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2021 Commercial Outpatient Benefit Preauthorization Fully Insured Medical Surgical Procedure Code List

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2021 Commercial Outpatient Benefit Preauthorization Fully Insured Medical Surgical Procedure Code List 2021 Commercial Outpatient Benefit Preauthorization Fully Insured Medical Surgical Procedure Code List This list is not exhaustive. Codes may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply. The following care categories require preauthorization through AIM for all Commercial members: Utilizing the AIM Healthcare Web Portal is the most efficient way tot initaite a case, check status, review guidelines, view authroziation/eigibility and more. Molecular and Genomic Tests Web portal available 24/7. Radiation Therapy URL: https://aimspecialtyhealth.com Advanced Imaging Musculoskeletal - Pain Management Or call toll-free at 1-866-745-1789 between 7 a.m. and 7 p.m. Musculoskeletal - Joint and Spine Surgery Monday through Friday except holidays. The following outpatient care categories may require preauthorization for Commercial - Fully Insured members: Molecular and Genomic Tests (AIM) Radiation Therapy (AIM) Advanced Imaging (AIM) Musculoskeletal - Pain Management (AIM) Musculoskeletal - Joint and Spine Surgery (AIM) Select Outpatient Procedures (see code list below) Ear, Nose and Throat (ENT) Gastroenterology Musculoskeletal Neurology Outpatient Surgery - Orthognathic Surgery (face reconstruction) Outpatient Surgery - Mastopexy (breast lift) Outpatient Surgery - Reduction Mammaplasty (breast reduction) Sleep Studies Wound Care ALL Services listed in Section 10.2 of the Provider Reference Manual, including ALL inpatient services Note: Specialty Pharmacy & Behavioral Health PA codes are also provided for review/download on separate lists. The following list of outpatient procedure codes may require preauthorization for commercial members. This list is not exhaustive. Codes may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply. PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE. Procedure Code Service/Category Description Medical Policy Number Medical Policy Title Updates Computed tomography, thorax, low dose for lung cancer screening, 71271 Radiology AIM Guidelines Add effective 01/01/2021 without contrast material(s) CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation 81168 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 analysis, major breakpoint, qualitative and quantitative, if performed NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) 81191 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 translocation analysis NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) 81192 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 translocation analysis NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) 81193 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 translocation analysis NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) 81194 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 (eg, solid tumors) translocation analysis IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, 81278 Molecular and Genetic Lab major breakpoint region (MBR) and minor cluster region (mcr) AIM Guidelines Add effective 01/01/2021 breakpoints, qualitative or quantitative JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted 81279 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 sequence analysis (eg, exons 12 and 13) MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, 81338 Molecular and Genetic Lab myeloproliferative disorder) gene analysis; common variants (eg, AIM Guidelines Add effective 01/01/2021 W515A, W515K, W515L, W515R) MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, 81339 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 myeloproliferative disorder) gene analysis; sequence analysis, exon 10 11/2020 Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.. SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic 81347 Molecular and Genetic Lab syndrome/acute myeloid leukemia) gene analysis, common variants AIM Guidelines Add effective 01/01/2021 (eg, A672T, E622D, L833F, R625C, R625L) SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic 81348 Molecular and Genetic Lab syndrome, acute myeloid leukemia) gene analysis, common variants AIM Guidelines Add effective 01/01/2021 (eg, P95H, P95L) TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; 81351 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 full gene sequence TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; 81352 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 targeted sequence analysis (eg, 4 oncology) TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; 81353 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 known familial variant U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic 81357 Molecular and Genetic Lab syndrome, acute myeloid leukemia) gene analysis, common variants AIM Guidelines Add effective 01/01/2021 (eg, S34F, S34Y, Q157R, Q157P) ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine- 81360 Molecular and Genetic Lab rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene AIM Guidelines Add effective 01/01/2021 analysis, common variant(s) (eg, E65fs, E122fs, R448fs) Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, 81419 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2 Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), 81529 Molecular and Genetic Lab utilizing formalin-fixed paraffin-embedded tissue, algorithm reported AIM Guidelines Add effective 01/01/2021 as recurrence risk, including likelihood of sentinel lymph node metastasis Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, 81546 Molecular and Genetic Lab utilizing fine needle aspirate, algorithm reported as a categorical AIM Guidelines Add effective 01/01/2021 result (eg, benign or suspicious) Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, 81554 Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalinfixed paraffin-embedded tissue, 0016M Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, 0104U Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) 0203U Molecular and Genetic Lab AI IBD MRNA XPRSN PRFL 17 _ AIM Guidelines Add effective 01/01/2021 0204U Molecular and Genetic Lab ONC THYR MRNA XPRSN ALYS 593 _ AIM Guidelines Add effective 01/01/2021 0205U Molecular and Genetic Lab OPH AMD ALYS 3 GENE VARIANTS _ AIM Guidelines Add effective 01/01/2021 0208U Molecular and Genetic Lab ONC MTC MRNA XPRSN ALYS 108 _ AIM Guidelines Add effective 01/01/2021 0209U Molecular and Genetic Lab CYTOG CONST ALYS INTERROG _ AIM Guidelines Add effective 01/01/2021 0211U Molecular and Genetic Lab ONC PAN-TUM DNA&RNA GNRJ SEQ _ AIM Guidelines Add effective 01/01/2021 0212U Molecular and Genetic Lab RARE DS GEN DNA ALYS PROBAND _ AIM Guidelines Add effective 01/01/2021 0213U Molecular and Genetic Lab RARE DS GEN DNA ALYS EA COMP _ AIM Guidelines Add effective 01/01/2021 0214U Molecular and Genetic Lab RARE DS XOM DNA ALYS PROBAND _ AIM Guidelines Add effective 01/01/2021 0215U Molecular and Genetic Lab RARE DS XOM DNA ALYS EA COMP _ AIM Guidelines Add effective 01/01/2021 0216U Molecular and Genetic Lab NEURO INH ATAXIA DNA 12 COM _ AIM Guidelines Add effective 01/01/2021 0217U Molecular and Genetic Lab NEURO INH ATAXIA DNA 51 GENE _ AIM Guidelines Add effective 01/01/2021 Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and 0218U Molecular and Genetic Lab AIM Guidelines Add effective 01/01/2021 variants
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