAOPERATIVE RADIATION THERAPY (SINGLE ADMINISTRATION) S8049 No MEDICAID ULTRASOUND GUIDANCE FOR MULTIFETAL PREGNANCY REDUCTION(S), TECHNICAL COMPONENT (ONLY TO BE USED WHEN THE PHYSICIAN DOING THE REDUCTION PROCEDURE DOES NOT PERFORM THE ULTRASOUND, GUIDANCE IS INCLUDED IN THE CPT CODE FOR MULTIFETAL PREGNANCY S8055 REDUCTION - 59866) Not Covered MEDICAID SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), UNILATERAL, INCLUDING SUPPLY OF S8080 RADIOPHARMACEUTICAL Not Covered MEDICAID FLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD COINCIDENCE DETECTION SYSTEM (NON-DEDICATED PET SCAN) S8085 Not Covered MEDICAID ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS S8092 ULTRAFAST CT, CINE CT) Not Covered MEDICAID INFECTION CONTROL SUPPLIES, NOT S8301 OTHERWISED SPECIFIED Not Covered MEDICAID SUPPLIES FOR HOME DELIVERY OF S8415 INFANT Not Covered MEDICAID

592 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the S8930 patient Not Covered MEDICAID EQUESTRIAN/HIPPOTHERAPY, PER S8940 SESSION Not Covered MEDICAID APPLICATION OF A MODALITY (REQUIRING CONSTANT PROVIDER ATTENDANCE) TO ONE OR, EACH 15 S8948 MIN Not Covered MEDICAID COMPLEX LYMPHEDEMA THERAPY, S8950 EACH 15 MINUTES No MEDICAID PHYSICAL OR MANIPULATIVE THERAPY PERFORMED FOR MAINTENANCE RATHER THAN S8990 RESTORATION Not Covered MEDICAID S9007 ULTRAFILTRATION MONITOR Not Covered MEDICAID S9024 PARANASAL SINUS ULTRASOUND Yes MEDICAID OMNICARDIOGRAM/CARDIOINTEGRA S9025 M No MEDICAID EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR GALL STONES (IF PERFORMED WITH ERCP, USE 43265) S9034 No MEDICAID PROCUREN OR OTHER GROWTH FACTOR PREPARATION TO PROMOTE S9055 WOUND HEALING Not Covered MEDICAID S9056 COMA STIMULATION PER DIEM Not Covered MEDICAID HOME ADMINISTRATION OF AEROSOLIZED DRUG THERAPY (E.G., PENTAMIDINE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), per diem S9061 No MEDICAID GLOBAL FEE URGENT CARE S9083 CENTERS No MEDICAID SERVICES PROVIDED IN AN URGENT S9088 CARE CENTER No MEDICAID VERTEBRAL AXIAL DECOMPRESSION, S9090 PER SESSION Not Covered MEDICAID S9097 HOME VISIT FOR WOUND CARE No MEDICAID HOME VISIT, PHOTOTHERAPY SERVICES (E.G. BILI-LITE), INCLUDING EQUIPMENT RENTAL, NURSING SERVICES, BLOOD DRAW, SUPPLIES, AND OTHER SERVICES, PER DIEM S9098 No MEDICAID S9110 Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month Not Covered MEDICAID S9117 BACK SCHOOL, PER VISIT Not Covered MEDICAID HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PROVIDING CARE S9122 IN THE HOME; PER HOUR No ExGEN MEDICAID NURSING CARE, IN THE HOME; BY REGISTERED NURSE, PER HOUR (USE FOR GENERAL NURSING CARE ONLY, NOT TO BE USED WHEN CPT CODES 99500-99602 CAN BE USED) S9123 No MEDICAID NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, PER S9124 HOUR No MEDICAID

593 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines RESPITE CARE, IN THE HOME, PER S9125 DIEM No MEDICAID HOSPICE CARE, IN THE HOME, PER S9126 DIEM No MEDICAID SOCIAL WORK VISIT, IN THE HOME, S9127 PER DIEM No MEDICAID SPEECH THERAPY, IN THE HOME, S9128 PER DIEM No * MEDICAID OCCUPATIONAL THERAPY, IN THE S9129 HOME, PER DIEM No MEDICAID PHYSICAL THERAPY; IN THE HOME, S9131 PER DIEM No MEDICAID DIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO NON-MD S9140 PROVIDER No MEDICAID DIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO MD PROVIDER S9141 No MEDICAID INSULIN PUMP INITIATION, INSTRUCTION IN INITIAL USE OF S9145 PUMP No MEDICAID S9150 EVALUATION BY OCULARIST No MEDICAID SPEECH THERAPY, RE-EVALUATION S9152 Yes MEDICAID HOME MANAGEMENT OF PRETERM LABOR, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NE S9208 No MEDICAID HOME MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM), INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) S9209 No MEDICAID HOME MANAGEMENT OF GESTATIONAL HYPERTENSION, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) S9211 No MEDICAID HOME MANAGEMENT OF POSTPARTUM HYPERTENSION, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) S9212 No MEDICAID

594 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME MANAGEMENT OF PREECLAMPSIA, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) S9213 No MEDICAID HOME MANAGEMENT OF GESTATIONAL DIABETES, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE) S9214 No MEDICAID HOME INFUSION THERAPY, PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH S9326, S9327 OR S9328) S9325 No MEDICAID HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, S9326 PROFESSIONAL PHARMACY Yes SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY- FOUR HOURS) PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL S9327 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, IMPLANTED PUMP PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9328 DIEM No MEDICAID

595 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, CHEMOTHERAPY INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH S9330 OR S9331) S9329 No MEDICAID HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) CHEMOTHERAPY INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL S9330 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY- FOUR HOURS) CHEMOTHERAPY INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL S9331 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME THERAPY, HEMODIALYSIS, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SRVCS, CARE COORDINATION,SUPPLIES & EQUIPMENT,PER DIEM S9335 No MEDICAID HOME INFUSION THERAPY, CONTINUOUS ANTICOAGULANT INFUSION THERAPY (E.G. HEPARIN), ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9336 No MEDICAID HOME INFUSION THERAPY, IMMUNOTHERAPY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE S9338 COORDINATION, AND ALL Yes NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME THERAPY; PERITONEAL DIALYSIS, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9339 DIEM No MEDICAID

596 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME THERAPY; ENTERNAL NUTRITION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL S9340 NECESSARY SU No MEDICAID HOME THERAPY; ENTERNAL NUTRITION VIA GRAVITY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, S9341 AND ALL No MEDICAID HOME THERAPY; ENTERNAL NUTRITION VIA PUMP; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, S9342 AND ALL NEC No MEDICAID HOME THERAPY; ENTERAL NUTRITION VIA BOLUS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, S9343 AND ALL NEC No MEDICAID HOME INFUSION THERAPY, ANTI- HEMOPHILIC AGENT INFUSION THERAPY (E.G. FACTOR VIII); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9345 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ALPHA-1- PROTEINASE INHIBITOR (E.G., PROLASTIN); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE S9346 COORDINATION, AND ALL Yes NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, UNINTERRUPTED, LONG-TERM, CONTROLLED RATE INTRAVENOUS OR SUBCUTANEOUS INFUSION THERAPY (E.G. EPOPROSTENOL); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9347 No MEDICAID HOME INFUSION THERAPY, SYMPATHOMIMETIC/INOTROPIC AGENT INFUSION THERAPY (E.G., DOBUTAMINE); ADMINISTRATIVE SERVICES, PROFESSIONAL S9348 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID

597 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, TOCOLYTIC INFUSION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9349 DIEM Not Covered MEDICAID HOME INFUSION THERAPY, CONTINUOUS OR INTERMITTENT ANTI-EMETIC INFUSION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9351 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, CONTINUOUS INSULIN INFUSION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9353 DIEM No MEDICAID HOME INFUSION THERAPY, CHELATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9355 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ENZYME REPLACEMENT INTRAVENOUS THERAPY; (E.G. IMIGLUCERASE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9357 No MEDICAID HOME INFUSION THERAPY, ANTI- TUMOR NECROSIS FACTOR INTRAVENOUS THERAPY; (E.G. INFLIXIMAB); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9359 No MEDICAID HOME INFUSION THERAPY, DIURETIC INTRAVENOUS THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9361 No MEDICAID

598 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, ANTI- SPASMOTIC THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9363 DIEM No MEDICAID HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); ADMIN SRVCS, PROF PHARMACY SRVCS, CARE COORD INC STANDARD S9364 TPN FORMULA No MEDICAID HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); 1 LITER P/DAY, ADMIN SRVCS, PROF PHARMACY SRVCS, CARE COORD, S9365 INC TPN FRM No MEDICAID HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN 1 LITER BUT NO MORE THAN 2 LITERS P/DAY, ADMIN SRV, S9366 PROF PHARMA No MEDICAID HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN 2 LITERS BUT NO MORE THAN 3 LITERS P/DAY, ADMIN/PROF S9367 PHARM SRVC No MEDICAID HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN 3 LITERS P/DAY, ADMIN SRVCS, PROF PHARM SRVCS, CARE S9368 COORD No MEDICAID HOME THERAPY, INTERMITTENT ANTI- EMETIC INJECTION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9370 DIEM No MEDICAID HOME THERAPY; INTERMITTENT ANTICOAGULANT INJECTION THERAPY (E.G. HEPARIN); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE FOR FLUSHING OF INFUSION DEVICES WITH HEPARIN TO MAINTAIN PATENCY) S9372 No MEDICAID HOME INFUSION THERAPY, HYDRATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE WITH HYDRATION THERAPY CODES S9374-S9377 USING DAILY VOLUME SCALES) S9373 No MEDICAID

599 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, HYDRATION THERAPY; ONE LITER PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE S9374 COORDINATION, AND ALL Yes NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN ONE LITER BUT NO MORE THAN TWO LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL S9375 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN TWO LITERS BUT NO MORE THAN THREE LITERS PER DAY, ADMINISTRATIVE SERVICES, S9376 PROFESSIONAL PHARMACY Yes SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN THREE LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9377 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, INFUSION THERAPY, NOT OTHERWISE CLASSIFIED; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE S9379 COORDINATION, AND ALL Yes NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID DELIVERY OR SERVICE TO HIGH RISK AREAS REQUIRING ESCORT OR S9381 EXTRA PROTECTION, PER VISIT Not Covered MEDICAID ANTICOAGULATION CLINIC, INCLUSIVE OF ALL SERVICES EXCEPT LABORATORY TESTS, PER SESSION S9401 No MEDICAID PHARMACY COMPOUNDING AND S9430 DISPENSING SERVICES No MEDICAID MEDICAL FOOD NUTRITIONALLY COMPLETE, ADMINISTERED ORALLY, PROVIDING 100% OF NUTRITIONAL S9433 INTAKE Not Covered MEDICAID MODIFIED SOLID FOOD SUPPLEMENTS FOR INBORN ERRORS S9434 OF METABOLISM Not Covered MEDICAID MEDICAL FOODS FOR INBORN S9435 ERRORS OF METABOLISM Not Covered MEDICAID

600 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines CHILDBIRTH PREPARATION/LAMAZE CLASSES, NON-PHYSICIAN S9436 PROVIDER, No MEDICAID CHILDBIRTH REFRESHER CLASSES, NON-PHYSICIAN PROVIDER, PER S9437 SESSION No MEDICAID CESAREAN BIRTH CLASSES, NON- PHYSICIAN PROVIDER, PER SESSION S9438 Not Covered MEDICAID VBAC (VAGINAL BIRTH AFTER CESAREAN) CLASSES, NON- PHYSICIAN PROVIDER, PER SESSION S9439 Not Covered MEDICAID ASTHMA EDUCATION, NON- PHYSICIAN PROVIDER, PER SESSION S9441 No MEDICAID BIRTHING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION S9442 No MEDICAID LACTATION CLASSES, NON- PHYSICIAN PROVIDER, PER SESSION S9443 No MEDICAID PARENTING CLASSES, NON- S9444 PHYSICIAN PROVIDER, PER SESSION No MEDICAID PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON- PHYSICIAN PROVIDER, INDIVIDUAL, S9445 PER SESSION Not Covered MEDICAID PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON- PHYSICIAN PROVIDER, GROUP, PER S9446 SESSION Not Covered MEDICAID INFANT SAFETY (INCLUDING CPR) CLASSES, NON-PHYSICIAN S9447 PROVIDER, PER SESSION Not Covered MEDICAID WEIGHT MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER S9449 SESSION Not Covered MEDICAID EXERCISE CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION S9451 Not Covered MEDICAID NUTRITION CLASSES, NON- PHYSICIAN PROVIDER, PER SESSION S9452 Not Covered MEDICAID SMOKING CESSATION CLASSES, NON- PHYSICIAN PROVIDER, PER SESSION S9453 No MEDICAID STRESS MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER S9454 SESSION Not Covered MEDICAID DIABETIC MANAGEMENT PROGRAM, S9455 GROUP SESSION No MEDICAID DIABETIC MANAGEMENT PROGRAM, S9460 NURSE VISIT No MEDICAID DIABETIC MANAGEMENT PROGRAM, S9465 DIETITIAN VISIT No MEDICAID NUTRITIONAL COUNSELING, S9470 DIETITIAN VISIT No * MEDICAID CARDIAC REHABILITATION PROGRAM, NON-PHYSICIAN S9472 PROVIDER, PER DIEM No MEDICAID PULMONARY REHABILITATION PROGRAM, NON PHYSICIAN S9473 PROVIDER, PER DIEM No MEDICAID ENTEROSTOMAL THERAPY BY A REGISTERED NURSE CERTIFIED IN S9474 ENTEROSTOMAL No MEDICAID VESTIBULAR REHABILITATION PROGRAM, NON-PHYSICIAN S9476 PROVIDER, PER DIEM No MEDICAID

601 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines FAMILY STABILIZATION SERVICES, S9482 PER 15 MINUTES Not Covered MEDICAID HOME INFUSION THERAPY, CORTICOSTEROID INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9490 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH HOME INFUSION CODES FOR HOURLY DOSING SCHEDULES S9497- S9504) S9494 No MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY 3 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL S9497 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY 24 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL S9500 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY 12 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL S9501 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY 8 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL S9502 PHARMACY SERVICES, CARE Yes COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID

602 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 6 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9503 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 4 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY S9504 SERVICES, CARE COORDINATION, Yes AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM MEDICAID ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S), SINGLE HOME BOUND, NURSING HOME, OR SKILLED NURSING S9529 FACILITY PATIENT Not Covered MEDICAID HOME THERAPY; HEMATOPOIETIC HORMONE INJECTION THERAPY (E.G.ERYTHROPOIETIN, G-CSF, GM- CSF); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9537 DIEM No MEDICAID HOME TRANSFUSION OF BLOOD PRODUCT(S); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9538 DIEM No MEDICAID HOME INJECTABLE THERAPY, NOT OTHERWISE CLASSIFIED, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9542 Not Covered MEDICAID HOME INJECTABLE THERAPY; GROWTH HORMONE, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9558 DIEM No MEDICAID

603 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HOME INJECTABLE THERAPY, INTERFERON, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER S9559 DIEM No MEDICAID HOME INJECTABLE THERAPY; HORMONAL THERAPY (E.G.; LEUPROLIDE, GOSERELIN), INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM S9560 No MEDICAID HOME INJECTABLE THERAPY, PALIVIZUMAB, INCLUDING S9562 ADMINISTRATIVE SERVICES No MEDICAID HOME THERAPY, IRRIGATION THERAPY (E.G. STERILE IRRIGATION S9590 OF AN ORGAN OR) No MEDICAID HOME THERAPY; PROFESSIONAL PHARMACY SERVICES FOR PROVISION OF INFUSION, SPECIALTY DRUG ADMINISTRATION, AND/OR DISEASE STATE MANAGEMENT, NOT OTHERWISE CLASSIFIED, PER HOUR (DO NOT USE THIS CODE WITH ANY PER DIEM CODE) S9810 No MEDICAID SERVICES BY AUTHORIZED CHRISTIAN SCIENCE PRACTITIONER FOR THE PROCESS OF HEALING, PER DIEM; NOT TO BE USED FOR REST OR STUDY; EXCLUDES IN-PATIENT SERVICES S9900 Not Covered MEDICAID Services by a journal-listed christian S9901 science nurse, per hour Not Covered MEDICAID Ambulance service, conventional air services, nonemergency transport, one S9960 way (fixed wing) Not Covered MEDICAID Ambulance service, conventional air service, nonemergency transport, one S9961 way (rotary wing) Not Covered MEDICAID HEALTH CLUB MEMBERSHIP, ANNUAL S9970 Not Covered MEDICAID TRANSPLANT RELATED LODGING, MEALS AND TRANSPORTATION, PER S9975 DIEM Not Covered MEDICAID LODGING, PER DIEM, NOT S9976 No OTHERWISE CLASSIFIED MEDICAID MEALS, PER DIEM, NOT OTHERWISE S9977 No SPECIFIED MEDICAID MEDICAL RECORDS COPYING FEE, S9981 ADMINISTRATIVE Not Covered MEDICAID MEDICAL RECORDS COPYING FEE, S9982 PER PAGE Not Covered MEDICAID NOT MEDICALLY NECESSARY SERVICE (PATIENT IS AWARE THAT SERVICE NOT MEDICALLY S9986 NECESSARY) Not Covered MEDICAID SERVICES PROVIDED AS PART OF A S9988 PHASE I CLINICAL TRIAL Not Covered MEDICAID

604 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SERVICES PROVIDED OUTSIDE OF THE UNITED STATES OF AMERICA (LIST IN ADDITION TO CODE(S) FOR S9989 SERVICES(S)) Not Covered MEDICAID SERVICES PROVIDED AS PART OF A S9990 PHASE II CLINICAL TRIAL No MEDICAID SERVICES PROVIDED AS PART OF A S9991 PHASE III CLINICAL TRIAL Yes MEDICAID TRANSPORTATION COSTS TO AND FROM TRIAL LOCATION AND LOCAL TRANSPORTATION COSTS (E.G. FARES FOR CAB OR BUS) FOR S9992 CLINICAL CAREGIVER/ Not Covered MEDICAID LODGING COSTS (E.G. HOTEL CHARGES) FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/ S9994 COMPANION Not Covered MEDICAID MEALS FOR CLINICAL TRIAL PARTICIPANT AND ONE S9996 CAREGIVER/COMPANION Not Covered MEDICAID S9999 SALES TAX Not Covered MEDICAID PRIVATE DUTY/ INDEPENDENT NURSING SERVICE(S) - LICENSED, UP T1000 TO 15 MINUTES Not Covered MEDICAID NURSING ASSESSMENT/EVALUATION T1001 Not Covered MEDICAID T1002 RN SERVICES, UP TO 15 MINUTES Not Covered MEDICAID LPN/LVN SERVICES UP TO 15 T1003 MINUTES Not Covered MEDICAID SERVICES OF A QUALIFIED NURSING T1004 AID, UP TO 15 MINUTES Not Covered MEDICAID RESPITE CARE SERVICES, UP TO 15 T1005 MINUTES Not Covered MEDICAID ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, FAMILY/COUPLE T1006 COUNSELING Not Covered MEDICAID ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, TREATMENT PLAN DEVELOPMENT AND/OR T1007 MODIFICATION Not Covered MEDICAID CHILD SITTING SERVICES FOR CHILDREN OF THE INDIVIDUAL RECEIVING ALCOHOL AND/OR T1009 SUBSTANCE ABUSE SERVICES Not Covered MEDICAID MEALS FOR INDIVIDUALS RECEIVING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES(WHEN MEALS NOT INCLUDED IN THE PROGRAM) T1010 Not Covered MEDICAID ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, SKILLS T1012 DEVELOPEMENT Not Covered MEDICAID SIGN LANGUAGE OR ORAL T1013 Yes INTERPRETER SERVICES MEDICAID TELEHEALTH TRANSMISSION, PER MINUTE, PROFESSIONAL SERVICES T1014 BILL SEPARATELY Not Covered MEDICAID CLINIC VISIT/ENCOUNTER, ALL T1015 INCLUSIVE Not Covered MEDICAID CASE MANAGEMENT, EACH 15 T1016 MINUTES Not Covered MEDICAID TARGETED CASE MANAGEMENT, T1017 EACH 15 MINUTES Not Covered MEDICAID SCHOOL-BASED INDIVIDUALIZED EDUCATION PROGRAM (IEP) T1018 SERVICES, BUNDLED Not Covered MEDICAID PERSONAL CARE SERVICES, PER 15 MINUTES, NOT FOR AN INPATEINT OR RESIDENT OF A HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF T T1019 Not Covered MEDICAID

605 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines PERSONAL CARE SERVICES, PER DIEM, NOT FOR AN INPATIENT OR RESIDENT OF A HOSPITAL, NURSING FACILITY, ICF/MR OR IMD. PART OF T1020 THE IND Not Covered MEDICAID HOME HEALTH AIDE OR CERTIFIED T1021 NURSE ASSISTANT, PER VISIT Not Covered ExGEN MEDICAID CONTRACTED HOME HEALTH AGENC SERVICES, ALL SERVICES PROVIDED T1022 UNDER CONTRACT, Not Covered MEDICAID SCREENING TO DETERMINE THE APPROPRIATENESS OF T1023 No CONSIDERATION OF AN INDIVIDUAL MEDICAID EVALUATION AND TREATMENT BY AN INTEGRATED, SPECIALTY TEAM T1024 CONTRACTED TO PROVIDE Not Covered MEDICAID INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES T1025 PROVIDED IN A CLINIC SETTING TO Not Covered MEDICAID INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES T1026 PROVIDED IN A CLINIC SETTING TO Not Covered MEDICAID FAMILY TRAINING AND COUNSELING FOR CHILD DEVELOPMENT, PER 15 T1027 MINUTES Not Covered MEDICAID ASSESSMENT OF HOME, PHYSICAL AND FAMILY ENVIRONMENT, TO T1028 DETERMINE SUITABILITY Not Covered MEDICAID COMPREHENSIVE ENVIRONMENT LEAD INVESTIGATION, NOT T1029 INCLUDING LABORATORY Not Covered MEDICAID NURSING CARE, IN THE HOME, BY T1030 REGISTERED NURSE, PER DIEM Not Covered MEDICAID NURSING CARE, IN THE HOME, BY LICENSED PRACTICAL NURSE, PER T1031 DIEM Not Covered MEDICAID Medicaid certified community behavioral health clinic services, per diem T1040 Not Covered MEDICAID Medicaid certified community behavioral health clinic services, per month T1041 Not Covered MEDICAID ADMINISTRATION OF ORAL, INTRAMUSCULAR AND/OR SUBCUTANEOUS MEDICATION BY T1502 HEALTH Not Covered MEDICAID ADMINISTRATION OF MEDICATION, OTHER THAN ORAL AND/OR INJECTABLE, BY A HEALTH CARE AGENCY/PROFESSIONAL, PER VISIT T1503 Not Covered MEDICAID MISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL T1999 PURCHASES, NOT OTHERWISE Yes MEDICAID NON- EMERGENCY TRANSPORTATION; PATIENT T2001 ATTENDANT/ESCORT Not Covered ExGEN MEDICAID NON-EMERGENCY T2002 TRANSPORTATION; PER DIEM Not Covered ExGEN MEDICAID NON-EMERGENCY TRANSPORTATION; T2003 ENCOUNTER/TRIP Not Covered ExGEN MEDICAID NON-EMERGENCY TRANSPORT; COMMERCIAL CARRIER, MULTI-PASS T2004 Not Covered ExGEN MEDICAID NON-EMERGENCY TRANSPORTATION; STRETCHER VAN T2005 Not Covered ExGEN MEDICAID

606 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TRANSPORTATION WAITING TIME, AIR AMBULANCE AND NON- T2007 EMERGENCY VEHICLE, ONE-HALF Not Covered ExGEN MEDICAID PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I IDENTIFICATION SCREENING, PER T2010 SCREEN Not Covered MEDICAID PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL II IDENTIFICATION SCREENING, PER T2011 EVALUATION Not Covered MEDICAID HABILITATION, EDUCATIONAL, T2012 WAIVER; PER DIEM Not Covered MEDICAID HABILITATION, EDUCATIONAL, T2013 WAIVER; PER HOUR Not Covered MEDICAID HABILITATION, PREVOCATIONAL, T2014 WAIVER; PER DIEM Not Covered MEDICAID HABILITATION, PREVOCATIONAL, T2015 WAIVER; PER HOUR Not Covered MEDICAID HABILITATION, RESIDENTIAL, T2016 WAIVER; PER DIEM Not Covered MEDICAID HABILITATION, RESIDENTIAL, T2017 WAIVER; PER 15 MINUTES Not Covered MEDICAID HABILITATION, SUPPORTED T2018 EMPLOYMENT, WAIVER; PER DIEM Not Covered MEDICAID HABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER 15 T2019 MINUTES Not Covered MEDICAID DAY HABILITATION, WAIVER; PER T2020 DIEM Not Covered MEDICAID ASSISTED LIVING; WAIVER, PER DIEM T2021 Not Covered MEDICAID T2022 CASE MANAGEMENT; PER MONTH Not Covered MEDICAID TARGETED CASE MANAGEMENT; PER T2023 MONTH Not Covered MEDICAID SERVICE ASSESSMENT/PLAN OF T2024 CARE DEVELOPMENT, WAIVER Not Covered MEDICAID WAIVER SERVICES; NOT OTHERWISE T2025 SPECIFIED (NOS) Not Covered MEDICAID SPECIALIZED CHILDCARE, WAIVER; T2026 PER DIEM Not Covered MEDICAID SPECIALIZED CHILDCARE, WAIVER; T2027 PER 15 MINUTES Not Covered MEDICAID SPECIALIZED SUPPLY, NOT OTHERWISE SPECIFIED (NOS), T2028 WAIVER Not Covered MEDICAID SPECIALIZED MEDICAL EQUIPMENT, NOT OTHERWISE SPECIFIED (NOS), T2029 WAIVER Not Covered MEDICAID ASSISTED LIVING, WAIVER; PER T2030 MONTH Not Covered MEDICAID ASSISTED LIVING, WAIVER; PER DIEM T2031 Not Covered MEDICAID RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), T2032 WAIVER; PER MONTH Not Covered MEDICAID RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), T2033 WAIVER; PER DIEM Not Covered MEDICAID CRISIS INTERVENTION, WAIVER; PER T2034 DIEM Not Covered MEDICAID UTILITY SERVICES TO SUPPORT MEDICAL EQUIPMENT AND ASSISTIVE TECHNOLOGY/DEVICES, WAIVER T2035 Not Covered MEDICAID THERAPEUTIC CAMPING, OVERNIGHT, WAIVER; EACH SESSION T2036 Not Covered MEDICAID THERAPEUTIC CAMPING, DAY, T2037 WAIVER; EACH SESSION Not Covered MEDICAID

607 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines COMMUNITY TRANSITION, WAIVER; T2038 PER SERVICE Not Covered MEDICAID VEHICLE MODIFICATIONS, WAIVER; T2039 PER SERVICE Not Covered MEDICAID FINANCIAL MANAGEMENT, SELF- DIRECTED, WAIVER; PER 15 MINUTES T2040 Not Covered MEDICAID SUPPORTS BROKERAGE, SELF- DIRECTED, WAIVER; PER 15 MINUTES T2041 Not Covered MEDICAID HOSPICE ROUTINE HOME CARE, PER T2042 DIEM Not Covered ExGEN MEDICAID HOSPICE CONTINUOUS HOME CARE, T2043 PER HOUR Not Covered MEDICAID HOSPICE INPATIENT RESPITE CARE; T2044 PER DIEM Not Covered MEDICAID HOSPICE GENERAL INPATIENT CARE; T2045 PER DIEM Not Covered MEDICAID HOSPICE LONG TERM CARE, R&B T2046 ONLY, PER DIEM Not Covered MEDICAID BEHAVIORAL HEALTH; LONG-TERM CARE RESIDENTIAL (NON-ACUTE CARE IN A RESID TREATMENT PROG STAY MORE THAN 30 DAYS) W/ T2048 ROOM&BOARD PD Not Covered MEDICAID NON-EMERGENCY TRANSPORTATION; STRECTHER VAN, T2049 MILEAGE; PER MILE Not Covered MEDICAID HUMAN BREAST MILK PROCESSING, STORAGE AND DISTRIBUTION ONLY T2101 Not Covered MEDICAID Adult sized disposable incontinence T4544 product, protective underwear/pull-on, Yes above extra large, each MEDICAID V2020 FRAMES, PURCHASES No * MEDICAID V2025 DELUXE FRAME No * MEDICAID SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00, PER LENS V2100 No * MEDICAID SPHERE, SINGLE VISION, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, V2101 PER LENS No MEDICAID SPHERE, SINGLE VISION, PLUS OR MINUS 7.12 TO PLUS OR MINUS V2102 20.00D, PER LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D CYLINDER, PER V2103 LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00D CYLINDER, V2104 PER LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D CYLINDER, V2105 PER LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER, PER V2106 LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00 SPHERE, .12 TO 2.00D V2107 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS V2108 No MEDICAID

608 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS V2109 No MEDICAID SPEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO 7.00D SPHERE, OVER 6.00D CYLINDER, PER V2110 LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D V2111 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25D TO 4.00D CYLINDER, PER LENS V2112 No MEDICAID SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS V2113 No MEDICAID SPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS V2114 12.00D, PER LENS No MEDICAID LENTICULAR, (MYODISC), PER LENS, V2115 SINGLE VISION No MEDICAID V2118 ANISEIKONIC LENS, SINGLE VISION No MEDICAID LENTICULAR LENS, PER LENS, V2121 SINGLE No MEDICAID NOT OTHERWISE CLASSIFIED, V2199 SINGLE VISION LENS Yes MEDICAID SPHERE, BIFOCAL, PLANO TO PLUS V2200 OR MINUS 4.00D, PER LENS No * MEDICAID SPHERE, BIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER V2201 LENS No MEDICAID SPHERE, BIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER V2202 LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS V2203 No MEDICAID SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS V2204 No MEDICAID SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS V2205 No MEDICAID SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS V2206 No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,.12 TO 2.00D V2207 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D V2208 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D V2209 CYLINDER, PER LENS No MEDICAID

609 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, OVER 6.00D V2210 CYLINDER,PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 25 TO 2.25D V2211 CYLINDER,PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4.00D V2212 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D V2213 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS V2214 12.00D, PER LENS No MEDICAID LENTICULAR (MYODISC), PER LENS, V2215 BIFOCAL No MEDICAID V2218 ANISEIKONIC, PER LENS, BIFOCAL No MEDICAID V2219 BIFOCAL SEG WIDTH OVER 28MM No MEDICAID V2220 BIFOCAL ADD OVER 3.25D No MEDICAID LENTICULAR LENS, PER LENS, V2221 BIFOCAL No MEDICAID V2299 SPECIALTY BIFOCAL (BY REPORT) Yes MEDICAID SPHERE, TRIFOCAL, PLANO TO PLUS V2300 OR MINUS 4.00.D, PER LENS No MEDICAID SPHERE, TRIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D PER V2301 LENS No MEDICAID SPHERE, TRIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00, PER V2302 LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D CYLINDER, PER V2303 LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.25-4.00D CYLINDER, PER V2304 LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00 CYLINDER, PER V2305 LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER, PER V2306 LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, .12 TO 2.00D V2307 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12 TO 4.00D V2308 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25 TO 6.00D V2309 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS V2310 Yes 7.00D SPHERE, OVER 6.00D CYLINDER, PER LENS MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25 TO 2.25D V2311 CYLINDER, PER LENS No MEDICAID

610 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 2.25 TO 4.00D V2312 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D V2313 CYLINDER, PER LENS No MEDICAID SPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12 V2314 .00D, PER LENS No MEDICAID LENTICULAR, (MYODISC), PER LENS, V2315 TRIFOCAL No MEDICAID V2318 ANISEIKONIC LENS, TRIFOCAL No MEDICAID V2319 TRIFOCAL SEG WIDTH OVER 28 MM No MEDICAID V2320 TRIFOCAL ADD OVER 3.25D No MEDICAID LENTICULAR LENS, PER LENS, V2321 TRIFOCAL No MEDICAID V2399 SPECIALTY TRIFOCAL (BY REPORT) Yes MEDICAID VARIABLE ASPHERICITY LENS, SINGLE VISION, FULL FIELD, GLASS V2410 OR PLASTIC, PER LENS No MEDICAID VARIABLE ASPHERICITY LENS, BIFOCAL, FULL FIELD, GLASS OR V2430 PLASTIC, PER LENS No MEDICAID VARIABLE SPHERICITY LENS, OTHER V2499 Yes TYPE MEDICAID CONTACT LENS, PMMA, SPHERICAL, V2500 Yes PER LENS MEDICAID CONTACT LENS, PMMA, TORIC OR V2501 Yes PRISM BALLAST, PER LENS MEDICAID CONTACT LENS PMMA, BIFOCAL, PER V2502 LENS No * MEDICAID CONTACT LENS PMMA, COLOR V2503 VISION DEFICIENCY, PER LENS No * MEDICAID CONTACT LENS, GAS PERMEABLE, V2510 Yes SPHERICAL, PER LENS MEDICAID CONTACT LENS, GAS PERMEABLE, V2511 Yes TORIC, PRISM BALLAST, PER LENS MEDICAID CONTACT LENS, GAS PERMEABLE, V2512 BIFOCAL, PER LENS No * MEDICAID CONTACT LENS, GAS PERMEABLE, V2513 EXTENDED WEAR, PER LENS No * MEDICAID CONTACT LENS HYDROPHILIC, V2520 Yes SPHERICAL, PER LENS MEDICAID CONTACT LENS HYDROPHILIC, V2521 TORIC, OR PRISM BALLAST, PER Yes LENS MEDICAID CONTACT LENS HYDROPHILLIC, V2522 BIFOCAL, PER LENS No * MEDICAID CONTACT LENS HYDROPHILIC, V2523 EXTENDED WEAR, PER LENS No * MEDICAID CONTACT LENS, SCLERAL, GAS IMPERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE V2530 92325) No * MEDICAID CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR V2531 Yes CONTACT LENS MODIFICATION, SEE 92325) MEDICAID V2599 CONTACT LENS, OTHER TYPE Yes MEDICAID HAND HELD LOW VISION AIDS AND V2600 OTHER NONSPECTACLE MOUNTED Yes AIDS MEDICAID SINGLE LENS SPECTACLE MOUNTED V2610 Yes LOW VISION AIDS MEDICAID

611 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines TELESCOPIC AND OTHER COMPOUND LENS SYSTEM, INCLUDING DISTANCE VISION V2615 TELESCOPIC, NEAR VISION Yes TELESCOPES AND COMPOUND MICROSCOPIC L MEDICAID PROSTHETIC EYE, PLASTIC, CUSTOM V2623 Yes MEDICAID POLISHING/RESURFACING OF V2624 Yes OCULAR PROSTHESIS MEDICAID ENLARGEMENT OF OCULAR V2625 Yes PROSTHESIS MEDICAID REDUCTION OF OCULAR V2626 Yes PROSTHESIS MEDICAID V2627 SCLERAL COVER SHELL Yes MEDICAID FABRICATION AND FITTING OF V2628 Yes OCULAR CONFORMER MEDICAID V2629 PROSTHETIC EYE, OTHER TYPE Yes MEDICAID ANTERIOR CHAMBER INTRAOCULAR V2630 LENS No MEDICAID IRIS SUPPORTED INTRAOCULAR V2631 LENS No MEDICAID POSTERIOR CHAMBER INTRAOCULAR V2632 LENS No MEDICAID V2700 BALANCE LENS, PER LENS No MEDICAID V2702 DELUXE LENS FEATURE Not Covered MEDICAID SLAB OFF PRISM, GLASS OR V2710 PLASTIC, PER LENS No MEDICAID V2715 PRISM, PER LENS No MEDICAID PRESS-ON LENS, FRESNELL PRISM, V2718 PER LENS No MEDICAID SPECIAL BASE CURVE, GLASS OR V2730 PLASTIC, PER LENS No MEDICAID V2756 EYE GLASS CASE Not Covered MEDICAID V2770 OCCLUDER LENS, PER LENS No MEDICAID LENS, INDEX 1.54 TO 1.65 PLASTIC OR 1.60 TO 1.9 GLASS, EXCLUDES V2782 POLYCARBONATE, No MEDICAID PROCESSING, PRESERVING AND V2785 TRANSPORTING CORNEAL TISSUE No MEDICAID SPECIALTY OCCUPATIONAL V2786 MULTIFOCAL LENS, PER LENS Not Covered MEDICAID ASTIGMATISM CORRECTING V2787 FUNCTION OF INTRAOCULAR LENS Not Covered MEDICAID PRESBYOPIA CORRECTING V2788 FUNCTION OF INTRAOCULAR LENS Not Covered MEDICAID AMNIOTIC MEMBRANE FOR SURGICAL RECONSTRUCTION, PER V2790 PROCEDURE No MEDICAID VISION SUPPLY, ACCESSORY AND/OR SERVICE COMPONENT OF ANOTHER V2797 HCPCS VISION CODE Not Covered MEDICAID V2799 VISION SERVICE, MISCELLANEOUS Yes MEDICAID V5008 HEARING SCREENING No MEDICAID V5010 ASSESSMENT FOR HEARING AID No MEDICAID FITTING/ORIENTATION/CHECKING OF V5011 Yes HEARING AID MEDICAID REPAIR/MODIFICATION OF A V5014 Yes HEARING AID MEDICAID V5020 CONFORMITY EVALUATION Yes MEDICAID HEARING AID, MONAURAL, BODY V5030 Yes WORN, AIR CONDUCTION MEDICAID HEARING AID, MONAURAL, BODY V5040 Yes WORN, BONE CONDUCTION MEDICAID HEARING AID, MONAURAL, IN THE V5050 Yes EAR MEDICAID HEARING AID, MONAURAL, BEHIND V5060 Yes THE EAR MEDICAID V5070 GLASSES, AIR CONDUCTION Not Covered MEDICAID V5080 GLASSES, BONE CONDUCTION Not Covered MEDICAID

612 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines DISPENSING FEE, UNSPECIFIED V5090 HEARING AID Not Covered MEDICAID SEMI-IMPLANT MIDDLE EAR HEARING V5095 PROSTHESIS No MEDICAID HEARING AID, BILATERAL, BODY V5100 Yes WORN MEDICAID V5110 DISPENSING FEE, BILATERAL Yes MEDICAID V5120 BINAURAL, BODY Yes MEDICAID V5130 BINAURAL, IN THE EAR Yes MEDICAID V5140 BINAURAL, BEHIND EAR Yes MEDICAID V5150 BINAURAL, GLASSES Yes MEDICAID V5160 DISPENSING FEE, BINAURAL Yes MEDICAID V5170 HEARING AID, CROS, IN THE EAR Yes MEDICAID HEARING AID, CROS, BEHIND THE V5180 Yes EAR MEDICAID V5190 HEARING AID, CROS, GLASSES Not Covered MEDICAID V5200 DISPENSING FEE, CROS Yes MEDICAID V5210 HEARING AID, BICROS, IN THE EAR Yes MEDICAID HEARING AID, BICROS, BEHIND THE V5220 Yes EAR MEDICAID V5230 HEARING AID, BICROS, GLASSES Not Covered MEDICAID V5240 DISPENSING FEE BICROS Yes MEDICAID DISPENSING FEE, MONAURAL V5241 Yes HEARING AID, ANY TYPE MEDICAID HEARING AID, ANALOG, MONAURAL, V5242 CIC (COMPLETELY IN THE EAR Yes CANAL) MEDICAID HEARING AID, ANALOG, MONAURAL, V5243 Yes ITC (IN THE CANAL) MEDICAID HEARING AID, DIGITALLY V5244 PROGRAMMABLE ANALOG, Yes MONAURAL, CIC MEDICAID HEARING AID, DIGITALLY V5245 PROGRAMMABLE ANALOG, Yes MONAURAL, ITC MEDICAID HEARING AID, DIGITALLY V5246 PROGRAMMABLE ANALOG, Yes MONAURAL, ITE (IN THE EAR) MEDICAID HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, V5247 Yes MONAURAL, BTE (BEHIND THE EAR) MEDICAID HEARING AID, ANALOG, BINAURAL, V5248 Yes CIC MEDICAID HEARING AID, ANALOG, BINAURAL, V5249 Yes ITC MEDICAID HEARING AID, DIGITALLY, V5250 PROGRAMMABLE, ANALOG, Yes BINAURAL, CIC MEDICAID HEARING AID, DIGITALLY, V5251 PROGRAMMABLE, ANALOG, Yes BINAURAL, ITC MEDICAID HEARING AID, DIGITALLY, V5252 Yes PROGRAMMABLE, BINAURAL, ITE MEDICAID HEARING AID, DIGITALLY, V5253 Yes PROGRAMMABLE, BINAURAL, BTE MEDICAID HEARING AID, DIGITAL, MONAURAL, V5254 Yes CIC MEDICAID HEARING AID, DIGITAL, MONAURAL, V5255 Yes ITC MEDICAID HEARING AID, DIGITAL, MONAURAL, V5256 Yes ITE MEDICAID HEARING AID, DIGITAL, MONAURAL, V5257 Yes BTE MEDICAID HEARING AID, DIGITAL, BINAURAL, V5258 Yes CIC MEDICAID HEARING AID, DIGITAL, BINAURAL, ITC V5259 Yes MEDICAID HEARING AID, DIGITAL, BINAURAL, ITE V5260 Yes MEDICAID

613 of 614 Revised: 10/01/2018 Services that require Prior Authorization List Description Prior Auth Code Required Key Rider Requirement Product Lines HEARING AID, DIGITAL, BINAURAL, V5261 Yes BTE MEDICAID HEARING AID, DISPOSABLE, ANY V5262 TYPE, MONAURAL Not Covered MEDICAID HEARING AID, DISPOSABLE, ANY V5263 TYPE, BINAURAL Not Covered MEDICAID EAR MOLD/INSERT, NOT V5264 Yes DISPOSABLE, ANY TYPE MEDICAID EAR MOLD/INSERT, DISPOSABLE, ANY V5265 TYPE Not Covered MEDICAID BATTERY FOR USE IN HEARING V5266 Yes DEVICE MEDICAID HEARING AID SUPPLIES/ V5267 Yes ACESSORIES MEDICAID ASSISTIVE LISTENING DEVICE, V5268 TELEPHONE AMPLIFIER, ANY TYPE Not Covered MEDICAID ASSISTIVE LISTENING DEVICE, V5269 ALERTING, ANY TYPE Not Covered MEDICAID ASSISTIVE LISTENING DEVICE, V5270 TELEVISION AMPLIFIER, ANY TYPE Not Covered MEDICAID ASSISTIVE LISTENING DEVICE, V5271 TELEVISION CAPTION DECODER Not Covered MEDICAID V5272 ASSISTIVE LISTENING DEVICE, TDD Not Covered MEDICAID ASSISTIVE LISTENING DEVICE, FOR V5273 USE WITH COCHLEAR IMPLANT Not Covered MEDICAID ASSISTIVE LISTENING DEVICE, NOT V5274 Yes OTHERWISE SPECIFIED MEDICAID V5275 EAR IMPRESSION, EACH Not Covered MEDICAID V5281 Assistive listening device, personal fm/dm system, monaural, (1 receiver, transmitter, microphone), any type Not Covered MEDICAID V5282 Assistive listening device, personal fm/dm system, binaural, (2 receivers, transmitter, microphone), any type Not Covered MEDICAID V5283 Assistive listening device, personal fm/dm neck, loop induction receiver Not Covered MEDICAID V5284 Assistive listening device, personal fm/dm, ear level receiver Not Covered MEDICAID V5285 Assistive listening device, personal fm/dm, direct audio input receiver Not Covered MEDICAID V5286 Assistive listening device, personal blue tooth fm/dm receiver Not Covered MEDICAID V5287 Assistive listening device, personal fm/dm receiver, not otherwise specified Not Covered MEDICAID V5288 Assistive listening device, personal fm/dm transmitter assistive listening device Not Covered MEDICAID V5289 Assistive listening device, personal fm/dm adapter/boot coupling device for receiver, any type Not Covered MEDICAID V5290 Assistive listening device, transmitter microphone, any type Not Covered MEDICAID HEARING AID, NOT OTHERWISE V5298 Yes CLASSIFIED MEDICAID HEARING SERVICE, MISCELLANEOUS V5299 Yes MEDICAID REPAIR/MODIFICATION OF AUGMENTATIVE COMMUNICATIVE SYSTEM OR DEVICE (EXCLUDES V5336 ADAPTIVE HEARING AID) No MEDICAID V5362 SPEECH SCREENING Not Covered MEDICAID V5363 LANGUAGE SCREENING Not Covered MEDICAID V5364 DYSPHAGIA SCREENING Not Covered MEDICAID

614 of 614 Revised: 10/01/2018