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OMNIBUS CODES Policy Number: OTH037 Effective Date: April 1, 2019

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OMNIBUS CODES Policy Number: OTH037 Effective Date: April 1, 2019 UnitedHealthcare® Commercial Medical Policy OMNIBUS CODES Policy Number: OTH037 Effective Date: April 1, 2019 Table of Contents Page COVERAGE SUMMARY............................................... 1 POLICY HISTORY/REVISION INFORMATION .............. 122 COVERAGE RATIONALE/CLINICAL EVIDENCE ............... 7 INSTRUCTIONS FOR USE ....................................... 122 COVERAGE SUMMARY All CPT/HCPCS codes/services addressed in this policy are noted in the table below. Click the code link to be directed to the full coverage rationale and clinical evidence applicable to each of the listed procedures. CPT® is a registered trademark of the American Medical Association Code Description Conclusion Computer-assisted musculoskeletal surgical navigational orthopedic 0054T procedure, with image-guidance based on fluoroscopic images (List separately Unproven in addition to code for primary procedure) Computer-assisted musculoskeletal surgical navigational orthopedic 0055T procedure, with image-guidance based on CT/MRI images (List separately in Unproven addition to code for primary procedure) Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular 0061U Unproven dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis Placement of a subconjunctival retinal prosthesis receiver and pulse 0100T generator, and implantation of intra-ocular retinal electrode array, with Unproven vitrectomy Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for 0174T interpretation and report, with or without digitization of film radiographic Unproven images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for 0175T Unproven interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation Evacuation of meibomian glands, automated, using heat and intermittent 0207T Unproven pressure, unilateral Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if 0263T Unproven performed; complete procedure including unilateral or bilateral bone marrow harvest Intramuscular autologous bone marrow cell therapy, with preparation of 0264T harvested cells, multiple injections, one leg, including ultrasound guidance, if Unproven performed; complete procedure excluding bone marrow harvest Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if 0265T Unproven performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy Omnibus Codes Page 1 of 122 UnitedHealthcare Commercial Medical Policy Effective 04/01/2019 Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc. Code Description Conclusion Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead 0266T Unproven placement, intra-operative interrogation, programming, and repositioning, when performed) Implantation or replacement of carotid sinus baroreflex activation device; lead 0267T only, unilateral (includes intra-operative interrogation, programming, and Unproven repositioning, when performed) Implantation or replacement of carotid sinus baroreflex activation device; 0268T pulse generator only (includes intra-operative interrogation, programming, Unproven and repositioning, when performed) 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 0272T Unproven interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) 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 0273T Unproven interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming 0330T Tear film imaging, unilateral or bilateral, with interpretation and report Unproven 0335T Insertion of sinus tarsi implant Unproven 0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral Unproven Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon, 0355T Unproven with interpretation and report Insertion of drug-eluting implant (including punctual dilation and implant 0356T Unproven removal when performed) into lacrimal canaliculus, each Bioelectrical impedance analysis whole body composition assessment, with 0358T Unproven interpretation and report Anoscopy with directed submucosal injection of bulking agent for fecal 0377T Unproven incontinence High dose rate electronic brachytherapy, skin surface application, per fraction, 0394T Unproven includes basic dosimetry, when performed High dose rate electronic brachytherapy, interstitial or intracavitary treatment, 0395T Unproven per fraction, includes basic dosimetry, when performed Intra-operative use of kinetic balance sensor for implant stability during knee 0396T replacement arthroplasty (List separately in addition to code for primary Unproven procedure) Endoscopic retrograde cholangiopancreatography (ERCP), with optical 0397T Unproven endomicroscopy (List separately in addition to code for primary procedure) Magnetic resonance image guided high intensity focused ultrasound 0398T (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder Unproven including stereotactic navigation and frame placement when performed Multi-spectral digital skin lesion analysis of clinically atypical cutaneous 0400T pigmented lesions for detection of melanomas and high risk melanocytic Unproven atypia; one to five lesions Multi-spectral digital skin lesion analysis of clinically atypical cutaneous 0401T pigmented lesions for detection of melanomas and high risk melanocytic Unproven atypia ;six or more lesions Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, 0421T Unproven cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) Omnibus Codes Page 2 of 122 UnitedHealthcare Commercial Medical Policy Effective 04/01/2019 Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc. Code Description Conclusion Insertion or replacement of neurostimulator system for treatment of central 0424T sleep apnea; complete system (transvenous placement of right or left Unproven stimulation lead, sensing lead, implantable pulse generator) Insertion or replacement of neurostimulator system for treatment of central 0425T Unproven sleep apnea; sensing lead only Insertion or replacement of neurostimulator system for treatment of central 0426T Unproven sleep apnea; stimulation lead only Insertion or replacement of neurostimulator system for treatment of central 0427T Unproven sleep apnea; pulse generator only Removal of neurostimulator system for treatment of central sleep apnea; 0428T Unproven pulse generator only Removal of neurostimulator system for treatment of central sleep apnea; 0429T Unproven sensing lead only 0430T Removal of neurostimulator system for treatment of central sleep apnea; Unproven Removal and replacement of neurostimulator system for treatment of central 0431T Unproven sleep apnea, pulse generator only Removal and replacement of neurostimulator system for treatment of central 0432T Unproven sleep apnea, pulse generator only Repositioning of neurostimulator system for treatment of central sleep apnea; 0433T Unproven sensing lead only Interrogation device evaluation implanted neurostimulator pulse generator 0434T Unproven system for central sleep apnea Programming device evaluation of implanted neurostimulator pulse generator 0435T Unproven system for central sleep apnea; single session Programming device evaluation of implanted neurostimulator pulse generator 0436T Unproven system for central sleep apnea; during sleep study Ablation, percutaneous, cryoablation, includes imaging guidance; upper 0440T Unproven extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes imaging guidance; lower 0441T Unproven extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus 0442T Unproven or other truncal nerve (e.g., brachial plexus, pudendal nerve) Real time spectral analysis of prostate tissue by fluorescence spectroscopy, 0443T including imaging guidance (List separately in addition to code for primary Unproven procedure) Initial placement of a drug-eluting ocular insert under one or more eyelids, 0444T Unproven including fitting,
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