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UnitedHealthcare® Commercial Medical Policy Omnibus Codes Policy Number: 2021T0535III Effective Date: May 1, 2021 Instructions for Use Table of Contents Page Community Plan Policy Coverage Summary........................................................................... 1 • Omnibus Codes Coverage Rationale/Clinical Evidence .........................................12 Policy History/Revision Information........................................... 171 Instructions for Use ...................................................................... 174 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 0042T Cerebral perfusion analysis using computed tomography with contrast Proven in certain administration, including post-processing of parametric maps with circumstances determination of cerebral blood flow, cerebral blood volume, and mean transit time 0061U Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], Unproven oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis 0100T Placement of a subconjunctival retinal prosthesis receiver and pulse Unproven generator, and implantation of intra-ocular retinal electrode array, with vitrectomy 0163U Oncology (colorectal) screening, biochemical enzyme-linked immunosorbent Unproven assay (ELISA) of 3 plasma or serum proteins (teratocarcinoma derived growth factor-1 [TDGF-1, Cripto-1], carcinoembryonic antigen [CEA], extracellular matrix protein [ECM]), with demographic data (age, gender, CRC-screening compliance) using a proprietary algorithm and reported as likelihood of CRC or advanced adenomas 0174T Computer-aided detection (CAD) (computer algorithm analysis of digital Unproven image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) 0175T Computer-aided detection (CAD) (computer algorithm analysis of digital Unproven image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation Omnibus Codes Page 1 of 174 UnitedHealthcare Commercial Medical Policy Effective 05/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Code Description Conclusion 0207T Evacuation of meibomian glands, automated, using heat and intermittent Unproven pressure, unilateral 0208T Pure tone audiometry (threshold), automated; air only Unproven 0209T Pure tone audiometry (threshold), automated; air and bone Unproven 0210T Speech audiometry threshold, automated; Unproven 0211T Speech audiometry threshold, automated; with speech recognition Unproven 0212T Comprehensive audiometry threshold evaluation and speech recognition Unproven (0209T, 0211T combined), automated 0247U Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), Unproven sex hormone-binding globulin (SHBG), quantitative measurement by LC- MS/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth 0266T Implantation or replacement of carotid sinus baroreflex activation device; Unproven total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) 0267T Implantation or replacement of carotid sinus baroreflex activation device; Unproven lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 0268T Implantation or replacement of carotid sinus baroreflex activation device; Unproven pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) 0269T Revision or removal of carotid sinus baroreflex activation device; total system Unproven (includes generator placement, unilateral or bilateral lead placement, intra- operative interrogation, programming, and repositioning, when performed) 0270T Revision or removal of carotid sinus baroreflex activation device; lead only, Unproven unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) 0271T Revision or removal of carotid sinus baroreflex activation device; pulse Unproven generator only (includes intra-operative interrogation, programming, and repositioning, when performed) 0272T Interrogation device evaluation (in person), carotid sinus baroreflex activation Unproven system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with 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) 0273T Interrogation device evaluation (in person), carotid sinus baroreflex activation Unproven system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with 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 0331T Myocardial sympathetic innervation imaging, planar qualitative and Unproven quantitative assessment Omnibus Codes Page 2 of 174 UnitedHealthcare Commercial Medical Policy Effective 05/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Code Description Conclusion 0332T Myocardial sympathetic innervation imaging, planar qualitative and Unproven quantitative assessment; with tomographic SPECT 0335T Insertion of sinus tarsi implant Unproven 0338T Transcatheter renal sympathetic denervation, percutaneous approach Unproven 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 0339T Transcatheter renal sympathetic denervation, percutaneous approach Unproven 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 0351T Optical coherence tomography of breast or axillary lymph node, excised Unproven tissue, each specimen; real-time intraoperative 0352T Optical coherence tomography of breast or axillary lymph node, excised Unproven tissue, each specimen; interpretation and report, real-time or referred 0353T Optical coherence tomography of breast, surgical cavity; real-time Unproven intraoperative 0354T Optical coherence tomography of breast, surgical cavity; interpretation and Unproven report, real-time or referred 0355T Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon, Unproven with interpretation and report 0356T Insertion of drug-eluting implant (including punctual dilation and implant Unproven removal when performed) into lacrimal canaliculus, each 0358T Bioelectrical impedance analysis whole body composition assessment, with Unproven interpretation and report 0394T High dose rate electronic brachytherapy, skin surface application, per Unproven fraction, includes basic dosimetry, when performed 0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment, Unproven per fraction, includes basic dosimetry, when performed 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical Unproven endomicroscopy (List separately in addition to code for primary procedure) 0398T Magnetic resonance image guided high intensity focused ultrasound Unproven (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed 0408T Insertion or replacement of permanent cardiac contractility modulation Unproven system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes 0409T Insertion or replacement of permanent cardiac contractility modulation Unproven system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only Omnibus Codes Page 3 of 174 UnitedHealthcare Commercial Medical Policy Effective 05/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Code Description Conclusion 0410T Insertion or replacement of permanent cardiac contractility modulation Unproven system, including contractility evaluation when performed, and programming
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