EFFECTIVE 05/17/21 FOR MEDICARE
The following items always require authorization:
Inpatient Services
Hospital inpatient admissions All other inpatient admissions (e.g. acute, skilled nursing facility, and rehabilitation) Services rendered at or provided by a non-par provider Covered services that do not have a fee attached Muskuloskeletal Surgery Procedures: Knee/Hip/Shoulder, and Cervical Lumbar Spine o Link to NIA
Outpatient Services
Potentially experimental, investigational or cosmetic services Home Health Care Prosthetics Power Wheelchairs Partial Hospitalizations for Behavioral Health Hospice Services Radiology Management, Physical Therapy, Occupational Therapy, Speech Therapy, Musculoskeletal Surgery Procedures (MSK), Trigger Point Injections and Interventional Pain Management o Link to NIA Services rendered at or provided by a non-par provider Covered services that do not have a fee attached Chemotherapeutic drugs, symptom management drugs and supportive agents will require authorization when prescribed for a member 18 years of age or older and being used for an oncology related indication. The Gateway Health Provider Portal Procedure Code Lookup Tool below can be used to determine if the medication being administered requires authorization. Miscellaneous J-codes (J3490, J3590, J8499, J8999, J9999) may require authorization on a drug-by-drug basis. The authorization information will not be identified in the Provider Search Tool due to system limitations. Please refer to notifications of authorization requirements posted on the provider update webpage: https://www.gatewayhealthplan.com/provider/medicaid-resources/medicaid-provider-updates. When permanent HCPCS codes are assigned to medications, the lookup tool below will be updated to reflect the authorization requirement.
Please utilize the Portal Code Search Tool to research authorization requirements for all other codes currently requiring authorization. The reference list attached outlines codes requiring authorization not included in the services listed above.
Attention:
Non covered benefits will not be paid unless special circumstances exists. Always review member benefits to determine covered & non-covered services. Authorization does not guarantee payment of claims. A service or supply will be reimbursed by Gateway Health only if it is medically necessary, a covered service, and provided to an eligible member. o The authorization process continues to be subject to the maximum unit and program exception policies.
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics
11920 TATTOOING 11950 THERAPY FOR CONTOUR DEFECTS 11954 THERAPY FOR CONTOUR DEFECTS 13152 REPAIR OF WOUND OR LESION 14040 TIS TRNFR F/C/C/M/N/A/G/H/F 14061 SKIN TISSUE REARRANGEMENT 14301 SKIN TISSUE REARRANGEMENT 15040 HARVEST CULTURED SKIN GRAFT 15050 SKIN PINCH GRAFT 15100 SKIN SPLT GRFT TRNK/ARM/LEG 15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 15115 EPIDRM A-GRFT FACE/NCK/HF/G 15120 SKN SPLT A-GRFT FAC/NCK/HF/G 15130 DERM AUTOGRAFT TRNK/ARM/LEG 15135 DERM AUTOGRAFT FACE/NCK/HF/G 15150 CULT SKIN GRFT T/ARM/LEG 15155 CULT SKIN GRAFT F/N/HF/G 15200 SKIN FULL GRAFT TRUNK 15220 SKIN FULL GRAFT SCLP/ARM/LEG 15240 SKIN FULL GRFT FACE/GENIT/HF 15260 SKIN FULL GRAFT EEN & LIPS 15271 SKIN SUB GRAFT TRNK/ARM/LEG 15273 SKIN SUB GRFT T/ARM/LG CHILD 15275 SKIN SUB GRAFT FACE/NK/HF/G 15277 SKN SUB GRFT F/N/HF/G CHILD 15734 MUSCLE-SKIN GRAFT TRUNK 15736 MUSCLE-SKIN GRAFT ARM 15760 COMPOSITE SKIN GRAFT 15770 DERMA-FAT-FASCIA GRAFT 15775 HAIR TRNSPL 1-15 PUNCH GRFTS 15776 HAIR TRNSPL >15 PUNCH GRAFTS 15783 ABRASION TREATMENT OF SKIN MP 15820 REVISION OF LOWER EYELID 15821 REVISION OF LOWER EYELID 15822 REVISION OF UPPER EYELID 15823 REVISION OF UPPER EYELID 15825 REMOVAL OF NECK WRINKLES 15830 Excision, excessive skin and subcutaneous tissue 15832 EXCISE EXCESSIVE SKIN TISSUE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 15833 EXCISE EXCESSIVE SKIN LEG 15834 EXCISE EXCESSIVE SKIN TISSUE 15835 EXCISE EXCESSIVE SKIN BUTTCK 15836 EXCISE EXCESSIVE SKIN TISSUE 15837 EXCISE EXCESS SKIN ARM/HAND 15838 EXCISE EXCESS SKIN FAT PAD 15839 EXCISE EXCESSIVE SKIN TISSUE MP 15847 Excision, excessive skin and subcutaneous tissue 15876 SUCTION LIPECTOMY HEAD&NECK 15877 SUCTION LIPECTOMY TRUNK 15878 SUCTION LIPECTOMY UPR EXTREM 15879 SUCTION LIPECTOMY LWR EXTREM 19300 REMOVAL OF BREAST TISSUE 19316 SUSPENSION OF BREAST 19318 REDUCTION OF LARGE BREAST 19324 ENLARGE BREAST 19325 ENLARGE BREAST WITH IMPLANT 19328 REMOVAL OF BREAST IMPLANT 19330 REMOVAL OF IMPLANT MATERIAL 19340 IMMEDIATE BREAST PROSTHESIS 19342 DELAYED BREAST PROSTHESIS 19350 BREAST RECONSTRUCTION 19355 CORRECT INVERTED NIPPLE(S) 19357 BREAST RECONSTRUCTION 19366 BREAST RECONSTRUCTION 19370 SURGERY OF BREAST CAPSULE 19371 REMOVAL OF BREAST CAPSULE 19380 REVISE BREAST RECONSTRUCTION 19396 DESIGN CUSTOM BREAST IMPLANT NIA 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) MP 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) NIA 20561 Needle insertion(s) without injection(s); 3 or more muscles MP 20561 Needle insertion(s) without injection(s); 3 or more muscles 20912 REMOVE CARTILAGE FOR GRAFT 21198 RECONSTR LWR JAW SEGMENT 21235 EAR CARTILAGE GRAFT 21240 RECONSTRUCTION OF JAW JOINT 21335 TREATMENT OF NOSE FRACTURE 22514 PERQ VERTEBRAL AUGMENTATION NIA 22533 Arthrodesis, lateral extracavitary technique; lumbar NIA 22534 Arthrodesis, lateral extracavitary technique; thoracic or lumbar NIA 22548 Arthrodesis, anterior transoral or extraoral technique
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 22551 Arthrodesis, anterior interbody; cervical below C2 NIA 22552 Arthrodesis, anterior interbody; cervical below C2, each additional NIA 22554 Arthrodesis, anterior interbody; cervical below C2 NIA 22558 Arthrodesis, anterior interbody; lumbar NIA 22585 Arthrodesis, anterior interbody; each additional NIA 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) NIA 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) NIA 22600 Arthrodesis, posterior or posterolateral, single level; cervical NIA 22612 Arthrodesis, posterior or posterolateral technique, single level NIA 22614 Arthrodesis, posterior or posterolateral technique, single level NIA 22630 Arthrodesis, posterior interbody technique, single interspace NIA 22632 Arthrodesis, posterior interbody technique, single interspace NIA 22633 Arthrodesis, combined posterior or posterolateral; lumbar NIA 22634 Arthrodesis, combined posterior or posterolateral; each additional NIA 22856 Total disc arthroplasty (artificial disc), anterior approach NIA 22858 Total disc arthroplasty (artificial disc), anterior approach NIA 22861 Revision including replacement of total disc arthroplasty; cervical NIA 22864 Removal of total disc arthroplasty; cervical NIA 23120 Claviculectomy; partial NIA 23125 Claviculectomy; total NIA 23130 Acromioplasty or acromionectomy, partial NIA 23405 Tenotomy, shoulder area; single tendon NIA 23410 Repair of ruptured musculotendinous cuff open; acute NIA 23412 Repair of ruptured musculotendinous cuff open; chronic NIA 23415 Coracoacromial ligament release, with or without acromioplasty NIA 23420 Reconstruction of complete shoulder cuff avulsion, chronic NIA 23430 Tenodesis of long tendon of biceps NIA 23450 Capsulorrhaphy, anterior; Putti-Platt procedure/Magnuson NIA 23455 Capsulorrhaphy, anterior; with labral repair NIA 23460 Capsulorrhaphy, anterior, any type; with bone block NIA 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer NIA 23465 Capsulorrhaphy, glenohumeral joint, posterior, w or w/o bone block NIA 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional NIA 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty NIA 23472 Arthroplasty, glenohumeral joint; total shoulder NIA 23473 Revision of total shoulder arthroplasty; humeral or glenoid NIA 23474 Revision of total shoulder arthroplasty; humeral and glenoid NIA 23700 Manipulation under anesthesia, shoulder joint 24305 ARM TENDON LENGTHENING 25107 REMOVE WRIST JOINT CARTILAGE 25111 REMOVE WRIST TENDON LESION 25447 REPAIR WRIST JOINTS
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 27096 Injection procedure for sacroiliac joint, anesthetic/steroid NIA 27130 Arthroplasty, acetabular and proximal femoral prosthetic NIA 27132 Conversion of previous hip surgery to total hip arthroplasty NIA 27134 Revision of total hip arthroplasty; both components NIA 27137 Revision of total hip arthroplasty; acetabular component only NIA 27138 Revision of total hip arthroplasty; femoral component only NIA 27332 Arthrotomy, with excision of semilunar cartilage knee NIA 27333 Arthrotomy, with excision of semilunar cartilage knee NIA 27403 Arthrotomy with meniscus repair, knee NIA 27405 Repair, primary, torn ligament and/or capsule, knee; collateral NIA 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate NIA 27409 Repair, primary, torn ligament and/or capsule, knee NIA 27412 Autologous chondrocyte implantation, knee NIA 27415 Osteochondral allograft, knee, open NIA 27416 Osteochondral autograft(s), knee, open NIA 27418 Anterior tibial tubercleplasty NIA 27420 Reconstruction of dislocating patella NIA 27422 Reconstruction of dislocating patella; with extensor realignment NIA 27424 Reconstruction of dislocating patella; with patellectomy NIA 27425 Lateral retinacular release, open NIA 27427 Ligamentous reconstruction, knee; extra-articular NIA 27428 Ligamentous reconstruction, knee; intra-articular (open) NIA 27429 Ligamentous reconstruction, knee; intra-articular (open) NIA 27438 Arthroplasty, patella; with prosthesis NIA 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral NIA 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral NIA 27486 Revision of total knee arthroplasty; 1 component NIA 27487 Revision of total knee arthroplasty; femoral/entire tibial NIA 27570 Manipulation of knee joint under general anesthesia NIA 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy NIA 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy NIA 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion NIA 29819 Arthroscopy, shoulder, surgical; with removal NIA 29820 Arthroscopy, shoulder, surgical; synovectomy, partial NIA 29821 Arthroscopy, shoulder, surgical; synovectomy, complete NIA 29822 Arthroscopy, shoulder, surgical; debridement, limited NIA 29823 Arthroscopy, shoulder, surgical; debridement, extensive NIA 29824 Arthroscopy, shoulder, surgical; distal claviculectomy NIA 29825 Arthroscopy, shoulder, surgical; with lysis and resection NIA 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space NIA 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair NIA 29828 Arthroscopy, shoulder, surgical; biceps tenodesis
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 29844 WRIST ARTHROSCOPY/SURGERY 29846 WRIST ARTHROSCOPY/SURGERY MP 29848 WRIST ENDOSCOPY/SURGERY NIA 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy NIA 29861 Arthroscopy, hip, surgical; with removal of loose/foreign body NIA 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular NIA 29863 Arthroscopy, hip, surgical; with synovectomy NIA 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) NIA 29867 Arthroscopy, knee, surgical; osteochondral allograft NIA 29868 Arthroscopy, knee, surgical; meniscal transplantation NIA 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy NIA 29873 Arthroscopy, knee, surgical; with lateral release NIA 29874 Arthroscopy, knee, surgical; for removal of loose/foreign body NIA 29875 Arthroscopy, knee, surgical; synovectomy, limited NIA 29876 Arthroscopy, knee, surgical; synovectomy, major NIA 29877 Arthroscopy, knee, surgical; debridement/shaving of articular NIA 29879 Arthroscopy, knee, surgical; abrasion arthroplasty NIA 29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral) NIA 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral) NIA 29882 Arthroscopy, knee, surgical; with meniscus repair NIA 29883 Arthroscopy, knee, surgical; with meniscus repair NIA 29884 Arthroscopy, knee, surgical; with lysis of adhesions NIA 29888 Arthroscopically aided anterior cruciate ligament repair NIA 29889 Arthroscopically aided posterior cruciate ligament repair NIA 29914 Arthroscopy, hip, surgical; with femoroplasty NIA 29915 Arthroscopy, hip, surgical; with acetabuloplasty NIA 29916 Arthroscopy, hip, surgical; with labral repair 30140 RESECT INFERIOR TURBINATE 30400 RECONSTRUCTION OF NOSE 30410 RECONSTRUCTION OF NOSE 30420 RECONSTRUCTION OF NOSE 30430 REVISION OF NOSE 30435 REVISION OF NOSE 30450 REVISION OF NOSE 30460 REVISION OF NOSE 30462 REVISION OF NOSE 30465 REPAIR NASAL STENOSIS 30520 REPAIR OF NASAL SEPTUM 31090 EXPLORATION OF SINUSES 31255 REMOVAL OF ETHMOID SINUS MP 31660 BRONCHOSCOPY MP 31661 BRONCHOSCOPY
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics MP 33270 INS/REP SUBQ DEFIBRILLATOR MP 33271 INSERTION OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE MP 33272 REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE MP 33273 REPOSITIONING OF SUBCUTANEOUS DEFIB ELECTRODE MP 33274 TRANSCATH INSERT/REPLACE PERM LEADLESS PACEMAKER, RIGHT VENT MP 33275 TRANSCATH REMOVAL PERM LEADLESS PACEMAKER, RIGHT VENT 36470 INJECTION THERAPY OF VEIN 36471 INJECTION THERAPY OF VEINS 36475 ENDOVENOUS RF, 1ST VEIN 36478 ENDOVENOUS LASER 1ST VEIN MP 37215 TRANSCATHETER PLACEMNT OF INTRAVACULAR STENT(S) 37700 REVISE LEG VEIN 37718 LIGATE/STRIP SHORT LEG VEIN 37722 LIGATE/STRIP LONG LEG VEIN 37735 REMOVAL OF LEG VEINS/LESION 37760 LIGATE LEG VEINS RADICAL 37761 LIGATE LEG VEINS OPEN 37765 STAB PHLEB VEINS XTR 10-20 37766 PHLEB VEINS - EXTREM 20+ 37780 REVISION OF LEG VEIN 37785 LIGATE/DIVIDE/EXCISE VEIN MP 37799 UNLISTED PROCEDURE, VASCULAR SURG 43770 LAP PLACE GASTR ADJ DEVICE 43886 REVISE GASTRIC PORT OPEN 43887 REMOVE GASTRIC PORT OPEN 43888 CHANGE GASTRIC PORT OPEN 44238 LAPAROSCOPE PROC INTESTINE MP 44705 PREP FECAL MICROBIOTA FOR INSTILLATION MP 44799 UNLISTED PROCEDURE INTESTINE 52327 CYSTOSCOPY INJECT MATERIAL 54405 INSERT MULTI-COMP PENIS PROS 54660 REVISION OF TESTIS 55400 REPAIR OF SPERM DUCT 56620 PARTIAL REMOVAL OF VULVA 57260 REPAIR OF VAGINA 57288 REPAIR BLADDER DEFECT 58260 VAGINAL HYSTERECTOMY 58262 VAG HYST INCLUDING T/O 58263 VAG HYST W/T/O & VAG REPAIR 58290 VAG HYST COMPLEX 58291 VAG HYST INCL T/O COMPLEX 58541 LSH, UTERUS 250 G OR LESS
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 58542 LSH W/T/O UT 250 G OR LESS 58543 LSH UTERUS ABOVE 250 G 58544 LSH W/T/O UTERUS ABOVE 250 G 58550 LAPARO-ASST VAG HYSTERECTOMY 58552 LAPARO-VAG HYST INCL T/O 58553 LAPARO-VAG HYST COMPLEX 58554 LAPARO-VAG HYST W/T/O COMPL 58570 TLH UTERUS 250 G OR LESS 58571 TLH W/T/O 250 G OR LESS 58572 TLH UTERUS OVER 250 G 58573 TLH W/T/O UTERUS OVER 250 G 58578 LAPARO PROC UTERUS 58679 LAPARO PROC OVIDUCT-OVARY 59897 FETAL INVAS PX W/US MP 61885 INSRT/REDO NEUROSTIM 1 ARRAY 62287 PERCUTANEOUS DISKECTOMY NIA 62320 Injection(s), of diagnostic or therapeutic substance(s) NIA 62321 Injection(s), of diagnostic or therapeutic substance(s) NIA 62322 Injection(s), of diagnostic or therapeutic substance(s) NIA 62323 Injection(s), of diagnostic or therapeutic substance(s) 62362 IMPLANT SPINE INFUSION PUMP NIA 62380 Endoscopic decompression of spinal cord, nerve root(s) NIA 63001 Laminectomy with exploration and/or decompression of spinal cord NIA 63005 Laminectomy with exploration and/or decompression of spinal cord NIA 63012 Laminectomy with removal of abnormal facets NIA 63015 Laminectomy with exploration and/or decompression of spinal cord NIA 63017 Laminectomy with exploration and/or decompression of spinal cord NIA 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63043 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s) NIA 63045 Laminectomy, facetectomy and foraminotomy; cervical NIA 63047 Laminectomy, facetectomy and foraminotomy; lumbar NIA 63048 Laminectomy, facetectomy and foraminotomy; each additional NIA 63050 Laminoplasty, cervical, with decompression of the spinal cord NIA 63051 Laminoplasty, cervical, with decompression of the spinal cord 63055 DECOMPRESS SPINAL CORD THRC NIA 63056 Transpedicular approach with decompression of spinal cord NIA 63057 Transpedicular approach with decompression of spinal cord
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 63075 Discectomy, anterior, with decompression of spinal cord NIA 63076 Discectomy, anterior, with decompression of spinal cord MP 63650 IMPLANT NEUROELECTRODES MP 63655 IMPLANT NEUROELECTRODES MP 63685 INSRT/REDO SPINE N GENERATOR NIA 64479 Injection(s), anesthetic agent and/or steroid, transforaminal NIA 64480 Injection(s), anesthetic agent and/or steroid, transforaminal NIA 64483 Injection(s), anesthetic agent and/or steroid, transforaminal NIA 64484 Injection(s), anesthetic agent and/or steroid, transforaminal NIA 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet MP 64553 Percutaneous implantation of neurostimulator electrode array MP 64555 Percutaneous implantation of neurostimulator electrode array MP 64561 Percutaneous implantation of neurostimulator electrode array MP 64568 Incision for vagus nerve electrical implant MP 64569 Revision or replacement of cranial nerve MP 64570 Removal of cranial nerve neurostimulator electrode array MP 64575 Incision for implantation of neurostimulator electrode array MP 64581 Incision for implantation of neurostimulator electrode array MP 64585 Revision or removal of peripheral neurostimulator electrode array MP 64590 Insertion/replacement of peripheral/gastric neurostimulator pulse MP 64595 Revision/removal of peripheral/gastric neurostimulator pulse NIA 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s) NIA 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s) NIA 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s) NIA 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s) 64718 REVISE ULNAR NERVE AT ELBOW 64721 CARPAL TUNNEL SURGERY 64905 NERVE PEDICLE TRANSFER 67900 REPAIR BROW DEFECT 67901 REPAIR EYELID DEFECT 67902 REPAIR EYELID DEFECT 67903 REPAIR EYELID DEFECT 67904 REPAIR EYELID DEFECT 67908 REPAIR EYELID DEFECT 69300 REVISE EXTERNAL EAR 69714 IMPLANT TEMPLE BONE W/STIMUL 69949 INNER EAR SURGERY PROCEDURE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 70336 MAGNETIC IMAGE JAW JOINT NIA 70450 CT HEAD/BRAIN W/O DYE NIA 70460 CT HEAD/BRAIN W/DYE NIA 70470 CT HEAD/BRAIN W/O & W/DYE NIA 70480 CT ORBIT/EAR/FOSSA W/O DYE NIA 70481 CT ORBIT/EAR/FOSSA W/DYE NIA 70482 CT ORBIT/EAR/FOSSA W/O&W/DYE NIA 70486 CT MAXILLOFACIAL W/O DYE NIA 70487 CT MAXILLOFACIAL W/DYE NIA 70488 CT MAXILLOFACIAL W/O & W/DYE NIA 70490 CT SOFT TISSUE NECK W/O DYE NIA 70491 CT SOFT TISSUE NECK W/DYE NIA 70492 CT SFT TSUE NCK W/O & W/DYE NIA 70496 CT ANGIOGRAPHY HEAD NIA 70498 CT ANGIOGRAPHY NECK NIA 70540 MRI ORBIT/FACE/NECK W/O DYE NIA 70542 MRI ORBIT/FACE/NECK W/DYE NIA 70543 MRI ORBT/FAC/NCK W/O &W/DYE NIA 70544 MR ANGIOGRAPHY HEAD W/O DYE NIA 70545 MR ANGIOGRAPHY HEAD W/DYE NIA 70546 MR ANGIOGRAPH HEAD W/O&W/DYE NIA 70547 MR ANGIOGRAPHY NECK W/O DYE NIA 70548 MR ANGIOGRAPHY NECK W/DYE NIA 70549 MR ANGIOGRAPH NECK W/O&W/DYE NIA 70551 MRI BRAIN STEM W/O DYE NIA 70552 MRI BRAIN STEM W/DYE NIA 70553 MRI BRAIN STEM W/O & W/DYE NIA 70554 FMRI BRAIN BY TECH NIA 70555 FMRI BRAIN BY PHYS/PSYCH NIA 71250 CT THORAX W/O DYE NIA 71260 CT THORAX W/DYE NIA 71270 CT THORAX W/O & W/DYE NIA 71271 Low Dose CT for Lung Cancer Screening NIA 71275 CT ANGIOGRAPHY CHEST NIA 71550 MRI CHEST W/O DYE NIA 71551 MRI CHEST W/DYE NIA 71552 MRI CHEST W/O & W/DYE NIA 71555 MRI ANGIO CHEST W OR W/O DYE NIA 72125 CT NECK SPINE W/O DYE NIA 72126 CT NECK SPINE W/ DYE NIA 72127 CT NECK SPINE W/O OR W/DYE NIA 72128 CT CHEST SPINE W/O DYE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 72129 CT CHEST SPINE W/DYE NIA 72130 CT CHEST SPINE W/O & W/DYE NIA 72131 CT LUMBAR SPINE W/O DYE NIA 72132 CT LUMBAR SPINE W/DYE NIA 72133 CT LUMBAR SPINE W/O & W/DYE NIA 72141 MRI NECK SPINE W/O DYE NIA 72142 MRI NECK SPINE W/DYE NIA 72146 MRI CHEST SPINE W/O DYE NIA 72147 MRI CHEST SPINE W/DYE NIA 72148 MRI LUMBAR SPINE W/O DYE NIA 72149 MRI LUMBAR SPINE W/DYE NIA 72156 MRI NECK SPINE W/O & W/DYE NIA 72157 MRI CHEST SPINE W/O & W/DYE NIA 72158 MRI LUMBAR SPINE W/O & W/DYE NIA 72159 MR ANGIO SPINE W/O&W/DYE NIA 72191 CT ANGIOGRAPH PELV W/O&W/DYE NIA 72192 CT PELVIS W/O DYE NIA 72193 CT PELVIS W/DYE NIA 72194 CT PELVIS W/O & W/DYE NIA 72195 MRI PELVIS W/O DYE NIA 72196 MRI PELVIS W/DYE NIA 72197 MRI PELVIS W/O & W/DYE NIA 72198 MR ANGIO PELVIS W/O & W/DYE NIA 73200 CT UPPER EXTREMITY W/O DYE NIA 73201 CT UPPER EXTREMITY W/DYE NIA 73202 CT UPPR EXTREMITY W/O&W/DYE NIA 73206 CT ANGIO UPR EXTRM W/O&W/DYE NIA 73218 MRI UPPER EXTREMITY W/O DYE NIA 73219 MRI UPPER EXTREMITY W/DYE NIA 73220 MRI UPPR EXTREMITY W/O&W/DYE NIA 73221 MRI JOINT UPR EXTREM W/O DYE NIA 73222 MRI JOINT UPR EXTREM W/DYE NIA 73223 MRI JOINT UPR EXTR W/O&W/DYE NIA 73225 MR ANGIO UPR EXTR W/O&W/DYE NIA 73700 CT LOWER EXTREMITY W/O DYE NIA 73701 CT LOWER EXTREMITY W/DYE NIA 73702 CT LWR EXTREMITY W/O&W/DYE NIA 73706 CT ANGIO LWR EXTR W/O&W/DYE NIA 73718 MRI LOWER EXTREMITY W/O DYE NIA 73719 MRI LOWER EXTREMITY W/DYE NIA 73720 MRI LWR EXTREMITY W/O&W/DYE NIA 73721 MRI JNT OF LWR EXTRE W/O DYE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 73722 MRI JOINT OF LWR EXTR W/DYE NIA 73723 MRI JOINT LWR EXTR W/O&W/DYE NIA 73725 MR ANG LWR EXT W OR W/O DYE NIA 74150 CT ABDOMEN W/O DYE NIA 74160 CT ABDOMEN W/DYE NIA 74170 CT ABDOMEN W/O & W/DYE NIA 74174 CT ANGIO ABD&PELV W/O&W/DYE NIA 74175 CT ANGIO ABDOM W/O & W/DYE NIA 74176 CT ABD & PELVIS W/O CONTRAST NIA 74177 CT ABD & PELV W/CONTRAST NIA 74178 CT ABD & PELV 1/> REGNS NIA 74181 MRI ABDOMEN W/O DYE NIA 74182 MRI ABDOMEN W/DYE NIA 74183 MRI ABDOMEN W/O & W/DYE NIA 74185 MRI ANGIO ABDOM W ORW/O DYE NIA 74261 CT COLONOGRAPHY DX NIA 74262 CT COLONOGRAPHY DX W/DYE NIA 75557 CARDIAC MRI FOR MORPH NIA 75559 CARDIAC MRI W/STRESS IMG NIA 75561 CARDIAC MRI FOR MORPH W/DYE NIA 75563 CARD MRI W/STRESS IMG & DYE NIA 75565 CARD MRI VELOC FLOW MAPPING NIA 75571 CT HRT W/O DYE W/CA TEST NIA 75572 CT HRT W/3D IMAGE NIA 75573 CT HRT W/3D IMAGE CONGEN NIA 75574 CT ANGIO HRT W/3D IMAGE NIA 75635 CT ANGIO ABDOMINAL ARTERIES NIA 76380 CAT SCAN FOLLOW-UP STUDY NIA 76497 CT PROCEDURE NIA 76498 MRI PROCEDURE 76977 ULTRASOUND BONE DENSITY NIA 77046 Magnetic resonance imaging, breast, without contrast material NIA 77047 Magnetic resonance imaging, breast, without contrast material NIA 77048 MRI, breast, without and with contrast material(s) NIA 77049 MRI, breast, without and with contrast material(s); bilateral 77072 BONE AGE STUDY 77073 BONE LENGTH STUDY 77074 RADIOLOGIC EXAM OSSEOUS SURVEY 77075 RADIOLOGIC EXAM OSSEOUS SURVEY 77076 RADIOLOGIC EXAM OSSEOUS SURVEY 77077 JOINT SURVEY NIA 77078 CT BONE DENSITY AXIAL
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 77080 DXA BONE DENSITY STUDY NIA 77084 MAGNETIC IMAGE BONE MARROW NIA 78451 HT MUSCLE IMAGE SPECT SING NIA 78452 HT MUSCLE IMAGE SPECT MULT NIA 78453 HT MUSCLE IMAGE PLANAR SING NIA 78454 HT MUSC IMAGE PLANAR MULT NIA 78459 MYOCARDIAL IMAGINT (PET) NIA 78466 Myocardial imaging, infarct avid, planar; qualitative/quantitative NIA 78468 Myocardial imaging, infarct avid, planar; with ejection fraction NIA 78469 Myocardial imaging, infarct avid, planar; tomographic SPECT NIA 78472 GATED HEART PLANAR SINGLE NIA 78473 GATED HEART MULTIPLE NIA 78481 HEART FIRST PASS SINGLE NIA 78483 HEART FIRST PASS MULTIPLE NIA 78491 HEART IMAGE (PET) SINGLE NIA 78492 HEART IMAGE (PET) MULTIPLE NIA 78494 HEART IMAGE SPECT NIA 78496 HEART FIRST PASS ADD-ON NIA 78499 CARDIOVASCULAR NUCLEAR EXAM NIA 78608 BRAIN IMAGING (PET) NIA 78811 PET IMAGE LTD AREA NIA 78812 PET IMAGE SKULL-THIGH NIA 78813 PET IMAGE FULL BODY NIA 78814 PET IMAGE W/CT LMTD NIA 78815 PET IMAGE W/CT SKULL-THIGH NIA 78816 PET IMAGE W/CT FULL BODY 81161 DMD DELETION ANALYSIS 81200 ASPA GENE MP 81201 APC GENE FULL SEQUENCE MP 81202 APC GENE KNOWN FAM VARIANTS MP 81203 APC GENE DUP/DELET VARIANTS 81205 BCKDHB GENE 81209 BLM GENE 81220 CFTR GENE COM VARIANTS 81221 CFTR GENE KNOWN FAM VARIANTS 81222 CFTR GENE DUP/DELET VARIANTS 81223 CFTR GENE FULL SEQUENCE 81224 CFTR GENE INTRON POLY T MP 81225 CYP2C19 MP 81226 BRAF MP 81227 CYP2C9 GENE ANALYSIS 81228 CYTOGENOMIC CONSTITUTIONAL (GENOME-WIDE) MICROARRAY ANALYSIS
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 81229 CYTOGENOMIC CONSTITUTIONAL (GENOME-WIDE) MICROARRAY ANALYSIS MP 81240 FMR1 (Fragile X mental retardation 1) MP 81241 FMR1 (Fragile X mental retardation 1) MP 81242 FANCC GENE 81243 FMR1 GENE DETECTION 81244 FMR1 GENE CHARACTERIZATION MP 81250 G6PC GENE MP 81251 GBA GENE MP 81252 GJB2 (GAP JUNCTION PROTEIN, COMMON VARIANTS) MP 81253 GJB2 KNOWN FAMILIAL VARIANTS MP 81254 GJB6 GAP JUNCTION PROTEIN GENE ANALYSIS, COMMON VARIANTS MP 81255 HEXA GENE (TAY SACHS) MP 81256 HFE GENE MP 81257 HBA1/HBA2 GENE MP 81258 HBA1/HBA2 GENE FAM VRNT MP 81259 HBA1/HBA2 FULL GENE SEQUENCE 81260 IKBKAP GENE MP 81265 Comparative analysis using Short Tandem Repeat (STR) markers MP 81266 JAK2 (Janus kinase 2) gene analysis MP 81267 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) MP 81268 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) MP 81269 HBA1/HBA2 GENE DUP/DEL VRNTS MP 81288 MLH1 GENE MP 81290 MCOLN1GENE 81291 MTHFR GENE 81292 MLH1 GENE FULL SEQ 81293 MLH1 GENE KNOWN VARIANTS 81294 MLH1 GENE DUP/DELETE VARIANT MP 81295 MSH2 GENE FULL SEQ MP 81296 MSH2 GENE KNOWN VARIANTS MP 81297 MSH2 GENE DUP/DELETE VARIANT MP 81298 MSH6 GENE FULL SEQ MP 81299 MSH6 GENE KNOWN VARIANTS MP 81300 MSH6 GENE DUP/DELETE VARIANT 81301 MICROSATELLITE INSTABILITY 81302 MECP2 GENE FULL SEQ (RHETTS) 81303 MECP2 GENE KNOWN VARIANT (RHETTS) 81304 MECP2 GENE DUP/DELETE VARIANTS (RHETTS) MP 81317 PMS2 GENE FULL SEQ ANALYSIS MP 81318 PMS2 KNOWN FAMILIAL VARIANTS MP 81319 PMS2 GENE DUP/DELET VARIANTS MP 81324 PMP22 GENE ANALYSIS, DUPLICATION/DELETION
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics MP 81325 PMP22 FULL SEQUENCE ANALYSIS MP 81326 PMP22 KNOWN FAMILIAL VARIANTS MP 81329 Sm1 gene dos/deletion alys 81330 SMPD1 GENE COMMON VARIANTS 81331 SNRPN/UBE3A GENE MP 81332 SERPINA1 GENE MP 81336 Smn1 gene full sequence MP 81337 Smn1 gene known famil seq vmt MP 81355 VKORC1 GENE ANALYSIS MP 81370 HLA Class I and II typing, low resolution MP 81371 HLA Class I and II typing, low resolution; HLA-A, -B, and -DRB1 MP 81372 HLA Class I typing, low resolution MP 81373 HLA Class I typing, low resolution MP 81374 HLA Class I typing, low resolution MP 81375 HLA Class II typing, low resolution MP 81376 HLA Class II typing, low resolution MP 81377 HLA Class II typing, low resolution MP 81378 HLA Class I and II typing, high resolution MP 81379 HLA Class I typing, high resolution MP 81380 Molecular pathology procedure, Level 1 MP 81381 Molecular pathology procedure, Level 2 MP 81382 Molecular pathology procedure, Level 3 MP 81383 Molecular pathology procedure, Level 4 81401 MOPATH PROCEDURE LEVEL 2 81403 MOPATH PROCEDURE LEVEL 4 81406 MOPATH PROCEDURE LEVEL 7 81410 AORTIC DYSFUNCTION/DILATION; GENOMIC SEQUENCE PANEL 81411 AORTIC DYSFUNCTION/DILATION; DUPLICATION/DELETION ANALYSIS PANEL 81412 ASHKENAZI JEWISH DISORDERS 81413 CAR ION CHNNLPATH INC 10 GNS 81414 CAR ION CHNNLPATH INC 2 GNS MP 81415 Exome sequence analysis MP 81416 Exome sequence analysis MP 81417 Exome re-evaluation MP 81425 Genome sequence analysis MP 81426 Genome sequence analysis MP 81427 Genome re-evaluation 81430 HEARING LOSS SEQUENCE ANALYSIS 81431 HEARING DUP/DEL ANALYSIS 81434 HEREDITARY RETINAL PANEL 81439 HRDTRY CARDMYPY GENE PANEL 81440 MITOCHONDRIAL GENE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 81442 NOONAN SPECTRUM DISORDERS 81460 WHOLE MITOCHONDRIAL GENOME; GENOMIC SEQUENCE 81465 WHOLE MITOCHONDRIAL GENOME; LARGE DELETION ANALYSIS 81470 X-LINKED INTELLECTUAL DBLT; GENOMIC SEQUENCE 81471 X-LINKED INTELLECTUAL DBLT; DUPLICATION/DELETION GENE ANALYSIS 81479 UNLISTED MOLECULAR PATHOLOGY MP 81490 Microdissection MP 81595 Antigens from 11 blood groups, utilizing whole blood, common RBC 81599 UNLISTED MAAA 91110 GI TRACT CAPSULE ENDOSCOPY 92506 SPEECH EVAL NIA 92507 Treatment of speech, language, voice, communication; individual NIA 92508 Treatment of speech, language, voice, communication; group NIA 92526 Treatment of swallowing dysfunction and/or oral function NIA 92606 Therapeutic service(s) for the use of non-speech-generating device NIA 92612 Flexible endoscopic eval of swallowing by cine/video recording NIA 92613 Flexible endoscopic eval of swallowing; interpretation/report only NIA 92614 Flexible endoscopic evaluation, laryngeal sensory testing NIA 92615 Flexible endoscopic evaluation, laryngeal sensory testing NIA 92616 Flexible endoscopic eval of swallowing/laryngeal sensory testing NIA 92617 Flexible endoscopic eval of swallowing/laryngeal sensory testing MP 93015 Cardiovascular Stress Test MP 93016 Cardiovascular Stress Test MP 93017 Cardiovascular Stress Test MP 93018 Cardiovascular Stress Test MP 93260 Program device evaluation; implantable subcutaneous lead defib MP 93261 Interrogation device evaluation;implantable subcutaneous lead defib NIA 93320 DOPPLER ECHO EXAM HEART NIA 93321 DOPPLER ECHO EXAM HEART NIA 93325 DOPPLER COLOR FLOW ADD-ON NIA 93350 STRESS TTE ONLY NIA 93351 STRESS TTE COMPLETE NIA 93352 ADMIN ECG CONTRAST AGENT MP 93644 Electrophysiologic evaluation of subcutaneous implantable defib MP 93668 PERIPHERAL ARTERIAL DISEASE (PAD) 95249 AMBULATORY CGM 95250 AMBULATORY CGM 95251 ANALYSIS, INTERPRETATION AND REPORT MP 95782 POLYSOM <6 YRS 4/> PARAMTRS MP 95783 Polysom <6 yrs. Cpap/bilvl MP 95800 SLP STDY UNATTENDED NIA 95851 Range of motion measurements and report
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 95852 Range of motion measurements and report; hand 96001 MOTION TEST W/FT PRESS MEAS 96002 DYNAMIC SURFACE EMG 96040 GENETIC COUNSELING 30 MIN NIA 96105 Assessment of aphasia with interpretation and report, per hour 96118 NEUROPSYCH TST BY PSYCH/PHYS 96119 NEUROPSYCH TESTING BY TEC NIA 96125 Standardized cognitive performance testing; per hour 96130 Psychological testing evaluation services 96131 Psychological testing evaluation services 96136 Psychological or neuropsychological test administration or scoring 96137 Psychological or neuropsychological test administration or scoring 96138 Psychological or neuropsychological test administration or scoring 96139 Psychological or neuropsychological test administration or scoring 96146 Psychological or neuropsychological test administration or scoring NIA 97010 Application of a modality to 1 or more areas; hot or cold packs NIA 97012 Application of a modality to 1 or more areas; traction, mechanical NIA 97014 Application of a modality to 1 or more areas; electrical stim NIA 97016 Application of a modality to 1 or more areas; vasopneumatic devices NIA 97018 Application of a modality to 1 or more areas; paraffin bath NIA 97022 Application of a modality to 1 or more areas; whirlpool NIA 97024 Application of a modality to 1 or more areas; diathermy NIA 97026 Application of a modality to 1 or more areas; infrared NIA 97028 Application of a modality to 1 or more areas; ultraviolet NIA 97032 Application of a modality to 1 or more areas; electrical stim NIA 97033 Application of a modality to 1 or more areas; iontophoresis NIA 97034 Application of a modality to 1 or more areas; contrast baths NIA 97035 Application of a modality to 1 or more areas; ultrasound NIA 97036 Application of a modality to 1 or more areas; Hubbard tank NIA 97039 Unlisted modality (specify type and time if constant attendance) NIA 97110 Therapeutic procedure, 1 or more areas, each 15 minutes NIA 97112 Therapeutic procedure, 1 or more areas, each 15 minutes NIA 97113 Therapeutic procedure, 1 or more areas, each 15 minutes NIA 97116 Therapeutic procedure, 1 or more areas, each 15 minutes NIA 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage NIA 97127 Therapeutic interventions that focus on cognitive function NIA 97129 Therapeutic interventions that focus on cognitive function NIA 97130 Therapeutic interventions that focus on cognitive function NIA 97139 Unlisted therapeutic procedure (specify) NIA 97140 Manual therapy techniques; 1 or more regions, each 15 minutes NIA 97150 Therapeutic procedure(s), group (2 or more individuals) NIA 97530 Therapeutic activities, direct (one-on-one) patient contact
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 97532 COGNITIVE SKILLS DEVELOPMENT NIA 97533 Sensory integrative techniques; direct (one-on-one) patient contact NIA 97535 Self-care/home management training and compensatory training NIA 97537 Community/work reintegration training NIA 97542 Wheelchair management (eg, assessment, fitting, training) NIA 97545 Work hardening/conditioning; initial 2 hours NIA 97546 Work hardening/conditioning; each additional hour NIA 97750 Physical performance test or measurement, with written report NIA 97755 Assistive technology assessment, with written report NIA 97760 Orthotic(s) management and training; upper/lower extremity(s) NIA 97761 Prosthetic training, upper and/or lower extremity(s) NIA 97763 Orthotic prosthetic management and/or training upper/lower MP 97810 Acupuncture, 1 or more needles; without electrical stimulation MP 97813 Acupuncture, 1 or more needles; with electrical stimulation MP 97814 Acupuncture, 1 or more needles; with electrical stimulation MP 98811 Acupuncture, 1 or more needles; without electrical stimulation 98925 OSTEOPATH MANJ 1-2 REGIONS 98926 OSTEOPATH MANJ 3-4 REGIONS 98927 OSTEOPATH MANJ 5-6 REGIONS 98928 OSTEOPATH MANJ 7-8 REGIONS 98929 OSTEOPATH MANJ 9-10 REGIONS 98940 CHIROPRACT MANJ 1-2 REGIONS 98941 CHIROPRACT MANJ 3-4 REGIONS 98942 CHIROPRACTIC MANJ 5 REGIONS MP 0001U RBC DNA HEA 35 AG 11 BLD GRP NIA 0095T Removal of total disc arthroplasty (artificial disc), anterior NIA 0098T Revision including replacement of total disc arthroplasty NIA 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet NIA 0228T Injection(s), anesthetic agent and/or steroid, transforaminal NIA 0229T Injection(s), anesthetic agent and/or steroid, transforaminal NIA 0230T Injection(s), anesthetic agent and/or steroid, transforaminal NIA 0231T Injection(s), anesthetic agent and/or steroid, transforaminal MP 0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS) MP 0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor MP 0447T Removal of implantable interstitial glucose sensor MP 0448T Removal of implantable interstitial glucose sensor MP 0466T Insertion of chest wall respiratory sensor electrode/array
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics MP 0467T Revision/replacement of chest wall respiratory sensor electrode/electrode array, including connection MP 0468T Removal of chest wall respiratory sensor electrode/array 0482T PET SCAN 0548T Transperineal periurethral balloon continence device; bilateral 0549T Transperineal periurethral balloon continence device; unilateral 0550T Transperineal periurethral balloon continence device; removal A0425 Ground mileage, per statute mile A0426 Ambulance service, advanced life support, non-emergency transport level 1 (ALS1) A0427 ALS1- Emergency A0428 Ambulance service, basic life support, non-emergency transport (BLS) A0429 BLS - Emergency A0430 Ambulance service, conventional air services, transport, one way (fixed wing) A0431 Ambulance service, conventional air services, transport, one way (rotary wing) A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company A0433 ALS 2 A0434 Specialty care transport A0435 Fixed wing air mileage, per statute mile A0436 Rotary wing air mileage, per statute mile A0888 Noncovered ambulance mileage A0999 Unlisted ambulance service (e.g., sea ambulance) A4595 TENS 2 LEAD MP A4641 RADIOPHARM DX AGENT NOC MP A6550 Wound care set, for negative pressure wound therapy electrical pump MP A7000 Canister, disposable, used with suction pump, each MP A9272 Wound suction, disposable, includes dressing MP A9500 TC99M SESTAMIBI MP A9501 TECHNETIUM TC99M TEBOROXIME MP A9502 TC99M TETROFOSMIN MP A9505 TL201 THALLIUM MP A9512 TC99M PERTECHNETATE OA A9513 Lutetium lu 177 dotatat ther, 1 millicurie MP A9538 TC99M PYROPHOSPHATE OA A9543 Y90 ibritumomab rx, 40 millicuries MP A9560 TC99M LABELED RBC OA A9600 Sr89 strontium, 1 millicurie OA A9604 Sm 153 lexidronam, 150 MILLICURIES OA A9606 Radium ra223 dichloride ther, 1 microCurie OA A9699 Iodine i-131 iobenguane tx,1 millicurie A9999 MISC DME SUPPLY/ACC NOS OA C9043 Injection levoleucovorin, 1 mg C9741 IMPL PRESSURE SENSOR W/ANGIO E0193 POWERED AIR FLOTATION BED
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics E0265 HOSP BED TOTAL ELECTR W/ MAT E0277 POWERED PRES-REDU AIR MATTRS E0470 RAD W/O BACKUP NON-INV INTFC E0471 RAD W/BACKUP NON INV INTRFC E0483 CHEST COMPRESSION GEN SYSTEM MP E0486 ORAL DEVICE/APPLIANCE MP E0607 Home blood glucose monitor E0617 EXTERNAL DIFIBRILLATOR MP E0620 Skin piercing device for collection of capillary blood, laser, each E0627 SEAT LIFT INCORP LIFT-CHAIR E0652 PNEUM COMPRES W/CAL PRESSURE E0671 PRESSURE PNEUM APPL FULL LEG E0694 UVL MD CABINET SYS 6 FT E0730 TENS FOUR LEAD E0745 NEUROMUSCULAR STIM FOR SHOCK E0747 ELEC OSTEOGEN STIM NOT SPINE E0748 ELEC OSTEOGEN STIM SPINAL E0760 OSTEOGEN ULTRASOUND STIMLTOR E0784 EXT AMB INFUSN PUMP INSULIN E0849 CERVICAL PNEUM TRAC EQUIP E0950 TRAY E0955 CUSHIONED HEADREST E0957 W/C MEDIAL THIGH SUPPORT E0958 WHLCHR ATT- CONV 1 ARM DRIVE E0960 W/C SHOULDER HARNESS/STRAPS E0981 SEAT UPHOLSTERY, REPLACEMENT E0982 BACK UPHOLSTERY, REPLACEMENT E0983 ADD PWR JOYSTICK E0986 MAN W/C PUSH-RIM POW ASSIST E1002 PWR SEAT TILT E1004 PWR SEAT RECLINE MECH E1007 PWR SEAT COMBO W/SHEAR E1008 PWR SEAT COMBO PWR SHEAR E1010 ADD PWR LEG ELEVATION E1014 RECLINING BACK ADD PED W/C E1016 SHOCK ABSORBER FOR POWER W/C E1029 W/C VENT TRAY FIXED E1030 W/C VENT TRAY GIMBALED E1038 TRANSPORT CHAIR PT WT<=300LB E1161 MANUAL ADULT WC W TILTINSPAC E1225 MANUAL SEMI-RECLINING BACK E1230 POWER OPERATED VEHICLE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics E1232 FOLDING PED WC TILT-IN-SPACE E1233 RIG PED WC TLTNSPC W/O SEAT E1234 FLD PED WC TLTNSPC W/O SEAT E1235 RIGID PED WC ADJUSTABLE E1236 FOLDING PED WC ADJUSTABLE E1237 RGD PED WC ADJSTABL W/O SEAT E1238 FLD PED WC ADJSTABL W/O SEAT E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS MP E2100 Blood glucose monitor with integrated voice synthesizer MP E2101 Blood glucose monitor with integrated lacing/blood sample E2201 MAN W/CH ACC SEAT W>=20”<24” E2202 SEAT WIDTH 24-27 IN E2203 FRAME DEPTH LESS THAN 22 IN E2204 FRAME DEPTH 22 TO 25 IN E2205 MANUAL WC ACCESSORY, HANDRIM E2206 COMPLETE WHEEL LOCK ASSEMBLY E2207 CRUTCH AND CANE HOLDER E2208 CYLINDER TANK CARRIER E2209 ARM TROUGH EACH E2211 PNEUMATIC PROPULSION TIRE E2212 PNEUMATIC PROP TIRE TUBE E2213 PNEUMATIC PROP TIRE INSERT E2214 PNEUMATIC CASTER TIRE EACH E2215 PNEUMATIC CASTER TIRE TUBE E2217 FOAM FILLED CASTER TIRE EACH E2218 FOAM PROPULSION TIRE EACH E2219 FOAM CASTER TIRE ANY SIZE EA E2220 SOLID PROPULSION TIRE EACH E2221 SOLID CASTER TIRE EACH E2222 SOLID CASTER INTEGRATED WHL E2224 PROPULSION WHL EXCLUDES TIRE E2225 CASTER WHEEL EXCLUDES TIRE E2226 CASTER FORK REPLACEMENT ONLY E2231 SOLID SEAT SUPPORT BASE E2292 PLANAR SEAT FOR PED SIZE WC E2293 CONTOUR BACK FOR PED SIZE WC E2294 CONTOUR SEAT FOR PED SIZE WC E2310 ELECTRO CONNECT BTW CONTROL E2311 ELECTRO CONNECT BTW 2 SYS E2312 MINI-PROP REMOTE JOYSTICK E2313 PWC HARNESS, EXPAND CONTROL E2321 HAND INTERFACE JOYSTICK
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics E2323 SPECIAL JOYSTICK HANDLE E2326 BREATH TUBE KIT E2328 HEAD/EXTREMITY CONTROL INTER E2330 HEAD CONTROL PROXIMITY SWITC E2331 ATTENDANT CONTROL E2340 W/C WDTH 20-23 IN SEAT FRAME E2342 W/C DPTH 20-21 IN SEAT FRAME E2359 GR34 SEALED LEADACID BATTERY E2361 22NF SEALED LEADACID BATTERY E2362 GR24 NONSEALED LEADACID E2363 GR24 SEALED LEADACID BATTERY E2364 U1NONSEALED LEADACID BATTERY E2365 U1 SEALED LEADACID BATTERY E2366 BATTERY CHARGER, SINGLE MODE E2367 BATTERY CHARGER, DUAL MODE E2368 PWR WC DRIVEWHEEL MOTOR REPL E2369 PWR WC DRIVEWHEEL GEAR REPL E2370 PWR WC DR WH MOTOR/GEAR COMB E2373 HAND/CHIN CTRL SPEC JOYSTICK E2374 HAND/CHIN CTRL STD JOYSTICK E2375 NON-EXPANDABLE CONTROLLER E2376 EXPANDABLE CONTROLLER, REPL E2377 EXPANDABLE CONTROLLER, INITL E2378 PW ACTUATOR REPLACEMENT E2381 PNEUM DRIVE WHEEL TIRE E2382 TUBE, PNEUM WHEEL DRIVE TIRE E2383 INSERT, PNEUM WHEEL DRIVE E2384 PNEUMATIC CASTER TIRE E2388 FOAM DRIVE WHEEL TIRE E2390 SOLID DRIVE WHEEL TIRE E2391 SOLID CASTER TIRE E2394 DRIVE WHEEL EXCLUDES TIRE E2395 CASTER WHEEL EXCLUDES TIRE E2396 CASTER FORK MP E2402 NEG PRESS WOUND THERAPY PUMP MP E2500 Speech generating device, digitized speech MP E2502 Speech generating device, digitized speech MP E2504 Speech generating device, digitized speech MP E2506 Speech generating device, digitized speech MP E2508 Speech generating device, synthesized speech MP E2510 Speech generating device, synthesized speech MP E2511 Speech generating software program
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics MP E2512 Accessory for speech generating device, mounting system MP E2599 Accessory for speech generating device, not otherwise classified E2602 GEN W/C CUSHION WDTH >=22 IN E2603 SKIN PROTECT WC CUS WD <22IN E2604 SKIN PROTECT WC CUS WD>=22IN E2605 POSITION WC CUSH WDTH <22 IN E2606 POSITION WC CUSH WDTH>=22 IN E2607 SKIN PRO/POS WC CUS WD <22IN E2608 SKIN PRO/POS WC CUS WD>=22IN E2609 CUSTOM FABRICATE W/C CUSHION E2612 GEN USE BACK CUSH WDTH>=22IN E2613 POSITION BACK CUSH WD <22IN E2614 POSITION BACK CUSH WD>=22IN E2615 POS BACK POST/LAT WDTH <22IN E2616 POS BACK POST/LAT WDTH>=22IN E2617 CUSTOM FAB W/C BACK CUSHION E2618 WHEELCHAIR ACC, SOLID SEAT SUPP BASE E2619 REPLACE COVER W/C SEAT CUSH E2620 WC PLANAR BACK CUSH WD <22IN E2621 WC PLANAR BACK CUSH WD>=22IN E2622 ADJ SKIN PRO W/C CUS WD<22IN E2623 ADJ SKIN PRO WC CUS WD>=22IN E2624 ADJ SKIN PRO/POS CUS<22IN E2625 ADJ SKIN PRO/POS WC CUS>=22 NIA G0129 Occupational therapy services; per session (45 minutes or more) NIA G0151 Services performed by a qualified physical therapist NIA G0152 Services performed by a qualified occupational therapist NIA G0153 Services performed by a qualified speech-language pathologist G0155 Services of clinical social worker in home health/hospice settings G0156 Services of home health/hospice aide in home health/hospice setting NIA G0260 Injection procedure for sacroiliac joint NIA G0283 Electrical stimulation (unattended) NIA G0289 Arthroscopy, knee, surgical G0299 Direct skilled nursing services of a registered nurse (RN) G0300 Direct skilled nursing services of a licensed practical nurse (LPN) MP G0455 PREP WITH INSTILLATION OF FECAL MICROBIOTA NIA G0515 Development of cognitive skills MP G9143 WARFARIN RESPONSIVENESS TESTING BY GENETIC TECHNIQUE RX J0129 abatacept (Orencia) RX J0135 adalimumab (Humira) MP J0153 ADENOSINE INJ 1 MG RX J0178 Injection, aflibercept, 1 mg
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics RX J0180 agalsidase beta (Fabrazyme) OA J0185 Inj aprepitant, 1 mg RX J0185 Cinvanti RX J0202 alemtuzumab (Lemtrada) OA J0207 Amifostine, 500 MG RX J0221 Lumizyme RX J0222 patisiran (Onpattro) RX J0223 givosiran (Givlaari) RX J0256 alpha 1- proteinase inhibitor (human) (Aralast NP, Prolastin-C, & Zemaira) RX J0270 alprostadil (Caverject & Edex) MP J0395 ARBUTAMINE HCL INJ RX J0490 belimumab (Benlysta) RX J0517 benralizumab (Fasenra & Fasenra Pen) RX J0567 Brineura RX J0584 burosumab-twza (Crysvita) RX J0585 onabotulinumtoxina (Botox) RX J0586 abobotulinumtoxina (Dysport) RX J0587 rimabotulinumtoxinb (Myobloc) RX J0588 incobotulinumtoxin a (Xeomin) RX J0593 lanadelumab-flyo (Takhzyro) OA J0594 Busulfan inj, 1 MG RX J0596 c1 esterase inhibitor recombinant (Ruconest) RX J0597 c-1 esterase inhibitor human (Berinert) RX J0598 c-1 esterase inhibitor human (Cinryze) RX J0599 c-1 esterase inhibitor, human (Haegarda) RX J0630 calcitonin salmon (Miacalcin) RX J0638 canakinumab (Ilaris) OA J0640 Leucovorin calcium inj, 50 MG OA J0641 Levoleucovorin inj, 0.5 MG RX J0717 certolizumab pegol (Cimzia) RX J0775 collagenase, clostridium histolyticum (Xiaflex) RX J0791 crizanlizumab-tmca (Adakveo) RX J0800 corticotropin (Acthar) OA J0881 Darbepoetin alfa non-esrd, 1 MCG RX J0881 Aranesp (non-ERSD) OA J0885 Epoetin alfa non-esrd, 1000 UNITS RX J0885 Epogen (non-ESRD) RX J0888 Mircera (non-ESRD) OA J0894 Decitabine inj, 1 MG RX J0896 luspatercept-aamt (Reblozyl) OA J0897 Denosumab inj, 1 MG RX J0897 denosumab (Prolia; Xgeva)
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics OA J1190 Dexrazoxane HCl inj, 250 MG RX J1201 cetirizine hydrochloride (Quzyttir) MP J1245 DIPYRIDAMOLE INJ MP J1250 INJ DOBUTAMINE HCL/250 MG OA J1260 Dolasetron mesylate, 10 MG RX J1290 ecallantide (Kalbitor) OA J1300 Eculizumab inj, 10 MG RX J1300 Soliris RX J1301 edaravone (Radicava) OA J1303 Ravulizumab-cwv inj, 10 mg RX J1303 Ultomiris RX J1322 Vimizim RX J1428 Exondys 51 RX J1429 golodirsen (Vyondys 53) RX J1437 ferric derisomaltose (Monoferric) RX J1438 etanercept (Enbrel) RX J1439 ferric carboxymaltose (Injectafer) OA J1442 Filgrastim g-csf inj, 1 MCG RX J1442 Neupogen OA J1447 Tbo-filgrastim inj, 1 MCG OA J1453 Fosaprepitant inj, 1 MG RX J1453 Emend OA J1454 Inj fosnetupitant palonoset, 0.25 MG RX J1458 galsulfase (Naglazyme) OA J1459 Ivig privigen inj, 500 MG OA J1460 Gamma globulin inj, 1 CC OA J1555 Inj cuvitru, 100 mg OA J1556 Imm glob bivigam inj, 500 MG OA J1557 Gammaplex inj, 500 MG RX J1558 immune globulin-klhw (Xembify) OA J1559 Hizentra inj, 100 MG RX J1560 immune globulin (Gamastan S/D) OA J1561 Injection, immune globulin, nonlyophilized, 500 mg OA J1566 Injection, immune globulin, intravenous, lyophiliz OA J1568 Octagam inj, 500 MG OA J1569 Gammagard liquid inj, 500 MG OA J1572 Flebogamma inj, 500 MG OA J1575 Hyqvia immuneglobulin, 100 MG OA J1599 Hizentra inj, 100 MG RX J1602 golimumab (Simponi Aria) OA J1626 Granisetron HCl inj, 100 MCG OA J1627 Inj granisetronxr, 0.1 mg
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics RX J1632 brexanolone (Zulresso) RX J1675 histrelin acetate (Vantas) RX J1726 hydroxyprogesterone caproate (Makena) RX J1740 ibandronate sodium (Boniva) RX J1743 idursulfase (Elaprase) RX J1744 icatibant (Firazyr) RX J1745 infliximab (Remicade) RX J1746 ibalizumab-uiyk (Trogarzo) RX J1823 inebilizumab-cdon (Uplizna) OA J1930 Lanreotide inj, 1 MG OA J1950 Leuprolide acetate, 3.75 MG RX J2182 mepolizumab (Nucala) OA J2353 Octreotide depot inj, 1 MG OA J2354 Octreotide non-depot inj, 25 MCG RX J2357 omalizumab (Xolair) OA J2405 Ondansetron HCl inj, 1 MG OA J2425 Palifermin inj, 50 MCG OA J2430 Pamidronate disodium, 30 MG OA J2469 Palonosetron HCl, 25 MCG RX J2502 pasireotide long acting (Signifor LAR) RX J2503 pegaptanib sodium (Macugen) OA J2505 Pegfilgrastim inj, 6 MG RX J2507 pegloticase (Krystexxa) OA J2562 Plerixafor inj, 1 MG RX J2778 ranibizumab (Lucentis) OA J2783 Rasburicase, 0.5 MG RX J2786 reslizumab (Cinqair) RX J2793 rilonacept (Arcalyst) OA J2796 Romiplostim inj, 10 MCG OA J2797 Rolapitant inj, 0.5 mg OA J2820 Sargramostim inj, 50 MCG OA J2860 Siltuximab inj, 10 MG RX J2941 somatropin (Genotropin; Humatrope; Norditropin; Nutropin; Omnitrope; Saizen; Serostim;) RX J3031 fremanezumab-vfrm (Ajovy) RX J3032 eptinezumab-jjmr (Vyepti) RX J3060 taliglucerase alfa (Elelyso) RX J3241 teprotumumab-trbw (Tepezza) RX J3245 tildrakizumab-asmn (Ilumya) RX J3262 tocilizumab (Actemra) RX J3285 treprostinil (Remodulin) OA J3315 Triptorelin pamoate, 3.75 MG OA J3316 Triptorelin xr inj, 3.75 mg
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics RX J3357 ustekinumab (Stelara) RX J3358 ustekinumab (Stelara) RX J3380 vedolizumab (Entyvio) RX J3385 velaglucerase alfa (Vpriv) RX J3396 verteporfin (Visudyne) RX J3397 vestronidase alfa-vjbk (Mepsevii) OA J3489 Zoledronic acid, 1 MG RX J3489 zoledronic acid (Reclast; Zometa) MP J3490 Unclassified drugs RX J3490 inotersen (Tegsedi) RX J3490 leuprolide acetate (Fensolvi) RX J3490 metreleptin (Myalept ) RX J3490 viltolarsen (Viltepso) RX J3490 lumasiran (Oxlumo) RX J3490 setmelanotide (Imcivree) RX J3490 casimersen (Amondys 45) RX J3490 fosdenopterin (Nulibry) MP J3590 Unclassified biologics RX J3590 asfotase alfa (Strensiq) RX J3590 dupilumab (Dupixent) RX J3590 immune globulin-hipp (Cutaquig) RX J3590 ofatumumab (Kesimpta) RX J3590 pegvisomant (Somavert) RX J3590 satralizumab-mqge (Enspryng) RX J3590 evinacumab-dgnb (Evkeeza) RX J7318 hyaluronic acid (Durolane) RX J7320 hyaluronate sodium (Genvisc 850) RX J7321 hyaluronate sodium (Hyalgan & Supartz FX) RX J7322 hyaluronate acid (Hymovis) RX J7323 hyaluronan sodium (Euflexxa) RX J7324 hyaluronic acid (OrthoVisc) RX J7325 Hyaluronan/derivative, Synvisc or Synvisc-One RX J7326 hyaluronate sodium (Gel-One) RX J7327 hyaluronic acid (Monovisc) RX J7328 hyaluronate sodium (Gelsyn-3) RX J7329 hyaluronate sodium (Trivisc) RX J7330 autologous cultured chondrocyte (MACI) RX J7331 sodium Hyaluronate (Synojoynt) RX J7333 hyaluronate sodium (Visco-3) RX J7340 carbidopa/levodopa (Duopa) RX J7351 bimatoprost implant (Durysta) RX J7352 afamelanotide (Scenesse)
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics RX J7401 mometasone furoate sinus implant (Sinuva) OA J7504 Lymphocyte immune globulin, 250 MG RX J7599 voclosporin (Lupkynis) RX J7686 Treprostinil (Tyvaso) RX J8499 monomethyl fumarate (Bafiertam) RX J8499 peanut (Arachis hypogaea) allergen powder-dnfp (Palforzia) RX J8499 risdiplam (Evrysdi) RX J8499 berotralstat (Orladeyo) RX J8499 lonafarnib (Zokinvy) RX J8499 ponesimod (Ponvory) OA J8501 Lymphocyte immune globulin, 250 MG OA J8510 Busulfan oral, 2 MG OA J8520 Capecitabine oral, 150 MG OA J8521 Capecitabine oral, 500 MG OA J8530 Cyclophosphamide oral, 25 MG OA J8560 Etoposide oral, 50 MG RX J8565 gefitinib (Iressa) OA J8600 Melphalan oral, 2 MG OA J8610 Methotrexate oral, 2.5 MG OA J8655 Netupitant palonosetron oral, 0.5 MG OA J8670 Rolapitant oral, 1 mg OA J8700 Temozolomide, 5 MG OA J8705 Topotecan oral, 0.25 mg OA J9000 Doxorubicin HCl inj, 10 MG OA J9015 Aldesleukin inj, 1 EA OA J9017 Arsenic trioxide inj, 1 MG OA J9019 Erwinaze inj, 1000 IU OA J9022 Inj atezolizumab, 10 mg OA J9023 Injection avelumab, 10 mg OA J9025 Azacitidine inj, 1 MG OA J9027 Clofarabine inj, 1 MG OA J9030 Bcg live intravesical, 1 mg OA J9032 Belinostat inj, 10 MG OA J9034 bendeka, 1 mg OA J9035 Injection, bevacizumab, 10 mg OA J9036 Belrapzo inj, 1 mg OA J9039 Blinatumomab inj, 1 MCG OA J9040 Bleomycin sulfate inj, 15 UNITS OA J9041 Bortezomib inj, 0.1 MG OA J9042 Brentuximab vedotin inj, 1 MG OA J9043 Cabazitaxel inj, 1 MG OA J9044 Inj bortezomib nos, 0.1 mg
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics OA J9045 Carboplatin inj, 50 MG OA J9047 Carfilzomib inj, 1 MG OA J9050 Carmustine inj, 100 MG OA J9055 Cetuximab inj, 10 MG OA J9057 Copanlisib inj, 1 mg OA J9060 Cisplatin inj, 10 MG OA J9065 Cladribine inj, 1 MG OA J9070 Cyclophosphamide inj, 100 MG OA J9098 Cytarabine liposome inj, 10 MG OA J9100 Cytarabine HCl inj, 100 MG OA J9118 Calaspargase pegol-mknl, 10 units OA J9119 Chemotherapy drug OA J9120 Dactinomycin inj, 0.5 MG OA J9130 Dacarbazine inj, 100 MG OA J9145 Inj daratumumab, 10 mg OA J9150 Daunorubicin inj, 10 MG OA J9151 Daunorubicin citrate inj, 10 MG OA J9153 Inj daunorubicin cytarabine, 1-2.27 mg OA J9155 Degarelix inj, 1 MG OA J9160 Denileukin diftitox inj, 300 MCG OA J9171 Docetaxel inj, 1 MG OA J9173 Durvalumab inj, 10 mg OA J9176 Inj elotuzumab, 1 mg OA J9178 Epirubicin HCl inj, 2 MG OA J9179 Eribulin mesylate inj, 0.1 MG OA J9181 Etoposide inj, 10 MG OA J9185 Fludarabine phosphate inj, 50 MG OA J9190 Fluorouracil inj, 500 MG OA J9200 Floxuridine inj, 500 MG OA J9201 Gemcitabine HCl inj, 200 MG OA J9202 Goserelin acetate implant, 3.6 MG OA J9203 Gemtuzumab ozogamicin, 0.1 mg OA J9204 Chemotherapy drug OA J9205 irinotecan liposome inj, 1 mg OA J9206 Irinotecan inj, 20 MG OA J9207 Ixabepilone inj, 1 MG OA J9208 Ifosfamide inj, 1 GM OA J9209 Mesna inj, 200 MG OA J9211 Idarubicin HCl inj, 5 MG OA J9214 Interferon alfa-2b inj, 1000000 UNITS OA J9216 Interferon gamma 1-b inj, 3000000 UNITS OA J9217 Leuprolide acetate suspnsion, 7.5 MG
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics OA J9218 Leuprolide acetate inj, 1 MG OA J9219 Leuprolide acetate implant, 65 MG OA J9225 Vantas implant, 50 MG RX J9226 histrelin implant (Supprelin LA) OA J9228 Ipilimumab inj, 1 MG OA J9229 Inotuzumab ozogam inj, 0.1 mg OA J9230 Mechlorethamine HCl inj, 10 MG OA J9245 Melphalan hydrochl inj, 50 MG OA J9250 Methotrexate sodium inj, 5 MG OA J9260 Methotrexate sodium inj, 50 MG OA J9261 Nelarabine inj, 50 MG OA J9262 omacetaxine mep inj, 0.01 mg OA J9263 Oxaliplatin, 0.5 MG OA J9264 Paclitaxel protein bound, 1 MG OA J9266 Pegaspargase inj, 1 EA OA J9267 Paclitaxel inj, 1 MG OA J9268 Pentostatin inj, 10 MG OA J9269 Tagraxofusp-erzs inj, 10 mcg OA J9271 Pembrolizumab inj, 1 MG OA J9280 Mitomycin inj, 5 MG OA J9285 Inj olaratumab, 10 mg OA J9293 Mitoxantrone hydrochl, 5 MG OA J9295 necitumumab injection, 1 mg OA J9299 Nivolumab inj, 1 MG OA J9301 Obinutuzumab inj, 10 MG OA J9302 Ofatumumab inj, 10 MG OA J9303 Panitumumab inj, 10 MG OA J9305 Pemetrexed inj, 10 MG OA J9306 Pertuzumab inj, 1 MG OA J9307 Pralatrexate inj, 1 MG OA J9308 Ramucirumab inj, 5 MG OA J9311 Inj rituximab hyaluronidase, 10 mg OA J9312 Injection, rituximab, 10 mg OA J9313 Inj moxetumomab pasudotox-tdfk, 0.01 mg OA J9315 Romidepsin inj, 1 MG RX J9316 pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo) OA J9320 Streptozocin inj, 1 GM OA J9325 Inj talimogene laherparepvec, 1000000 PFU OA J9328 Temozolomide inj, 1 MG OA J9330 Temsirolimus inj, 1 MG OA J9340 Thiotepa inj, 15 MG OA J9351 Topotecan inj, 0.1 MG
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics OA J9352 Injection trabectedin, 0.1 mg OA J9354 Ado-trastuzumab emt inj, 1 MG OA J9355 Trastuzumab excl biosimi inj, 10 MG OA J9356 Herceptin hylecta inj, 10 mg OA J9357 Valrubicin inj, 200 MG OA J9360 Vinblastine sulfate inj, 1 MG OA J9370 Vincristine sulfate inj, 1 MG OA J9371 Vincristine sul lip inj, 1 MG OA J9390 Vinorelbine tartrate inj, 10 MG OA J9395 Fulvestrant inj, 25 MG OA J9400 Ziv-aflibercept inj, 1 MG OA J9600 Injection, porfimer sodium, 75 mg RX J9999 rituximab-arrx (Riabni) RX J9999 idecabtagene vicleucel (Abecma) K0005 ULTRALIGHTWEIGHT WHEELCHAIR K0006 HEAVY DUTY WHEELCHAIR K0007 EXTRA HEAVY DUTY WHEELCHAIR K0015 DETACH NON-ADJUS HGHT ARMRST K0037 HIGH MOUNT FLIP UP FOOT REST K0042 STANDARD SIZE FOOTPLATE EACH K0047 ELEVAT LEGRST UP HANGR BRACK K0051 CAM RELESE ASSEM FTRST/LGRST K0053 ELEVATE FOOTREST ARTICULATE K0056 SEAT HT <17 OR >=21 LTWT WC K0069 REAR WHL COMPLETE SOLID TIRE K0070 REAR WHL COMPL PNEUM TIRE K0071 FRONT CASTR COMPL PNEUM TIRE K0072 FRNT CSTR CMPL SEM-PNEUM TIR K0108 W/C COMPONENT-ACCESSORY NOS MP K0554 RECIEVER CGM K0606 AED GARMENT W ELEC ANALYSIS K0607 REPL BATT FOR AED K0608 REPL GARMENT FOR AED K0609 REPL ELECTRODE FOR AED K0672 REMOVABLE SOFT INTERFACE LE K0733 12-24HR SEALED LEAD ACID K0800 POV GROUP 1 STD UP TO 300LBS K0801 POV GROUP 1 HD 301-450 LBS K0802 POV GROUP 1 VHD 451-600 LBS K0806 POV GROUP 2 STD UP TO 300LBS K0808 POV GROUP 2 VHD 451-600 LBS K0816 PWC GP 1 STD CAP CHAIR
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics K0821 PWC GP 2 STD PORT CAP CHAIR K0822 PWC GP 2 STD SEAT/BACK K0823 PWC GP 2 STD CAP CHAIR K0824 PWC GP 2 HD SEAT/BACK K0825 PWC GP 2 HD CAP CHAIR K0826 PWC GP 2 VHD SEAT/BACK K0827 PWC GP VHD CAP CHAIR K0835 PWC GP2 STD SING POW OPT S/B K0837 PWC GP 2 HD SING POW OPT S/B K0839 PWC GP2 VHD SING POW OPT S/B K0841 PWC GP2 STD MULT POW OPT S/B K0843 PWC GP2 HD MULT POW OPT S/B K0848 PWC GP 3 STD SEAT/BACK K0849 PWC GP 3 STD CAP CHAIR K0850 PWC GP 3 HD SEAT/BACK K0851 PWC GP 3 HD CAP CHAIR K0856 PWC GP3 STD SING POW OPT S/B K0857 PWC GP3 STD SING POW OPT CAP K0858 PWC GP3 HD SING POW OPT S/B K0861 PWC GP3 STD MULT POW OPT S/B K0862 PWC GP3 HD MULT POW OPT S/B K0902 KO DOUBLE UPRIGHT PRE OTS L1830 KO IMMOB CANVAS LONG PRE OTS L1831 KNEE ORTH POS LOCKING JOINT L1852 Knee orthosis (KO), double upright, thigh and calf L1951 AFO SPIRAL PREFABRICATED L5632 SYMES TYPE PTB BRIM DESIGN S L5814 ENDO KNEE-SHIN HYDRAL SWG PH L6635 LIFT ASSIST FOR ELBOW L6721 HOOK/HAND, HVY DTY, VOL OPEN L7368 LITHIUM ION BATTERY CHARGER MP L7510 PROSTHETIC DEVICE REPAIR L7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES RX Q0138 ferumoxytol (Feraheme) OA Q0162 Ondansetron oral, 1 MG OA Q0166 Granisetron HCl oral, 1 MG OA Q0167 Dronabinol oral, 2.5 MG OA Q0180 Dolasetron mesylate oral, 100 MG OA Q2017 Teniposide, 50 MG OA Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR OA Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells OA Q2043 Sipuleucel-t auto cd54+, 1 infusion
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics OA Q2049 Imported lipodox inj, 10 MG OA Q2050 Doxorubicin inj, 10 MG RX Q4074 Iloprost (Ventavis) OA Q5101 Zarxio inj, 1 MCG RX Q5103 infliximab (Inflectra) RX Q5104 infliximab (Renflexis) OA Q5106 Inj Retacrit non-esrd use, 1000 units OA Q5107 Mvasi inj, 10 mg OA Q5108 Fulphila inj, 0.5 MG RX Q5109 Injection, infliximab-qbtx, biosimilar, (Ixifi), 10 mg OA Q5110 Nivestym, 1 mcg OA Q5111 Udenyca inj, 0.5 mg OA Q5112 Injection, Trastuzumab-dttb, Biosimilar (Ontruzant), 10 mg OA Q5113 Injection, trastuzumab-pkrb, 10 mg OA Q5114 Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg OA Q5115 Injection, rituximab-abbs, 10 mg OA Q5116 Injection, Trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg OA Q5117 Inj., kanjinti, 10 mg OA Q5118 Inj., zirabev, 10 mg RX Q5119 rituximab-pvvr (Ruxience) RX Q5120 pegfilgrastim-bmez (Ziextenzo) RX Q5121 infliximab-axxq (Avsola) RX Q5122 pegfilgrastim-apgf (Nyvepria); Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg RX S0013 esketamine nasal (Spravato) NIA S2118 Metal-on-metal total hip resurfacing NIA S8948 Application of a modality to one or more areas; low-level laser NIA S9128 Speech therapy, in the home, per diem NIA S9129 Occupational therapy, in the home, per diem NIA S9131 Physical therapy; in the home, per diem V2530 CONTACT LENS GAS IMPERMEABLE V2531 CONTACT LENS GAS PERMEABLE
MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics