OFFICE FOR OREGON HEALTH POLICY & RESEARCH Health Evidence Review Commission Kate Brown, Governor

500 Summer St NE, E-65 Salem, OR 97301 Voice (503) 373-1985 FAX (503) 378-5511 September 1, 2016

The Honorable Peter Courtney The Honorable Tina Kotek Senate President Speaker of the House Oregon State Senate Oregon House of Representatives 900 Court St. NE, S-201 900 Court St NE, Rm 269 Salem, OR 97301 Salem, OR 97301

Dear Senator Courtney and Representative Kotek:

The Health Evidence Review Commission of the Oregon Health Authority’s Health Policy & Analytics Division respectfully reports to you that, in accordance with ORS 414.690(7), several interim modifications have been made to the Prioritized List of Health Services appearing in the Health Evidence Review Commission’s May, 2015 Report to the Governor and 78th Oregon Legislative Assembly. In accordance with ORS 414.690(8), the Health Evidence Review Commission is reporting that the revised line items documented in Attachments A and B will supersede the previous definition of these lines. Additionally, the new/revised guideline notes and multisector interventions appearing in Attachments C through G will be associated with the list to better indicate the appropriate and effective use of State resources in the provision of health care to Oregon Health Plan clients.

Attachments A and B document the placement of 1463 new ICD-10-CM diagnosis codes on the Prioritized List. 151 ICD-10 codes and 116 CPT codes were removed from lines as inappropriate pairings; four CPT codes were removed from the list due to evidence of ineffectiveness. 3 HCPCS codes, two ICD-10-CM Codes and six CPT codes were added to the Prioritized List as omissions; one HCPCS code, 137 ICD-10-CM codes and seven CPT codes were moved to more appropriate lines. 12 ICD-10 codes and 14 CPT codes were reclassified and thus removed from the Prioritized List. Seven HCPCS Codes, 142 ICD-10-CM codes and 140 CPT codes were each added to one or more lines to add an appropriate pairing. In addition, Attachment C documents the removal of 224 obsolete ICD-10-CM codes.

In addition to the changes outlined in Attachments A through C, there are some changes being made to practice guidelines and multisector interventions associated with the Prioritized List. Attachment D shows eight new guidelines, Attachment E includes revisions to thirteen existing guidelines and Attachment F lists five deleted guideline notes. Three of these new/revised guidelines involve changes to reflect recent coverage guidances completed by the Health Evidence Review Commission, developed using systematic reviews of the best evidence available from trusted sources on these topics. Finally, Attachment G shows revisions made to the statement on multisector interventions for tobacco prevention and cessation, which was modified to include interventions found to have evidence of effectiveness specifically during pregnancy. With the implementation of ICD-10-CM on October 1, 2015, a number of errata have been made to the list to reflect previously established commission intent. The errata published since the January 1, 2016 Prioritized List appear in Attachment H.

The changes appearing in Attachments A through H are being forwarded to the HSD which, in consultation with the OHA Actuarial Services Unit, will determine if these changes will involve a significant financial impact under the Medicaid Demonstration. If the changes are found to be within the current funding level of the Prioritized List, the HSD will determine the effective date for these changes pending approval from CMS, which will be no earlier than October 1, 2016. In the event any of these technical changes are determined to impact the funding level of the list as defined by HSD’s legislatively authorized budget, we will send a separate notice to you prior to requesting direction from the Joint Ways & Means Committee.

OFFICE FOR OREGON HEALTH POLICY & RESEARCH Health Evidence Review Commission

Kate Brown, Governor

Interim Modifications to the Prioritized List of Health Services 9/1/2016 Page 2

The Health Evidence Review Commission thanks you for the opportunity to continue to serve the citizens of Oregon. Should you have any questions, please feel free to contact the Commission or its staff for clarification.

Respectfully submitted,

Darren D. Coffman Director

Enclosure cc: Health Evidence Review Commission Lynne Saxton, Director, Oregon Health Authority Lori Coyner, State Medicaid Director, Oregon Health Authority Leslie Clement, Director of Policy and Analytics, Oregon Health Authority James Rickards, MD, Chief Medical Officer, Oregon Health Authority BethAnne Darby, External Relations Director, Oregon Health Authority Varsha Chauhan, MD, Chief Health Systems Officer, Oregon Health Authority Mark Fairbanks, Chief Financial Officer, Oregon Health Authority Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 1 Condition: PREGNANCY Treatment: MATERNITY CARE Delete: O33.7 Maternal care for disproportion due to other fetal deformities Add: O33.7XX1 Maternal care for disproportion due to other fetal deformities, fetus 1 Add: O33.7XX2 Maternal care for disproportion due to other fetal deformities, fetus 2 Add: O33.7XX3 Maternal care for disproportion due to other fetal deformities, fetus 3 Add: O33.7XX4 Maternal care for disproportion due to other fetal deformities, fetus 4 Add: O33.7XX5 Maternal care for disproportion due to other fetal deformities, fetus 5 Add: O33.7XX9 Maternal care for disproportion due to other fetal deformities, other fetus Delete: O34.21 Maternal care for scar from previous cesarean delivery Add: O34.211 Maternal care for low transverse scar from previous cesarean delivery Add: O34.212 Maternal care for vertical scar from previous cesarean delivery Add: O34.219 Maternal care for unspecified type scar from previous cesarean delivery Add: O44.20 Partial placenta previa NOS or without hemorrhage, unspecified trimester Add: O44.21 Partial placenta previa NOS or without hemorrhage, first trimester Add: O44.22 Partial placenta previa NOS or without hemorrhage, second trimester Add: O44.23 Partial placenta previa NOS or without hemorrhage, third trimester Add: O44.30 Partial placenta previa with hemorrhage, unspecified trimester Add: O44.31 Partial placenta previa with hemorrhage, first trimester Add: O44.32 Partial placenta previa with hemorrhage, second trimester Add: O44.33 Partial placenta previa with hemorrhage, third trimester Add: O44.40 Low lying placenta NOS or without hemorrhage, unspecified trimester Add: O44.41 Low lying placenta NOS or without hemorrhage, first trimester Add: O44.42 Low lying placenta NOS or without hemorrhage, second trimester Add: O44.43 Low lying placenta NOS or without hemorrhage, third trimester Add: O44.50 Low lying placenta with hemorrhage, unspecified trimester Add: O44.51 Low lying placenta with hemorrhage, first trimester Add: O44.52 Low lying placenta with hemorrhage, second trimester Add: O44.53 Low lying placenta with hemorrhage, third trimester Delete: O70.2 Third degree perineal laceration during delivery Add: O70.20 Third degree perineal laceration during delivery, unspecified Add: O70.21 Third degree perineal laceration during delivery, IIIa Add: O70.22 Third degree perineal laceration during delivery, IIIb Add: O70.23 Third degree perineal laceration during delivery, IIIc Add: Z29.13 Encounter for prophylactic Rho(D) immune globulin Add: 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Add: 12042 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Add: 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Add: 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm

Line: 2 Condition: BIRTH OF INFANT Treatment: NEWBORN CARE Add: P05.01 Newborn light for gestational age, less than 500 grams Add: P05.02 Newborn light for gestational age, 500-749 grams Add: P05.03 Newborn light for gestational age, 750-999 grams Add: P05.04 Newborn light for gestational age, 1000-1249 grams Add: P05.05 Newborn light for gestational age, 1250-1499 grams Add: P05.06 Newborn light for gestational age, 1500-1749 grams Add: P05.07 Newborn light for gestational age, 1750-1999 grams Add: P05.08 Newborn light for gestational age, 2000-2499 grams Add: P05.09 Newborn light for gestational age, 2500 grams and over Add: P05.11 Newborn small for gestational age, less than 500 grams Add: P05.12 Newborn small for gestational age, 500-749 grams Add: P05.13 Newborn small for gestational age, 750-999 grams Add: P05.14 Newborn small for gestational age, 1000-1249 grams Add: P05.15 Newborn small for gestational age, 1250-1499 grams Add: P05.16 Newborn small for gestational age, 1500-1749 grams Add: P05.17 Newborn small for gestational age, 1750-1999 grams Add: P05.18 Newborn small for gestational age, 2000-2499 grams Add: P05.19 Newborn small for gestational age, other Add: P05.2 Newborn affected by fetal (intrauterine) malnutrition not light or small for gestational age Add: Z05.0 Observation and evaluation of newborn for suspected cardiac condition ruled out

Page A-1 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: Z05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Add: Z05.2 Observation and evaluation of newborn for suspected neurological condition ruled out Add: Z05.3 Observation and evaluation of newborn for suspected respiratory condition ruled out Add: Z05.41 Observation and evaluation of newborn for suspected genetic condition ruled out Add: Z05.42 Observation and evaluation of newborn for suspected metabolic condition ruled out Add: Z05.43 Observation and evaluation of newborn for suspected immunologic condition ruled out Add: Z05.5 Observation and evaluation of newborn for suspected gastrointestinal condition ruled out Add: Z05.6 Observation and evaluation of newborn for suspected genitourinary condition ruled out Add: Z05.71 Observation and evaluation of newborn for suspected skin and subcutaneous tissue condition ruled out Add: Z05.72 Observation and evaluation of newborn for suspected musculoskeletal condition ruled out Add: Z05.73 Observation and evaluation of newborn for suspected connective tissue condition ruled out Add: Z05.8 Observation and evaluation of newborn for other specified suspected condition ruled out Add: Z05.9 Observation and evaluation of newborn for unspecified suspected condition ruled out

Line: 3 Condition: PREVENTION SERVICES WITH EVIDENCE OF EFFECTIVENESS Treatment: MEDICAL THERAPY Add: Z13.5 Encounter for screening for eye and ear disorders Add: Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV) Add: Z29.12 Encounter for prophylactic antivenin Add: Z29.14 Encounter for prophylactic rabies immune globin Add: Z29.8 Encounter for other specified prophylactic measures Add: 96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Add: 96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Add: 96152 Health and behavior intervention, each 15 minutes, face-to-face; individual Add: 96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Add: 96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)

Line: 4 Condition: SUBSTANCE USE DISORDER Treatment: MEDICAL/PSYCHOTHERAPY Add: G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention 15 to 30 minutes Add: G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and intervention, greater than 30 minutes Add: H0032 Mental health service plan development by non-physician Delete: 99184 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

Line: 6 Condition: REPRODUCTIVE SERVICES Treatment: CONTRACEPTION MANAGEMENT; STERILIZATION Add: Z30.015 Encounter for initial prescription of vaginal ring hormonal contraceptive Add: Z30.016 Encounter for initial prescription of transdermal patch hormonal contraceptive device Add: Z30.017 Encounter for initial prescription of implantable subdermal contraceptive Add: Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Add: Z30.45 Encounter for surveillance of transdermal patch hormonal contraceptive device Add: Z30.46 Encounter for surveillance of implantable subdermal contraceptive

Page A-2 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 7 Condition: MAJOR DEPRESSION, RECURRENT; MAJOR DEPRESSION, SINGLE EPISODE, SEVERE Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 8 Condition: TYPE 1 DIABETES MELLITUS Treatment: MEDICAL THERAPY Delete: E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Delete: E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Delete: E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Delete: E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Delete: E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Delete: E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Delete: E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema Delete: E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: 92250 Fundus photography with interpretation and report

Line: 9 Condition: ASTHMA Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 11 Condition: RESPIRATORY CONDITIONS OF FETUS AND NEWBORN Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 17 Condition: VERY LOW BIRTH WEIGHT (UNDER 1500 GRAMS) Treatment: MEDICAL THERAPY Add: 92227 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Add: 92228 Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral

Line: 20 Condition: HYDROCEPHALUS AND BENIGN INTRACRANIAL HYPERTENSION Treatment: MEDICAL AND SURGICAL TREATMENT Add: 61120 Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material)

Line: 23 Condition: LOW BIRTH WEIGHT (1500-2500 GRAMS) Treatment: MEDICAL THERAPY Add: 92227 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Add: 92228 Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral

Line: 24 Condition: CYSTIC FIBROSIS Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Page A-3 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 25 Condition: VESICOURETERAL REFLUX Treatment: MEDICAL THERAPY, SURGERY Add: 50605 Ureterotomy for insertion of indwelling stent, all types

Line: 26 Condition: SCHIZOPHRENIC DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 29 Condition: BIPOLAR DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 30 Condition: TYPE 2 DIABETES MELLITUS Treatment: MEDICAL THERAPY, BARIATRIC SURGERY WITH BMI >= 35 Delete: E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema Add: E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema Add: E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema Add: E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema Add: E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

Page A-4 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema Add: E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema Add: E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema Add: E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye Add: E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye Add: E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral Add: E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye Add: E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye Add: E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral Add: E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye Delete: E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema Add: E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye Add: E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye

Page A-5 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral Add: E08.3599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye Add: E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye Add: E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral Add: E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye Delete: E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3319 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3399 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

Page A-6 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E09.3519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E09.3539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E09.3549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E09.3559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E09.3599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Add: E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Add: E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Add: E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

Page A-7 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Add: E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Add: E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Add: E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Add: E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Add: E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Delete: E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

Page A-8 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

Page A-9 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Delete: E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

Page A-10 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E13.37X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Add: 92250 Fundus photography with interpretation and report

Line: 32 Condition: REGIONAL ENTERITIS, IDIOPATHIC PROCTOCOLITIS, ULCERATION OF INTESTINE Treatment: MEDICAL AND SURGICAL TREATMENT Add: K52.3 Indeterminate colitis

Line: 41 Condition: ECTOPIC PREGNANCY; HYDATIDIFORM MOLE; CHORIOCARCINOMA Treatment: MEDICAL AND SURGICAL TREATMENT Delete: O00.0 Abdominal pregnancy Delete: O00.1 Tubal pregnancy Delete: O00.2 Ovarian pregnancy Delete: O00.8 Other ectopic pregnancy Delete: O00.9 Ectopic pregnancy, unspecified

Line: 46 Condition: INTUSSCEPTION, VOLVULUS, INTESTINAL OBSTRUCTION, HAZARDOUS FOREIGN BODY IN GI TRACT WITH RISK OF PERFORATION OR OBSTRUCTION Treatment: MEDICAL AND SURGICAL TREATMENT Delete: K59.3 Megacolon, not elsewhere classified Add: K59.31 Toxic megacolon Add: K59.39 Other megacolon

Line: 48 Condition: COARCTATION OF THE AORTA Treatment: SURGICAL TREATMENT Delete: Q25.2 Atresia of aorta Add: Q25.29 Other atresia of aorta Delete: Q25.4 Other congenital malformations of aorta Add: Q25.40 Congenital malformation of aorta unspecified Add: Q25.41 Absence and aplasia of aorta Add: Q25.42 Hypoplasia of aorta Add: Q25.45 Double aortic arch

Page A-11 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: Q25.46 Tortuous aortic arch Add: Q25.48 Anomalous origin of subclavian artery Add: Q25.49 Other congenital malformations of aorta

Line: 50 Condition: RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY POLYARTHROPATHIES Treatment: MEDICAL THERAPY, INJECTIONS Delete: M45.0 Ankylosing spondylitis of multiple sites in spine Delete: M45.1 Ankylosing spondylitis of occipito-atlanto-axial region Delete: M45.2 Ankylosing spondylitis of cervical region Delete: M45.3 Ankylosing spondylitis of cervicothoracic region Delete: M45.4 Ankylosing spondylitis of thoracic region Delete: M45.5 Ankylosing spondylitis of thoracolumbar region Delete: M45.6 Ankylosing spondylitis lumbar region Delete: M45.7 Ankylosing spondylitis of lumbosacral region Delete: M45.8 Ankylosing spondylitis sacral and sacrococcygeal region Delete: M45.9 Ankylosing spondylitis of unspecified sites in spine Delete: M46.50 Other infective spondylopathies, site unspecified Delete: M46.51 Other infective spondylopathies, occipito-atlanto-axial region Delete: M46.52 Other infective spondylopathies, cervical region Delete: M46.53 Other infective spondylopathies, cervicothoracic region Delete: M46.54 Other infective spondylopathies, thoracic region Delete: M46.55 Other infective spondylopathies, thoracolumbar region Delete: M46.56 Other infective spondylopathies, lumbar region Delete: M46.57 Other infective spondylopathies, lumbosacral region Delete: M46.58 Other infective spondylopathies, sacral and sacrococcygeal region Delete: M46.59 Other infective spondylopathies, multiple sites in spine Delete: M46.80 Other specified inflammatory spondylopathies, site unspecified Delete: M46.81 Other specified inflammatory spondylopathies, occipito-atlanto-axial region Delete: M46.82 Other specified inflammatory spondylopathies, cervical region Delete: M46.83 Other specified inflammatory spondylopathies, cervicothoracic region Delete: M46.84 Other specified inflammatory spondylopathies, thoracic region Delete: M46.85 Other specified inflammatory spondylopathies, thoracolumbar region Delete: M46.86 Other specified inflammatory spondylopathies, lumbar region Delete: M46.87 Other specified inflammatory spondylopathies, lumbosacral region Delete: M46.88 Other specified inflammatory spondylopathies, sacral and sacrococcygeal region Delete: M46.89 Other specified inflammatory spondylopathies, multiple sites in spine Delete: M46.90 Unspecified inflammatory spondylopathy, site unspecified Delete: M46.91 Unspecified inflammatory spondylopathy, occipito-atlanto-axial region Delete: M46.92 Unspecified inflammatory spondylopathy, cervical region Delete: M46.93 Unspecified inflammatory spondylopathy, cervicothoracic region Delete: M46.94 Unspecified inflammatory spondylopathy, thoracic region Delete: M46.95 Unspecified inflammatory spondylopathy, thoracolumbar region Delete: M46.96 Unspecified inflammatory spondylopathy, lumbar region Delete: M46.97 Unspecified inflammatory spondylopathy, lumbosacral region Delete: M46.98 Unspecified inflammatory spondylopathy, sacral and sacrococcygeal region Delete: M46.99 Unspecified inflammatory spondylopathy, multiple sites in spine

Line: 51 Condition: DEEP ABSCESSES, INCLUDING APPENDICITIS AND PERIORBITAL ABSCESS Treatment: MEDICAL AND SURGICAL TREATMENT Add: M46.30 Infection of intervertebral disc (pyogenic), site unspecified Add: M46.31 Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region Add: M46.32 Infection of intervertebral disc (pyogenic), cervical region Add: M46.33 Infection of intervertebral disc (pyogenic), cervicothoracic region Add: M46.34 Infection of intervertebral disc (pyogenic), thoracic region Add: M46.35 Infection of intervertebral disc (pyogenic), thoracolumbar region Add: M46.36 Infection of intervertebral disc (pyogenic), lumbar region Add: M46.37 Infection of intervertebral disc (pyogenic), lumbosacral region Add: M46.38 Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region Add: M46.39 Infection of intervertebral disc (pyogenic), multiple sites in spine Add: 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach Add: 39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy Page A-12 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 52 Condition: CHRONIC RESPIRATORY DISEASE ARISING IN THE NEONATAL PERIOD Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 53 Condition: CONGENITAL HYDRONEPHROSIS Treatment: NEPHRECTOMY/REPAIR Add: 50760 Ureteroureterostomy Add: 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder Add: 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder Add: 50783 Ureteroneocystostomy; with extensive ureteral tailoring Add: 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap Add: 50860 Ureterostomy, transplantation of ureter to skin

Line: 57 Condition: PREVENTIVE DENTAL SERVICES Treatment: CLEANING, FLUORIDE AND SEALANTS Add: Z29.3 Encounter for prophylactic fluoride administration

Line: 60 Condition: ULCERS, GASTRITIS, DUODENITIS, AND GI HEMORRHAGE Treatment: MEDICAL AND SURGICAL TREATMENT Add: P54.1 Neonatal melena Add: P54.2 Neonatal rectal hemorrhage Add: P54.3 Other neonatal gastrointestinal hemorrhage Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 65 Condition: TORSION OF OVARY Treatment: OOPHORECTOMY, OVARIAN CYSTECTOMY Delete: N83.51 Torsion of ovary and ovarian pedicle Delete: N83.52 Torsion of fallopian tube

Line: 66 Condition: SUBSTANCE-INDUCED MOOD, ANXIETY, DELUSIONAL AND OBSESSIVE-COMPULSIVE DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Add: H0006 Alcohol and/or drug services; case management Add: H0032 Mental health service plan development by non-physician Delete: 99184 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

Line: 69 Condition: SUBSTANCE-INDUCED DELIRIUM; SUBSTANCE INTOXICATION AND WITHDRAWAL Treatment: MEDICAL/PSYCHOTHERAPY Add: H0032 Mental health service plan development by non-physician

Line: 70 Condition: LARYNGEAL STENOSIS OR PARALYSIS WITH AIRWAY COMPLICATIONS Treatment: INCISION/EXCISION/ENDOSCOPY Add: 31570 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; Add: 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope Add: 31590 Laryngeal reinnervation by neuromuscular pedicle

Page A-13 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Add: 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals Add: 92524 Behavioral and qualitative analysis of voice and resonance

Line: 75 Condition: NEUROLOGICAL DYSFUNCTION IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL CAUSED BY CHRONIC CONDITIONS; ATTENTION TO OSTOMIES Treatment: MEDICAL AND SURGICAL TREATMENT (EG. G-TUBES, J-TUBES, RESPIRATORS, TRACHEOSTOMY, UROLOGICAL PROCEDURES) Add: G61.82 Multifocal motor neuropathy Delete: G96.8 Other specified disorders of central nervous system Add: G97.61 Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure Add: G97.62 Postprocedural hematoma of a nervous system organ or structure following other procedure Add: G97.63 Postprocedural seroma of a nervous system organ or structure following a nervous system procedure Add: G97.64 Postprocedural seroma of a nervous system organ or structure following other procedure Delete: G98.8 Other disorders of nervous system Delete: I69.01 Cognitive deficits following nontraumatic subarachnoid hemorrhage Add: I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage Add: I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage Add: I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage Add: I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage Add: I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage Add: I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage Add: I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage Delete: I69.11 Cognitive deficits following nontraumatic intracerebral hemorrhage Add: I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage Add: I69.111 Memory deficit following nontraumatic intracerebral hemorrhage Add: I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage Add: I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage Add: I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage Add: I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage Add: I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage Delete: I69.21 Cognitive deficits following other nontraumatic intracranial hemorrhage Add: I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage Add: I69.211 Memory deficit following other nontraumatic intracranial hemorrhage Add: I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage Add: I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage Add: I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage Add: I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage Add: I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage Delete: I69.31 Cognitive deficits following cerebral infarction Add: I69.310 Attention and concentration deficit following cerebral infarction Add: I69.311 Memory deficit following cerebral infarction Add: I69.312 Visuospatial deficit and spatial neglect following cerebral infarction Add: I69.313 Psychomotor deficit following cerebral infarction Add: I69.314 Frontal lobe and executive function deficit following cerebral infarction Add: I69.315 Cognitive social or emotional deficit following cerebral infarction Add: I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction Delete: I69.81 Cognitive deficits following other cerebrovascular disease Add: I69.810 Attention and concentration deficit following other cerebrovascular disease Add: I69.811 Memory deficit following other cerebrovascular disease Add: I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease Add: I69.813 Psychomotor deficit following other cerebrovascular disease Add: I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease Add: I69.815 Cognitive social or emotional deficit following other cerebrovascular disease Add: I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease Delete: I69.91 Cognitive deficits following unspecified cerebrovascular disease Add: I69.910 Attention and concentration deficit following unspecified cerebrovascular disease Add: I69.911 Memory deficit following unspecified cerebrovascular disease Add: I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease Add: I69.913 Psychomotor deficit following unspecified cerebrovascular disease Add: I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease Add: I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease

Page A-14 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Delete: P05.01 Newborn light for gestational age, less than 500 grams Delete: P05.02 Newborn light for gestational age, 500-749 grams Delete: P05.03 Newborn light for gestational age, 750-999 grams Delete: P05.04 Newborn light for gestational age, 1000-1249 grams Delete: P05.05 Newborn light for gestational age, 1250-1499 grams Delete: P05.06 Newborn light for gestational age, 1500-1749 grams Delete: P05.07 Newborn light for gestational age, 1750-1999 grams Delete: P05.08 Newborn light for gestational age, 2000-2499 grams Delete: P05.11 Newborn small for gestational age, less than 500 grams Delete: P05.12 Newborn small for gestational age, 500-749 grams Delete: P05.13 Newborn small for gestational age, 750-999 grams Delete: P05.14 Newborn small for gestational age, 1000-1249 grams Delete: P05.15 Newborn small for gestational age, 1250-1499 grams Delete: P05.16 Newborn small for gestational age, 1500-1749 grams Delete: P05.17 Newborn small for gestational age, 1750-1999 grams Delete: P05.18 Newborn small for gestational age, 2000-2499 grams Delete: P05.2 Newborn affected by fetal (intrauterine) malnutrition not light or small for gestational age Delete: P54.0 Neonatal hematemesis Delete: P55.0 Rh isoimmunization of newborn Add: Q87.82 Arterial tortuosity syndrome Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Line: 80 Condition: HYPERTENSION AND HYPERTENSIVE DISEASE Treatment: MEDICAL THERAPY Add: I16.0 Hypertensive urgency Add: I16.1 Hypertensive emergency Add: I16.9 Hypertensive crisis, unspecified

Line: 82 Condition: INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES AND NECK Treatment: LIGATION/REPAIR Add: 35261 Repair blood vessel with graft other than vein; neck

Line: 84 Condition: INJURY TO INTERNAL ORGANS Treatment: MEDICAL AND SURGICAL TREATMENT Add: 47534 Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; internal-external Add: 47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation Add: 47536 Exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal-external to external only), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

Line: 85 Condition: FRACTURE OF HIP Treatment: MEDICAL AND SURGICAL TREATMENT Add: M84.359D Stress fracture, hip, unspecified, subsequent encounter for fracture with routine healing Add: M84.359G Stress fracture, hip, unspecified, subsequent encounter for fracture with delayed healing Add: M84.659A Pathological fracture in other disease, hip, unspecified, initial encounter for fracture Add: M84.659D Pathological fracture in other disease, hip, unspecified, subsequent encounter for fracture with routine healing Add: M84.659G Pathological fracture in other disease, hip, unspecified, subsequent encounter for fracture with delayed healing

Page A-15 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 91 Condition: CONGENITAL ANOMALIES OF GENITOURINARY SYSTEM Treatment: RECONSTRUCTION Add: Q60.3 Renal hypoplasia, unilateral Add: Q62.4 Agenesis of ureter Add: Q62.5 Duplication of ureter Add: Q62.60 Malposition of ureter, unspecified Add: Q62.61 Deviation of ureter Add: Q62.62 Displacement of ureter Add: Q63.0 Accessory kidney Add: Q63.1 Lobulated, fused and horseshoe kidney Add: Q63.2 Ectopic kidney Add: Q63.3 Hyperplastic and giant kidney Add: Q63.8 Other specified congenital malformations of kidney Add: Q63.9 Congenital malformation of kidney, unspecified Add: 50605 Ureterotomy for insertion of indwelling stent, all types Add: 50760 Ureteroureterostomy Add: 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder Add: 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder Add: 50783 Ureteroneocystostomy; with extensive ureteral tailoring Add: 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap Add: 50860 Ureterostomy, transplantation of ureter to skin

Line: 92 Condition: NECROTIZING ENTEROCOLITIS IN FETUS OR NEWBORN Treatment: MEDICAL AND SURGICAL TREATMENT Add: K55.30 Necrotizing enterocolitis, unspecified Add: K55.31 Stage 1 necrotizing enterocolitis Add: K55.32 Stage 2 necrotizing enterocolitis Add: K55.33 Stage 3 necrotizing enterocolitis

Line: 96 Condition: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH PERSISTENT SYMPTOMS Treatment: MEDICAL AND SURGICAL TREATMENT Add: S02.101A Fracture of base of skull, right side, initial encounter for closed fracture Add: S02.101B Fracture of base of skull, right side, initial encounter for open fracture Add: S02.101D Fracture of base of skull, right side, subsequent encounter for fracture with routine healing Add: S02.101G Fracture of base of skull, right side, subsequent encounter for fracture with delayed healing Add: S02.101S Fracture of base of skull, right side, sequela Add: S02.102A Fracture of base of skull, left side, initial encounter for closed fracture Add: S02.102B Fracture of base of skull, left side, initial encounter for open fracture Add: S02.102D Fracture of base of skull, left side, subsequent encounter for fracture with routine healing Add: S02.102G Fracture of base of skull, left side, subsequent encounter for fracture with delayed healing Add: S02.109A Fracture of base of skull, unspecified side, initial encounter for closed fracture Add: S02.109B Fracture of base of skull, unspecified side, initial encounter for open fracture Add: S02.109D Fracture of base of skull, unspecified side, subsequent encounter for fracture with routine healing Add: S02.109G Fracture of base of skull, unspecified side, subsequent encounter for fracture with delayed healing Delete: S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture Delete: S02.10XB Unspecified fracture of base of skull, initial encounter for open fracture Delete: S02.10XD Unspecified fracture of base of skull, subsequent encounter for fracture with routine healing Delete: S02.10XG Unspecified fracture of base of skull, subsequent encounter for fracture with delayed healing Add: S02.11AA Type I occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11AB Type I occipital condyle fracture, right side, initial encounter for open fracture Add: S02.11AD Type I occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11AG Type I occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.11BA Type I occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11BB Type I occipital condyle fracture, left side, initial encounter for open fracture Add: S02.11BD Type I occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11BG Type I occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11CA Type II occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11CB Type II occipital condyle fracture, right side, initial encounter for open fracture Add: S02.11CD Type II occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11CG Type II occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Page A-16 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S02.11DA Type II occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11DB Type II occipital condyle fracture, left side, initial encounter for open fracture Add: S02.11DD Type II occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11DG Type II occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11EA Type III occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11EB Type III occipital condyle fracture, right side, initial encounter for open fracture Add: S02.11ED Type III occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11EG Type III occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.11FA Type III occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11FB Type III occipital condyle fracture, left side, initial encounter for open fracture Add: S02.11FD Type III occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11FG Type III occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11GA Other fracture of occiput, right side, initial encounter for closed fracture Add: S02.11GB Other fracture of occiput, right side, initial encounter for open fracture Add: S02.11GD Other fracture of occiput, right side, subsequent encounter for fracture with routine healing Add: S02.11GG Other fracture of occiput, right side, subsequent encounter for fracture with delayed healing Add: S02.11HA Other fracture of occiput, left side, initial encounter for closed fracture Add: S02.11HB Other fracture of occiput, left side, initial encounter for open fracture Add: S02.11HD Other fracture of occiput, left side, subsequent encounter for fracture with routine healing Add: S02.11HG Other fracture of occiput, left side, subsequent encounter for fracture with delayed healing Add: S02.80XA Fracture of other specified skull and facial bones, unspecified side, initial encounter for closed fracture Add: S02.80XB Fracture of other specified skull and facial bones, unspecified side, initial encounter for open fracture Add: S02.80XD Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with routine healing Add: S02.80XG Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.81XA Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture Add: S02.81XB Fracture of other specified skull and facial bones, right side, initial encounter for open fracture Add: S02.81XD Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with routine healing Add: S02.81XG Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with delayed healing Add: S02.82XA Fracture of other specified skull and facial bones, left side, initial encounter for closed fracture Add: S02.82XB Fracture of other specified skull and facial bones, left side, initial encounter for open fracture Add: S02.82XD Fracture of other specified skull and facial bones, left side, subsequent encounter for fracture with routine healing Add: S02.82XG Fracture of other specified skull and facial bones, left side, subsequent encounter for fracture with delayed healing Delete: S02.8XXA Fractures of other specified skull and facial bones, initial encounter for closed fracture Delete: S02.8XXB Fractures of other specified skull and facial bones, initial encounter for open fracture Delete: S02.8XXD Fractures of other specified skull and facial bones, subsequent encounter for fracture with routine healing Delete: S02.8XXG Fractures of other specified skull and facial bones, subsequent encounter for fracture with delayed healing Delete: S06.0X2A Concussion with loss of consciousness of 31 minutes to 59 minutes, initial encounter Delete: S06.0X2D Concussion with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter Delete: S06.0X3A Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter Delete: S06.0X3D Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter Delete: S06.0X4A Concussion with loss of consciousness of 6 hours to 24 hours, initial encounter Delete: S06.0X4D Concussion with loss of consciousness of 6 hours to 24 hours, subsequent encounter Delete: S06.0X5A Concussion with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter Delete: S06.0X5D Concussion with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter Delete: S06.0X6A Concussion with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter Delete: S06.0X6D Concussion with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter Delete: S06.0X7A Concussion with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter Delete: S06.0X7D Concussion with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, subsequent encounter Delete: S06.0X8A Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter Delete: S06.0X8D Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, subsequent encounter

Page A-17 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 97 Condition: CHILDHOOD LEUKEMIAS Treatment: MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex

Line: 98 Condition: UNDESCENDED TESTICLE Treatment: SURGICAL TREATMENT Add: Q55.22 Retractile testis

Line: 100 Condition: DIABETIC AND OTHER RETINOPATHY Treatment: MEDICAL, SURGICAL, AND LASER TREATMENT Delete: E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema Add: E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema Add: E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema Add: E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema Add: E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema Add: E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral Page A-18 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema Add: E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema Add: E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye Add: E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye Add: E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral Add: E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye Add: E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye Add: E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral Add: E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye Delete: E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema Add: E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye Add: E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye Add: E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral Add: E08.3599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye Add: E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye Add: E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral

Page A-19 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye Delete: E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3319 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3399 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E09.3419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E09.3499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

Page A-20 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E09.3519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E09.3539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E09.3549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E09.3559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E09.3599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Delete: E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

Page A-21 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye Delete: E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

Page A-22 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

Page A-23 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Add: E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Add: E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Add: E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Add: E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Add: E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye Add: E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye Add: E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral Add: E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye Delete: E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Add: E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye Add: E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye Add: E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral Add: E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye Delete: E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema Add: E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye Add: E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye Add: E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral Add: E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye Add: E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

Page A-24 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye Add: E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye Add: E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral Add: E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye Delete: E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Add: E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye Add: E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye Add: E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral Add: E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye Add: E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye Add: E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye Add: E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral Add: E13.37X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

Line: 101 Condition: BORDERLINE PERSONALITY DISORDER Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 106 Condition: HEMOLYTIC DISEASE DUE TO ISOIMMUNIZATION, ANEMIA DUE TO TRANSPLACENTAL HEMORRHAGE, AND FETAL AND NEONATAL JAUNDICE Treatment: MEDICAL THERAPY Delete: E80.4 Gilbert syndrome Delete: E80.6 Other disorders of bilirubin metabolism Delete: E80.7 Disorder of bilirubin metabolism, unspecified Delete: P54.1 Neonatal melena Delete: P54.2 Neonatal rectal hemorrhage Delete: P54.3 Other neonatal gastrointestinal hemorrhage

Line: 107 Condition: POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTS Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens

Line: 122 Condition: NUTRITIONAL DEFICIENCIES Treatment: MEDICAL THERAPY Delete: D62 Acute posthemorrhagic anemia Add: E50.0 Vitamin A deficiency with conjunctival xerosis Add: E50.1 Vitamin A deficiency with Bitot's spot and conjunctival xerosis Add: E50.2 Vitamin A deficiency with corneal xerosis Add: E50.3 Vitamin A deficiency with corneal ulceration and xerosis Add: 99184 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

Page A-25 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) Add: 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99224 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 physicians, other qualified health care professionals, 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. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99225 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 physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99226 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 physicians, other qualified health care professionals, 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. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

Page A-26 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99232 Subsequent hospital 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 physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99233 Subsequent hospital 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 physicians, other qualified health care professionals, 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. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99236 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit. Add: 99238 Hospital discharge day management; 30 minutes or less Add: 99239 Hospital discharge day management; more than 30 minutes Add: 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Add: 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) Add: 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit.

Page A-27 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99308 Subsequent nursing facility 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 low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99309 Subsequent nursing facility 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 moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99315 Nursing facility discharge day management; 30 minutes or less Add: 99316 Nursing facility discharge day management; more than 30 minutes Add: 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient's facility floor or unit. Add: 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. Add: 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. Add: 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. Add: 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. Add: 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver.

Page A-28 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. Add: 99335 Domiciliary or rest home visit for the evaluation and management of an established 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 low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. Add: 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. Add: 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Add: 99339 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Add: 99340 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Add: 99379 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Add: 99380 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Add: 99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger Add: 99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger Add: 99471 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 Add: 99472 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 of age Add: 99475 Initial 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 Add: 99476 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

Page A-29 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 99477 Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services Add: 99478 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) Add: 99479 Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) Add: 99480 Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams)

Line: 125 Condition: ABUSE AND NEGLECT Treatment: MEDICAL/ PSYCHOTHERAPY Add: H0038 Self-help/peer services, per 15 minutes Add: H2027 Psychoeducational service, per 15 minutes

Line: 128 Condition: ANAPHYLACTIC SHOCK; EDEMA OF LARYNX Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens

Line: 133 Condition: GRANULOMATOSIS WITH POLYANGIITIS Treatment: MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex Delete: 31528 Laryngoscopy direct, with or without tracheoscopy; with dilation, initial

Line: 135 Condition: CRUSH INJURIES OTHER THAN DIGITS; COMPARTMENT SYNDROME; INJURIES TO BLOOD VESSEL(S) OF THE NECK Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 35261 Repair blood vessel with graft other than vein; neck

Line: 136 Condition: OPEN FRACTURE/DISLOCATION OF EXTREMITIES Treatment: MEDICAL AND SURGICAL TREATMENT Add: S92.811B Other fracture of right foot, initial encounter for open fracture Add: S92.812B Other fracture of left foot, initial encounter for open fracture Add: S92.819B Other fracture of unspecified foot, initial encounter for open fracture Add: S99.001B Unspecified physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.002B Unspecified physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.009B Unspecified physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.011B Salter-Harris Type I physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.012B Salter-Harris Type I physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.019B Salter-Harris Type I physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.021B Salter-Harris Type II physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.022B Salter-Harris Type II physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.029B Salter-Harris Type II physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.031B Salter-Harris Type III physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.032B Salter-Harris Type III physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.039B Salter-Harris Type III physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.041B Salter-Harris Type IV physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.042B Salter-Harris Type IV physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.049B Salter-Harris Type IV physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.091B Other physeal fracture of right calcaneus, initial encounter for open fracture Add: S99.092B Other physeal fracture of left calcaneus, initial encounter for open fracture Add: S99.099B Other physeal fracture of unspecified calcaneus, initial encounter for open fracture Add: S99.101B Unspecified physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.102B Unspecified physeal fracture of left metatarsal, initial encounter for open fracture

Page A-30 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.109B Unspecified physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.111B Salter-Harris Type I physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.112B Salter-Harris Type I physeal fracture of left metatarsal, initial encounter for open fracture Add: S99.119B Salter-Harris Type I physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.121B Salter-Harris Type II physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.122B Salter-Harris Type II physeal fracture of left metatarsal, initial encounter for open fracture Add: S99.129B Salter-Harris Type II physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.131B Salter-Harris Type III physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.132B Salter-Harris Type III physeal fracture of left metatarsal, initial encounter for open fracture Add: S99.139B Salter-Harris Type III physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.141B Salter-Harris Type IV physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.142B Salter-Harris Type IV physeal fracture of left metatarsal, initial encounter for open fracture Add: S99.149B Salter-Harris Type IV physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.191B Other physeal fracture of right metatarsal, initial encounter for open fracture Add: S99.192B Other physeal fracture of left metatarsal, initial encounter for open fracture Add: S99.199B Other physeal fracture of unspecified metatarsal, initial encounter for open fracture Add: S99.201B Unspecified physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.202B Unspecified physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.209B Unspecified physeal fracture of phalanx of unspecified toe, initial encounter for open fracture Add: S99.211B Salter-Harris Type I physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.212B Salter-Harris Type I physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.219B Salter-Harris Type I physeal fracture of phalanx of unspecified toe, initial encounter for open fracture Add: S99.221B Salter-Harris Type II physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.222B Salter-Harris Type II physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.229B Salter-Harris Type II physeal fracture of phalanx of unspecified toe, initial encounter for open fracture Add: S99.231B Salter-Harris Type III physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.232B Salter-Harris Type III physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.239B Salter-Harris Type III physeal fracture of phalanx of unspecified toe, initial encounter for open fracture Add: S99.241B Salter-Harris Type IV physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.242B Salter-Harris Type IV physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.249B Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, initial encounter for open fracture Add: S99.291B Other physeal fracture of phalanx of right toe, initial encounter for open fracture Add: S99.292B Other physeal fracture of phalanx of left toe, initial encounter for open fracture Add: S99.299B Other physeal fracture of phalanx of unspecified toe, initial encounter for open fracture

Line: 138 Condition: INTERRUPTED AORTIC ARCH Treatment: TRANSVERSE ARCH GRAFT Delete: Q25.2 Atresia of aorta Add: Q25.21 Interruption of aortic arch Add: Q25.29 Other atresia of aorta Add: Q25.40 Congenital malformation of aorta unspecified Add: Q25.41 Absence and aplasia of aorta Add: Q25.42 Hypoplasia of aorta Add: Q25.49 Other congenital malformations of aorta

Line: 143 Condition: GLAUCOMA, OTHER THAN PRIMARY ANGLE-CLOSURE Treatment: MEDICAL,SURGICAL AND LASER TREATMENT Add: H40.1110 Primary open-angle glaucoma, right eye, stage unspecified Add: H40.1111 Primary open-angle glaucoma, right eye, mild stage Add: H40.1112 Primary open-angle glaucoma, right eye, moderate stage Add: H40.1113 Primary open-angle glaucoma, right eye, severe stage Add: H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage Add: H40.1120 Primary open-angle glaucoma, left eye, stage unspecified Add: H40.1121 Primary open-angle glaucoma, left eye, mild stage Add: H40.1122 Primary open-angle glaucoma, left eye, moderate stage Add: H40.1123 Primary open-angle glaucoma, left eye, severe stage Add: H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage Add: H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified Add: H40.1131 Primary open-angle glaucoma, bilateral, mild stage Add: H40.1132 Primary open-angle glaucoma, bilateral, moderate stage Add: H40.1133 Primary open-angle glaucoma, bilateral, severe stage Add: H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage Page A-31 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: H40.1190 Primary open-angle glaucoma, unspecified eye, stage unspecified Add: H40.1191 Primary open-angle glaucoma, unspecified eye, mild stage Add: H40.1192 Primary open-angle glaucoma, unspecified eye, moderate stage Add: H40.1193 Primary open-angle glaucoma, unspecified eye, severe stage Add: H40.1194 Primary open-angle glaucoma, unspecified eye, indeterminate stage Delete: H40.11X0 Primary open-angle glaucoma, stage unspecified Delete: H40.11X1 Primary open-angle glaucoma, mild stage Delete: H40.11X2 Primary open-angle glaucoma, moderate stage Delete: H40.11X3 Primary open-angle glaucoma, severe stage Delete: H40.11X4 Primary open-angle glaucoma, indeterminate stage

Line: 152 Condition: ACQUIRED HEMOLYTIC ANEMIAS Treatment: MEDICAL THERAPY Add: D62 Acute posthemorrhagic anemia

Line: 154 Condition: CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; OTHER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR UNSTABLE; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY Treatment: MEDICAL AND SURGICAL TREATMENT Add: M43.3 Recurrent atlantoaxial dislocation with myelopathy Add: M43.4 Other recurrent atlantoaxial dislocation Add: M43.5X2 Other recurrent vertebral dislocation, cervical region Add: M43.5X3 Other recurrent vertebral dislocation, cervicothoracic region Delete: M99.10 Subluxation complex (vertebral) of head region Delete: M99.11 Subluxation complex (vertebral) of cervical region

Line: 158 Condition: VASCULAR INSUFFICIENCY OF INTESTINE Treatment: SURGICAL TREATMENT Delete: K55.0 Acute vascular disorders of intestine Add: K55.011 Focal (segmental) acute (reversible) ischemia of small intestine Add: K55.012 Diffuse acute (reversible) ischemia of small intestine Add: K55.019 Acute (reversible) ischemia of small intestine, extent unspecified Add: K55.021 Focal (segmental) acute infarction of small intestine Add: K55.022 Diffuse acute infarction of small intestine Add: K55.029 Acute infarction of small intestine, extent unspecified Add: K55.031 Focal (segmental) acute (reversible) ischemia of large intestine Add: K55.032 Diffuse acute (reversible) ischemia of large intestine Add: K55.039 Acute (reversible) ischemia of large intestine, extent unspecified Add: K55.041 Focal (segmental) acute infarction of large intestine Add: K55.042 Diffuse acute infarction of large intestine Add: K55.049 Acute infarction of large intestine, extent unspecified Add: K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified Add: K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified Add: K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified Add: K55.061 Focal (segmental) acute infarction of intestine, part unspecified Add: K55.062 Diffuse acute infarction of intestine, part unspecified Add: K55.069 Acute infarction of intestine, part and extent unspecified

Line: 161 Condition: CANCER OF COLON, RECTUM, SMALL INTESTINE AND ANUS Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: C49.A0 Gastrointestinal stromal tumor, unspecified site Add: C49.A3 Gastrointestinal stromal tumor of small intestine Add: C49.A4 Gastrointestinal stromal tumor of large intestine Add: C49.A5 Gastrointestinal stromal tumor of rectum Add: C49.A9 Gastrointestinal stromal tumor of other sites

Page A-32 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 162 Condition: NON-HODGKIN'S LYMPHOMAS Treatment: MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: D47.Z2 Castleman disease

Line: 168 Condition: CARCINOMA IN SITU OF UPPER AIRWAY, INCLUDING ORAL CAVITY Treatment: INCISION/EXCISION, MEDICAL THERAPY Delete: K13.23 Excessive keratinized residual ridge mucosa Delete: K13.24 Leukokeratosis nicotina palati

Line: 169 Condition: PREVENTIVE FOOT CARE IN HIGH RISK PATIENTS Treatment: MEDICAL AND SURGICAL TREATMENT OF TOENAILS AND HYPERKERATOSES OF FOOT Add: E11.49 Type 2 diabetes mellitus with other diabetic neurological complication Add: E11.59 Type 2 diabetes mellitus with other circulatory complications Add: E11.628 Type 2 diabetes mellitus with other skin complications

Line: 172 Condition: COMPLICATED HERNIAS; UNCOMPLICATED INGUINAL HERNIA IN CHILDREN AGE 18 AND UNDER; PERSISTENT HYDROCELE Treatment: REPAIR Add: 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Add: 39540 Repair, diaphragmatic hernia (other than neonatal), traumatic; acute Add: 39541 Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic Add: 39560 Resection, diaphragm; with simple repair (eg, primary suture) Add: 39561 Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap)

Line: 177 Condition: POSTTRAUMATIC STRESS DISORDER Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 184 Condition: URETERAL STRICTURE OR OBSTRUCTION; HYDRONEPHROSIS; HYDROURETER Treatment: MEDICAL AND SURGICAL TREATMENT Add: 50760 Ureteroureterostomy Add: 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder Add: 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder Add: 50783 Ureteroneocystostomy; with extensive ureteral tailoring Add: 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap Add: 50860 Ureterostomy, transplantation of ureter to skin Add: 50948 Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement

Line: 195 Condition: CANCER OF BREAST; AT HIGH RISK OF BREAST CANCER Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY AND BREAST RECONSTRUCTION Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex

Page A-33 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 197 Condition: AUTISM SPECTRUM DISORDERS Treatment: MEDICAL THERAPY/BEHAVIORAL MODIFICATION INCLUDING APPLIED BEHAVIOR ANALYSIS Add: H0004 Behavioral health counseling and therapy, per 15 minutes

Line: 199 Condition: ACUTE PANCREATITIS Treatment: MEDICAL THERAPY Delete: K85.0 Idiopathic acute pancreatitis Add: K85.00 Idiopathic acute pancreatitis without necrosis or infection Add: K85.01 Idiopathic acute pancreatitis with uninfected necrosis Add: K85.02 Idiopathic acute pancreatitis with infected necrosis Delete: K85.1 Biliary acute pancreatitis Add: K85.10 Biliary acute pancreatitis without necrosis or infection Add: K85.11 Biliary acute pancreatitis with uninfected necrosis Add: K85.12 Biliary acute pancreatitis with infected necrosis Delete: K85.2 Alcohol induced acute pancreatitis Add: K85.20 Alcohol induced acute pancreatitis without necrosis or infection Add: K85.21 Alcohol induced acute pancreatitis with uninfected necrosis Add: K85.22 Alcohol induced acute pancreatitis with infected necrosis Delete: K85.3 Drug induced acute pancreatitis Add: K85.30 Drug induced acute pancreatitis without necrosis or infection Add: K85.31 Drug induced acute pancreatitis with uninfected necrosis Add: K85.32 Drug induced acute pancreatitis with infected necrosis Delete: K85.8 Other acute pancreatitis Add: K85.80 Other acute pancreatitis without necrosis or infection Add: K85.81 Other acute pancreatitis with uninfected necrosis Add: K85.82 Other acute pancreatitis with infected necrosis Delete: K85.9 Acute pancreatitis, unspecified Add: K85.90 Acute pancreatitis without necrosis or infection, unspecified Add: K85.91 Acute pancreatitis with uninfected necrosis, unspecified Add: K85.92 Acute pancreatitis with infected necrosis, unspecified

Line: 200 Condition: SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE/HEMATOMA; CEREBRAL ANEURYSM; COMPRESSION OF BRAIN Treatment: BURR HOLES, CRANIECTOMY/CRANIOTOMY Add: I60.2 Nontraumatic subarachnoid hemorrhage from anterior communicating artery Delete: I60.20 Nontraumatic subarachnoid hemorrhage from unspecified anterior communicating artery Delete: I60.21 Nontraumatic subarachnoid hemorrhage from right anterior communicating artery Delete: I60.22 Nontraumatic subarachnoid hemorrhage from left anterior communicating artery Delete: 61630 Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous Delete: 61640 Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel Delete: 61641 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (List separately in addition to code for primary procedure) Delete: 61642 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (List separately in addition to code for primary procedure)

Line: 202 Condition: CONGENITAL LUNG ANOMALIES Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 205 Condition: CANCER OF BONES Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex

Page A-34 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

Line: 207 Condition: SLEEP APNEA, NARCOLEPSY AND REM BEHAVIORAL DISORDER Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Line: 208 Condition: DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE Treatment: MEDICAL/PSYCHOTHERAPY Delete: F32.8 Other depressive episodes Add: F32.81 Premenstrual dysphoric disorder Add: F32.89 Other specified depressive episodes Delete: F34.8 Other persistent mood [affective] disorders Add: F34.81 Disruptive mood dysregulation disorder Add: F34.89 Other specified persistent mood disorders

Line: 209 Condition: PNEUMOCOCCAL PNEUMONIA, OTHER BACTERIAL PNEUMONIA, BRONCHOPNEUMONIA Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 210 Condition: SUPERFICIAL ABSCESSES AND CELLULITIS Treatment: MEDICAL AND SURGICAL TREATMENT Add: L03.213 Periorbital cellulitis Delete: 31590 Laryngeal reinnervation by neuromuscular pedicle Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Line: 212 Condition: DEEP OPEN WOUND, WITH OR WITHOUT TENDON OR NERVE INVOLVEMENT Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

Line: 217 Condition: BULLOUS DERMATOSES OF THE SKIN Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 220 Condition: CANCER OF STOMACH Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: C49.A0 Gastrointestinal stromal tumor, unspecified site Add: C49.A2 Gastrointestinal stromal tumor of stomach Add: C49.A9 Gastrointestinal stromal tumor of other sites Delete: 43653 Laparoscopy, surgical; gastrostomy, without construction of gastric tube (eg, Stamm procedure) (separate procedure)

Line: 223 Condition: DENTAL CONDITIONS (EG. PERIODONTAL DISEASE) Treatment: BASIC PERIODONTICS Delete: K05.21 Aggressive periodontitis, localized Add: K05.211 Aggressive periodontitis, localized, slight Add: K05.212 Aggressive periodontitis, localized, moderate Add: K05.213 Aggressive periodontitis, localized, severe

Page A-35 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: K05.219 Aggressive periodontitis, localized, unspecified severity Delete: K05.22 Aggressive periodontitis, generalized Add: K05.221 Aggressive periodontitis, generalized, slight Add: K05.222 Aggressive periodontitis, generalized, moderate Add: K05.223 Aggressive periodontitis, generalized, severe Add: K05.229 Aggressive periodontitis, generalized, unspecified severity Delete: K05.31 Chronic periodontitis, localized Add: K05.311 Chronic periodontitis, localized, slight Add: K05.312 Chronic periodontitis, localized, moderate Add: K05.313 Chronic periodontitis, localized, severe Add: K05.319 Chronic periodontitis, localized, unspecified severity Delete: K05.32 Chronic periodontitis, generalized Add: K05.321 Chronic periodontitis, generalized, slight Add: K05.322 Chronic periodontitis, generalized, moderate Add: K05.323 Chronic periodontitis, generalized, severe Add: K05.329 Chronic periodontitis, generalized, unspecified severity Add: K06.3 Horizontal alveolar bone loss

Line: 224 Condition: PULMONARY FIBROSIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 225 Condition: DYSLIPIDEMIAS Treatment: MEDICAL THERAPY Delete: E78.0 Pure hypercholesterolemia Add: E78.00 Pure hypercholesterolemia, unspecified Add: E78.01 Familial hypercholesterolemia

Line: 227 Condition: OCCUPATIONAL LUNG DISEASES Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens

Line: 232 Condition: INTESTINAL MALABSORPTION Treatment: MEDICAL THERAPY Add: K86.81 Exocrine pancreatic insufficiency Delete: K90.4 Malabsorption due to intolerance, not elsewhere classified Add: K90.49 Malabsorption due to intolerance, not elsewhere classified

Line: 233 Condition: FRACTURE OF FACE BONES; INJURY TO OPTIC AND OTHER CRANIAL NERVES Treatment: SURGICAL TREATMENT Delete: S02.2XXA Fracture of nasal bones, initial encounter for closed fracture Add: S02.30XA Fracture of orbital floor, unspecified side, initial encounter for closed fracture Add: S02.30XB Fracture of orbital floor, unspecified side, initial encounter for open fracture Add: S02.30XD Fracture of orbital floor, unspecified side, subsequent encounter for fracture with routine healing Add: S02.30XG Fracture of orbital floor, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.31XA Fracture of orbital floor, right side, initial encounter for closed fracture Add: S02.31XB Fracture of orbital floor, right side, initial encounter for open fracture Add: S02.31XD Fracture of orbital floor, right side, subsequent encounter for fracture with routine healing Add: S02.31XG Fracture of orbital floor, right side, subsequent encounter for fracture with delayed healing Add: S02.32XA Fracture of orbital floor, left side, initial encounter for closed fracture Add: S02.32XB Fracture of orbital floor, left side, initial encounter for open fracture Add: S02.32XD Fracture of orbital floor, left side, subsequent encounter for fracture with routine healing Add: S02.32XG Fracture of orbital floor, left side, subsequent encounter for fracture with delayed healing Delete: S02.3XXA Fracture of orbital floor, initial encounter for closed fracture Delete: S02.3XXB Fracture of orbital floor, initial encounter for open fracture Delete: S02.3XXD Fracture of orbital floor, subsequent encounter for fracture with routine healing

Page A-36 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: S02.3XXG Fracture of orbital floor, subsequent encounter for fracture with delayed healing Add: S02.40AA Malar fracture, right side, initial encounter for closed fracture Add: S02.40AB Malar fracture, right side, initial encounter for open fracture Add: S02.40AD Malar fracture, right side, subsequent encounter for fracture with routine healing Add: S02.40AG Malar fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.40BA Malar fracture, left side, initial encounter for closed fracture Add: S02.40BB Malar fracture, left side, initial encounter for open fracture Add: S02.40BD Malar fracture, left side, subsequent encounter for fracture with routine healing Add: S02.40BG Malar fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.40CA Maxillary fracture, right side, initial encounter for closed fracture Add: S02.40CB Maxillary fracture, right side, initial encounter for open fracture Add: S02.40CD Maxillary fracture, right side, subsequent encounter for fracture with routine healing Add: S02.40CG Maxillary fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.40DA Maxillary fracture, left side, initial encounter for closed fracture Add: S02.40DB Maxillary fracture, left side, initial encounter for open fracture Add: S02.40DD Maxillary fracture, left side, subsequent encounter for fracture with routine healing Add: S02.40DG Maxillary fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.40EA Zygomatic fracture, right side, initial encounter for closed fracture Add: S02.40EB Zygomatic fracture, right side, initial encounter for open fracture Add: S02.40ED Zygomatic fracture, right side, subsequent encounter for fracture with routine healing Add: S02.40EG Zygomatic fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.40FA Zygomatic fracture, left side, initial encounter for closed fracture Add: S02.40FB Zygomatic fracture, left side, initial encounter for open fracture Add: S02.40FD Zygomatic fracture, left side, subsequent encounter for fracture with routine healing Add: S02.40FG Zygomatic fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.601A Fracture of unspecified part of body of right mandible, initial encounter for closed fracture Add: S02.601B Fracture of unspecified part of body of right mandible, initial encounter for open fracture Add: S02.601D Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with routine healing Add: S02.601G Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with delayed healing Add: S02.602A Fracture of unspecified part of body of left mandible, initial encounter for closed fracture Add: S02.602B Fracture of unspecified part of body of left mandible, initial encounter for open fracture Add: S02.602D Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with routine healing Add: S02.602G Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with delayed healing Add: S02.610A Fracture of condylar process of mandible, unspecified side, initial encounter for closed fracture Add: S02.610B Fracture of condylar process of mandible, unspecified side, initial encounter for open fracture Add: S02.610D Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.610G Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.611A Fracture of condylar process of right mandible, initial encounter for closed fracture Add: S02.611B Fracture of condylar process of right mandible, initial encounter for open fracture Add: S02.611D Fracture of condylar process of right mandible, subsequent encounter for fracture with routine healing Add: S02.611G Fracture of condylar process of right mandible, subsequent encounter for fracture with delayed healing Add: S02.612A Fracture of condylar process of left mandible, initial encounter for closed fracture Add: S02.612B Fracture of condylar process of left mandible, initial encounter for open fracture Add: S02.612D Fracture of condylar process of left mandible, subsequent encounter for fracture with routine healing Add: S02.612G Fracture of condylar process of left mandible, subsequent encounter for fracture with delayed healing Delete: S02.61XA Fracture of condylar process of mandible, initial encounter for closed fracture Delete: S02.61XB Fracture of condylar process of mandible, initial encounter for open fracture Delete: S02.61XD Fracture of condylar process of mandible, subsequent encounter for fracture with routine healing Delete: S02.61XG Fracture of condylar process of mandible, subsequent encounter for fracture with delayed healing Add: S02.620A Fracture of subcondylar process of mandible, unspecified side, initial encounter for closed fracture Add: S02.620B Fracture of subcondylar process of mandible, unspecified side, initial encounter for open fracture Add: S02.620D Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.620G Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.621A Fracture of subcondylar process of right mandible, initial encounter for closed fracture Add: S02.621B Fracture of subcondylar process of right mandible, initial encounter for open fracture Add: S02.621D Fracture of subcondylar process of right mandible, subsequent encounter for fracture with routine healing Add: S02.621G Fracture of subcondylar process of right mandible, subsequent encounter for fracture with delayed healing Add: S02.622A Fracture of subcondylar process of left mandible, initial encounter for closed fracture Add: S02.622B Fracture of subcondylar process of left mandible, initial encounter for open fracture Add: S02.622D Fracture of subcondylar process of left mandible, subsequent encounter for fracture with routine healing Add: S02.622G Fracture of subcondylar process of left mandible, subsequent encounter for fracture with delayed healing

Page A-37 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: S02.62XA Fracture of subcondylar process of mandible, initial encounter for closed fracture Delete: S02.62XB Fracture of subcondylar process of mandible, initial encounter for open fracture Delete: S02.62XD Fracture of subcondylar process of mandible, subsequent encounter for fracture with routine healing Delete: S02.62XG Fracture of subcondylar process of mandible, subsequent encounter for fracture with delayed healing Add: S02.630A Fracture of coronoid process of mandible, unspecified side, initial encounter for closed fracture Add: S02.630B Fracture of coronoid process of mandible, unspecified side, initial encounter for open fracture Add: S02.630D Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.630G Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.631A Fracture of coronoid process of right mandible, initial encounter for closed fracture Add: S02.631B Fracture of coronoid process of right mandible, initial encounter for open fracture Add: S02.631D Fracture of coronoid process of right mandible, subsequent encounter for fracture with routine healing Add: S02.631G Fracture of coronoid process of right mandible, subsequent encounter for fracture with delayed healing Add: S02.632A Fracture of coronoid process of left mandible, initial encounter for closed fracture Add: S02.632B Fracture of coronoid process of left mandible, initial encounter for open fracture Add: S02.632D Fracture of coronoid process of left mandible, subsequent encounter for fracture with routine healing Add: S02.632G Fracture of coronoid process of left mandible, subsequent encounter for fracture with delayed healing Delete: S02.63XA Fracture of coronoid process of mandible, initial encounter for closed fracture Delete: S02.63XB Fracture of coronoid process of mandible, initial encounter for open fracture Delete: S02.63XD Fracture of coronoid process of mandible, subsequent encounter for fracture with routine healing Delete: S02.63XG Fracture of coronoid process of mandible, subsequent encounter for fracture with delayed healing Add: S02.640A Fracture of ramus of mandible, unspecified side, initial encounter for closed fracture Add: S02.640B Fracture of ramus of mandible, unspecified side, initial encounter for open fracture Add: S02.640D Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.640G Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.641A Fracture of ramus of right mandible, initial encounter for closed fracture Add: S02.641B Fracture of ramus of right mandible, initial encounter for open fracture Add: S02.641D Fracture of ramus of right mandible, subsequent encounter for fracture with routine healing Add: S02.641G Fracture of ramus of right mandible, subsequent encounter for fracture with delayed healing Add: S02.642A Fracture of ramus of left mandible, initial encounter for closed fracture Add: S02.642B Fracture of ramus of left mandible, initial encounter for open fracture Add: S02.642D Fracture of ramus of left mandible, subsequent encounter for fracture with routine healing Add: S02.642G Fracture of ramus of left mandible, subsequent encounter for fracture with delayed healing Delete: S02.64XA Fracture of ramus of mandible, initial encounter for closed fracture Delete: S02.64XB Fracture of ramus of mandible, initial encounter for open fracture Delete: S02.64XD Fracture of ramus of mandible, subsequent encounter for fracture with routine healing Delete: S02.64XG Fracture of ramus of mandible, subsequent encounter for fracture with delayed healing Add: S02.650A Fracture of angle of mandible, unspecified side, initial encounter for closed fracture Add: S02.650B Fracture of angle of mandible, unspecified side, initial encounter for open fracture Add: S02.650D Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.650G Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.651A Fracture of angle of right mandible, initial encounter for closed fracture Add: S02.651B Fracture of angle of right mandible, initial encounter for open fracture Add: S02.651D Fracture of angle of right mandible, subsequent encounter for fracture with routine healing Add: S02.651G Fracture of angle of right mandible, subsequent encounter for fracture with delayed healing Add: S02.652A Fracture of angle of left mandible, initial encounter for closed fracture Add: S02.652B Fracture of angle of left mandible, initial encounter for open fracture Add: S02.652D Fracture of angle of left mandible, subsequent encounter for fracture with routine healing Add: S02.652G Fracture of angle of left mandible, subsequent encounter for fracture with delayed healing Delete: S02.65XA Fracture of angle of mandible, initial encounter for closed fracture Delete: S02.65XB Fracture of angle of mandible, initial encounter for open fracture Delete: S02.65XD Fracture of angle of mandible, subsequent encounter for fracture with routine healing Delete: S02.65XG Fracture of angle of mandible, subsequent encounter for fracture with delayed healing Add: S02.670A Fracture of alveolus of mandible, unspecified side, initial encounter for closed fracture Add: S02.670B Fracture of alveolus of mandible, unspecified side, initial encounter for open fracture Add: S02.670D Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with routine healing Add: S02.670G Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.671A Fracture of alveolus of right mandible, initial encounter for closed fracture Add: S02.671B Fracture of alveolus of right mandible, initial encounter for open fracture Add: S02.671D Fracture of alveolus of right mandible, subsequent encounter for fracture with routine healing Add: S02.671G Fracture of alveolus of right mandible, subsequent encounter for fracture with delayed healing Add: S02.672A Fracture of alveolus of left mandible, initial encounter for closed fracture Add: S02.672B Fracture of alveolus of left mandible, initial encounter for open fracture Add: S02.672D Fracture of alveolus of left mandible, subsequent encounter for fracture with routine healing

Page A-38 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S02.672G Fracture of alveolus of left mandible, subsequent encounter for fracture with delayed healing Delete: S02.67XA Fracture of alveolus of mandible, initial encounter for closed fracture Delete: S02.67XB Fracture of alveolus of mandible, initial encounter for open fracture Delete: S02.67XD Fracture of alveolus of mandible, subsequent encounter for fracture with routine healing Delete: S02.67XG Fracture of alveolus of mandible, subsequent encounter for fracture with delayed healing Add: S02.80XA Fracture of other specified skull and facial bones, unspecified side, initial encounter for closed fracture Add: S02.80XB Fracture of other specified skull and facial bones, unspecified side, initial encounter for open fracture Add: S02.80XD Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with routine healing Add: S02.80XG Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with delayed healing Add: S02.81XA Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture Add: S02.81XB Fracture of other specified skull and facial bones, right side, initial encounter for open fracture Add: S02.81XD Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with routine healing Add: S02.81XG Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with delayed healing Add: S02.82XA Fracture of other specified skull and facial bones, left side, initial encounter for closed fracture Add: S02.82XB Fracture of other specified skull and facial bones, left side, initial encounter for open fracture Add: S02.82XD Fracture of other specified skull and facial bones, left side, subsequent encounter for fracture with routine healing Add: S02.82XG Fracture of other specified skull and facial bones, left side, subsequent encounter for fracture with delayed healing Delete: S02.8XXA Fractures of other specified skull and facial bones, initial encounter for closed fracture Delete: S02.8XXB Fractures of other specified skull and facial bones, initial encounter for open fracture

Line: 234 Condition: MALIGNANT MELANOMA OF SKIN Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 237 Condition: HYPOPLASTIC LEFT HEART SYNDROME Treatment: REPAIR Delete: Q25.2 Atresia of aorta Add: Q25.29 Other atresia of aorta Add: Q25.40 Congenital malformation of aorta unspecified Add: Q25.41 Absence and aplasia of aorta Add: Q25.42 Hypoplasia of aorta Add: Q25.49 Other congenital malformations of aorta

Line: 238 Condition: ADULT RESPIRATORY DISTRESS SYNDROME; ACUTE RESPIRATORY FAILURE; RESPIRATORY CONDITIONS DUE TO PHYSICAL AND CHEMICAL AGENTS Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Line: 240 Condition: LIMB THREATENING VASCULAR DISEASE, INFECTIONS, AND VASCULAR COMPLICATIONS Treatment: MEDICAL AND SURGICAL TREATMENT Add: I77.76 Dissection of artery of upper extremity Add: I77.77 Dissection of artery of lower extremity

Line: 242 Condition: ACUTE PROMYELOCYTIC LEUKEMIA Treatment: MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY, RADIATION AND RADIONUCLEIDE THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate

Page A-39 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: 77525 Proton treatment delivery; complex

Line: 244 Condition: SHORT BOWEL SYNDROME - AGE 5 OR UNDER Treatment: INTESTINE AND INTESTINE/LIVER TRANSPLANT Delete: K55.0 Acute vascular disorders of intestine Add: K55.30 Necrotizing enterocolitis, unspecified Add: K55.31 Stage 1 necrotizing enterocolitis Add: K55.32 Stage 2 necrotizing enterocolitis Add: K55.33 Stage 3 necrotizing enterocolitis

Line: 246 Condition: ACUTE AND SUBACUTE NECROSIS OF LIVER; SPECIFIED INBORN ERRORS OF METABOLISM (EG. MAPLE SYRUP URINE DISEASE, TYROSINEMIA) Treatment: LIVER TRANSPLANT Add: E80.5 Crigler-Najjar syndrome

Line: 249 Condition: CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA Treatment: CONJUNCTIVAL FLAP; MEDICAL THERAPY Add: E50.3 Vitamin A deficiency with corneal ulceration and xerosis

Line: 255 Condition: CHRONIC PANCREATITIS Treatment: MEDICAL THERAPY Delete: K86.8 Other specified diseases of pancreas Add: K86.89 Other specified diseases of pancreas

Line: 257 Condition: PSYCHOLOGICAL FACTORS AGGRAVATING PHYSICAL CONDITION (EG. ASTHMA, CHRONIC GI CONDITIONS, HYPERTENSION) Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 259 Condition: CHRONIC OSTEOMYELITIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: M46.30 Infection of intervertebral disc (pyogenic), site unspecified Delete: M46.31 Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region Delete: M46.32 Infection of intervertebral disc (pyogenic), cervical region Delete: M46.33 Infection of intervertebral disc (pyogenic), cervicothoracic region Delete: M46.34 Infection of intervertebral disc (pyogenic), thoracic region Delete: M46.35 Infection of intervertebral disc (pyogenic), thoracolumbar region Delete: M46.36 Infection of intervertebral disc (pyogenic), lumbar region Delete: M46.37 Infection of intervertebral disc (pyogenic), lumbosacral region Delete: M46.38 Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region Delete: M46.39 Infection of intervertebral disc (pyogenic), multiple sites in spine

Line: 261 Condition: DEFORMITIES OF HEAD Treatment: CRANIOTOMY/CRANIECTOMY Delete: M99.80 Other biomechanical lesions of head region

Page A-40 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 266 Condition: CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM AND MESENTERY Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: C49.A9 Gastrointestinal stromal tumor of other sites

Line: 267 Condition: CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM AND OTHER RESPIRATORY ORGANS Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: J98.5 Diseases of mediastinum, not elsewhere classified Add: J98.59 Other diseases of mediastinum, not elsewhere classified Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 271 Condition: DENTAL CONDITIONS (TIME SENSITIVE EVENTS) Treatment: URGENT DENTAL SERVICES Delete: K04.0 Pulpitis Add: K04.01 Reversible pulpitis Add: K04.02 Irreversible pulpitis

Line: 272 Condition: RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASES Treatment: MEDICAL THERAPY Add: A92.5 Zika virus disease

Line: 278 Condition: RETINOPATHY OF PREMATURITY Treatment: CRYOSURGERY Add: Q82.3 Incontinentia pigmenti Add: 92227 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Add: 92228 Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral

Line: 280 Condition: CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex Add: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 282 Condition: OTHER PSYCHOTIC DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 284 Condition: RETINAL DETACHMENT AND OTHER RETINAL DISORDERS Treatment: RETINAL REPAIR, VITRECTOMY Add: E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

Page A-41 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E08.3529 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E08.3539 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E08.3549 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E09.3539 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E09.3549 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

Page A-42 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye Add: E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye Add: E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye Add: E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral Add: E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye Add: E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye Add: E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye Add: E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral Add: E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye Add: E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye Add: E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye Add: E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral Add: E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

Line: 286 Condition: LIFE-THREATENING CARDIAC ARRHYTHMIAS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Page A-43 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 287 Condition: ANOREXIA NERVOSA Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 289 Condition: DISSECTING OR RUPTURED AORTIC ANEURYSM Treatment: MEDICAL AND SURGICAL TREATMENT Add: I77.72 Dissection of iliac artery Add: I77.73 Dissection of renal artery

Line: 290 Condition: COMPLICATIONS OF A PROCEDURE ALWAYS REQUIRING TREATMENT Treatment: MEDICAL AND SURGICAL TREATMENT Add: G97.61 Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure Add: G97.62 Postprocedural hematoma of a nervous system organ or structure following other procedure Add: G97.63 Postprocedural seroma of a nervous system organ or structure following a nervous system procedure Add: G97.64 Postprocedural seroma of a nervous system organ or structure following other procedure Add: T83.032D Leakage of nephrostomy catheter, subsequent encounter Add: T83.092A Other mechanical complication of nephrostomy catheter, initial encounter Add: T83.092D Other mechanical complication of nephrostomy catheter, subsequent encounter Add: T83.113A Breakdown (mechanical) of other urinary stents, initial encounter Add: T83.113D Breakdown (mechanical) of other urinary stents, subsequent encounter Add: T83.123A Displacement of other urinary stents, initial encounter Add: T83.123D Displacement of other urinary stents, subsequent encounter Add: T83.193A Other mechanical complication of other urinary stent, initial encounter Add: T83.193D Other mechanical complication of other urinary stent, subsequent encounter Add: T83.24XA Erosion of graft of urinary organ, initial encounter Add: T83.24XD Erosion of graft of urinary organ, subsequent encounter Add: T83.25XA Exposure of graft of urinary organ, initial encounter Add: T83.25XD Exposure of graft of urinary organ, subsequent encounter Add: T83.510A Infection and inflammatory reaction due to cystostomy catheter, initial encounter Add: T83.510D Infection and inflammatory reaction due to cystostomy catheter, subsequent encounter Add: T83.511A Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter Add: T83.511D Infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter Add: T83.512A Infection and inflammatory reaction due to nephrostomy catheter, initial encounter Add: T83.512D Infection and inflammatory reaction due to nephrostomy catheter, subsequent encounter Add: T83.518A Infection and inflammatory reaction due to other urinary catheter, initial encounter Add: T83.518D Infection and inflammatory reaction due to other urinary catheter, subsequent encounter Delete: T83.51XA Infection and inflammatory reaction due to indwelling urinary catheter, initial encounter Delete: T83.51XD Infection and inflammatory reaction due to indwelling urinary catheter, subsequent encounter Add: T83.590A Infection and inflammatory reaction due to implanted urinary neurostimulation device, initial encounter Add: T83.590D Infection and inflammatory reaction due to implanted urinary neurostimulation device, subsequent encounter Add: T83.591A Infection and inflammatory reaction due to implanted urinary sphincter, initial encounter Add: T83.591D Infection and inflammatory reaction due to implanted urinary sphincter, subsequent encounter Add: T83.592A Infection and inflammatory reaction due to indwelling ureteral stent, initial encounter Add: T83.592D Infection and inflammatory reaction due to indwelling ureteral stent, subsequent encounter Add: T83.593A Infection and inflammatory reaction due to other urinary stents, initial encounter Add: T83.593D Infection and inflammatory reaction due to other urinary stents, subsequent encounter Add: T83.598A Infection and inflammatory reaction due to other prosthetic device, implant and graft in urinary system, initial encounter Add: T83.598D Infection and inflammatory reaction due to other prosthetic device, implant and graft in urinary system, subsequent encounter Delete: T83.59XA Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system, initial encounter Delete: T83.59XD Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system, subsequent encounter Add: T83.61XA Infection and inflammatory reaction due to implanted penile prosthesis, initial encounter Add: T83.61XD Infection and inflammatory reaction due to implanted penile prosthesis, subsequent encounter Add: T83.62XA Infection and inflammatory reaction due to implanted testicular prosthesis, initial encounter Page A-44 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: H59.331 Postprocedural hematoma of right eye and adnexa following an ophthalmic procedure Add: H59.332 Postprocedural hematoma of left eye and adnexa following an ophthalmic procedure Add: H59.333 Postprocedural hematoma of eye and adnexa following an ophthalmic procedure, bilateral Add: H59.339 Postprocedural hematoma of unspecified eye and adnexa following an ophthalmic procedure Add: H59.341 Postprocedural hematoma of right eye and adnexa following other procedure Add: H59.342 Postprocedural hematoma of left eye and adnexa following other procedure Add: H59.343 Postprocedural hematoma of eye and adnexa following other procedure, bilateral Add: H59.349 Postprocedural hematoma of unspecified eye and adnexa following other procedure Add: H59.351 Postprocedural seroma of right eye and adnexa following an ophthalmic procedure Add: H59.352 Postprocedural seroma of left eye and adnexa following an ophthalmic procedure Add: H59.353 Postprocedural seroma of eye and adnexa following an ophthalmic procedure, bilateral Add: H59.359 Postprocedural seroma of unspecified eye and adnexa following an ophthalmic procedure Add: H59.361 Postprocedural seroma of right eye and adnexa following other procedure Add: H59.362 Postprocedural seroma of left eye and adnexa following other procedure Add: H59.363 Postprocedural seroma of eye and adnexa following other procedure, bilateral Add: H59.369 Postprocedural seroma of unspecified eye and adnexa following other procedure Add: H95.51 Postprocedural hematoma of ear and mastoid process following a procedure on the ear and mastoid process Add: H95.52 Postprocedural hematoma of ear and mastoid process following other procedure Add: H95.53 Postprocedural seroma of ear and mastoid process following a procedure on the ear and mastoid process Add: H95.54 Postprocedural seroma of ear and mastoid process following other procedure Delete: I67.0 Dissection of cerebral arteries, nonruptured Delete: I77.71 Dissection of carotid artery Delete: I77.72 Dissection of iliac artery Delete: I77.73 Dissection of renal artery Delete: I77.74 Dissection of vertebral artery Delete: I97.62 Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure Add: I97.620 Postprocedural hemorrhage of a circulatory system organ or structure following other procedure Add: I97.621 Postprocedural hematoma of a circulatory system organ or structure following other procedure Add: I97.622 Postprocedural seroma of a circulatory system organ or structure following other procedure Add: I97.630 Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization Add: I97.631 Postprocedural hematoma of a circulatory system organ or structure following cardiac bypass Add: I97.638 Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure Add: I97.640 Postprocedural seroma of a circulatory system organ or structure following a cardiac catheterization Add: I97.641 Postprocedural seroma of a circulatory system organ or structure following cardiac bypass Add: I97.648 Postprocedural seroma of a circulatory system organ or structure following other circulatory system procedure Add: J95.860 Postprocedural hematoma of a respiratory system organ or structure following a respiratory system procedure Add: J95.861 Postprocedural hematoma of a respiratory system organ or structure following other procedure Add: J95.862 Postprocedural seroma of a respiratory system organ or structure following a respiratory system procedure Add: J95.863 Postprocedural seroma of a respiratory system organ or structure following other procedure Add: J98.51 Mediastinitis Add: K91.870 Postprocedural hematoma of a digestive system organ or structure following a digestive system procedure Add: K91.871 Postprocedural hematoma of a digestive system organ or structure following other procedure Add: K91.872 Postprocedural seroma of a digestive system organ or structure following a digestive system procedure Add: K91.873 Postprocedural seroma of a digestive system organ or structure following other procedure Add: T82.855A Stenosis of coronary artery stent, initial encounter Add: T82.855D Stenosis of coronary artery stent, subsequent encounter Add: T82.856A Stenosis of peripheral vascular stent, initial encounter Add: T82.856D Stenosis of peripheral vascular stent, subsequent encounter Add: T83.011A Breakdown (mechanical) of indwelling urethral catheter, initial encounter Add: T83.011D Breakdown (mechanical) of indwelling urethral catheter, subsequent encounter Add: T83.012A Breakdown (mechanical) of nephrostomy catheter, initial encounter Add: T83.012D Breakdown (mechanical) of nephrostomy catheter, subsequent encounter Add: T83.022A Displacement of nephrostomy catheter, initial encounter Add: T83.022D Displacement of nephrostomy catheter, subsequent encounter Add: T83.032A Leakage of nephrostomy catheter, initial encounter Add: T83.62XD Infection and inflammatory reaction due to implanted testicular prosthesis, subsequent encounter Add: T83.69XA Infection and inflammatory reaction due to other prosthetic device, implant and graft in genital tract, initial encounter Add: T83.69XD Infection and inflammatory reaction due to other prosthetic device, implant and graft in genital tract, subsequent encounter Delete: T83.6XXA Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract, initial encounter Delete: T83.6XXD Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract, subsequent encounter Add: T83.712A Erosion of implanted urethral mesh to surrounding organ or tissue, initial encounter

Page A-45 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: T83.712D Erosion of implanted urethral mesh to surrounding organ or tissue, subsequent encounter Add: T83.713A Erosion of implanted urethral bulking agent to surrounding organ or tissue, initial encounter Add: T83.713D Erosion of implanted urethral bulking agent to surrounding organ or tissue, subsequent encounter Add: T83.714A Erosion of implanted ureteral bulking agent to surrounding organ or tissue, initial encounter Add: T83.714D Erosion of implanted ureteral bulking agent to surrounding organ or tissue, subsequent encounter Add: T83.719A Erosion of other prosthetic materials to surrounding organ or tissue, initial encounter Add: T83.719D Erosion of other prosthetic materials to surrounding organ or tissue, subsequent encounter Add: T83.722A Exposure of implanted urethral mesh into urethra, initial encounter Add: T83.722D Exposure of implanted urethral mesh into urethra, subsequent encounter Add: T83.723A Exposure of implanted urethral bulking agent into urethra, initial encounter Add: T83.723D Exposure of implanted urethral bulking agent into urethra, subsequent encounter Add: T83.724A Exposure of implanted ureteral bulking agent into ureter, initial encounter Add: T83.724D Exposure of implanted ureteral bulking agent into ureter, subsequent encounter Add: T83.729A Exposure of other prosthetic materials into organ or tissue, initial encounter Add: T83.729D Exposure of other prosthetic materials into organ or tissue, subsequent encounter Add: T83.79XA Other specified complications due to other genitourinary prosthetic materials, initial encounter Add: T83.79XD Other specified complications due to other genitourinary prosthetic materials, subsequent encounter Delete: T84.040A Periprosthetic fracture around internal prosthetic right hip joint, initial encounter Delete: T84.040D Periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter Delete: T84.041A Periprosthetic fracture around internal prosthetic left hip joint, initial encounter Delete: T84.041D Periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter Delete: T84.042A Periprosthetic fracture around internal prosthetic right knee joint, initial encounter Delete: T84.042D Periprosthetic fracture around internal prosthetic right knee joint, subsequent encounter Delete: T84.043A Periprosthetic fracture around internal prosthetic left knee joint, initial encounter Delete: T84.043D Periprosthetic fracture around internal prosthetic left knee joint, subsequent encounter Delete: T84.048A Periprosthetic fracture around other internal prosthetic joint, initial encounter Delete: T84.048D Periprosthetic fracture around other internal prosthetic joint, subsequent encounter Delete: T84.049A Periprosthetic fracture around unspecified internal prosthetic joint, initial encounter Delete: T84.049D Periprosthetic fracture around unspecified internal prosthetic joint, subsequent encounter Add: T85.113A Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter Add: T85.113D Breakdown (mechanical) of implanted electronic neurostimulator, generator, subsequent encounter Add: T85.123A Displacement of implanted electronic neurostimulator, generator, initial encounter Add: T85.123D Displacement of implanted electronic neurostimulator, generator, subsequent encounter Add: T85.193A Other mechanical complication of implanted electronic neurostimulator, generator, initial encounter Add: T85.193D Other mechanical complication of implanted electronic neurostimulator, generator, subsequent encounter Add: T85.615A Breakdown (mechanical) of other nervous system device, implant or graft, initial encounter Add: T85.615D Breakdown (mechanical) of other nervous system device, implant or graft, subsequent encounter Add: T85.625A Displacement of other nervous system device, implant or graft, initial encounter Add: T85.625D Displacement of other nervous system device, implant or graft, subsequent encounter Add: T85.635A Leakage of other nervous system device, implant or graft, initial encounter Add: T85.635D Leakage of other nervous system device, implant or graft, subsequent encounter Add: T85.695A Other mechanical complication of other nervous system device, implant or graft, initial encounter Add: T85.695D Other mechanical complication of other nervous system device, implant or graft, subsequent encounter Add: T85.730A Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt, initial encounter Add: T85.730D Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt, subsequent encounter Add: T85.731A Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode (lead), initial encounter Add: T85.731D Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode (lead), subsequent encounter Add: T85.732A Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead), initial encounter Add: T85.732D Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead), subsequent encounter Add: T85.733A Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead), initial encounter Add: T85.733D Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead), subsequent encounter Add: T85.734A Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, initial encounter Add: T85.734D Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, subsequent encounter Add: T85.735A Infection and inflammatory reaction due to cranial or spinal infusion catheter, initial encounter Add: T85.735D Infection and inflammatory reaction due to cranial or spinal infusion catheter, subsequent encounter Add: T85.738A Infection and inflammatory reaction due to other nervous system device, implant or graft, initial encounter Add: T85.738D Infection and inflammatory reaction due to other nervous system device, implant or graft, subsequent encounter

Page A-46 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: T85.810A Embolism due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.810D Embolism due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.818A Embolism due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.818D Embolism due to other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.81XA Embolism due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.81XD Embolism due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: T85.820A Fibrosis due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.820D Fibrosis due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.828A Fibrosis due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.828D Fibrosis due to other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.82XA Fibrosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.82XD Fibrosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: T85.830A Hemorrhage due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.830D Hemorrhage due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.838A Hemorrhage due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.838D Hemorrhage due to other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.83XA Hemorrhage due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.83XD Hemorrhage due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Delete: T85.84XA Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.84XD Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: T85.850A Stenosis due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.850D Stenosis due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.858A Stenosis due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.858D Stenosis due to other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.85XA Stenosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.85XD Stenosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: T85.860A Thrombosis due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.860D Thrombosis due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.868A Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.868D Thrombosis due to other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.86XA Thrombosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.86XD Thrombosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: T85.890A Other specified complication of nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.890D Other specified complication of nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.898A Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter Add: T85.898D Other specified complication of other internal prosthetic devices, implants and grafts, subsequent encounter Delete: T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.89XD Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter Add: 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach Add: 39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy

Line: 292 Condition: CANCER OF ORAL CAVITY, PHARYNX, NOSE AND LARYNX Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex Delete: 31603 Tracheostomy, emergency procedure; transtracheal Add: 42900 Suture pharynx for wound or injury Add: 42950 Pharyngoplasty (plastic or reconstructive operation on pharynx)

Page A-47 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 295 Condition: ACUTE STRESS DISORDER Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 297 Condition: NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS Treatment: MEDICAL AND SURGICAL TREATMENT (EG. DURABLE MEDICAL EQUIPMENT AND ORTHOPEDIC PROCEDURE) Add: G61.82 Multifocal motor neuropathy Delete: G96.8 Other specified disorders of central nervous system Add: G97.61 Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure Add: G97.62 Postprocedural hematoma of a nervous system organ or structure following other procedure Add: G97.63 Postprocedural seroma of a nervous system organ or structure following a nervous system procedure Add: G97.64 Postprocedural seroma of a nervous system organ or structure following other procedure Delete: G98.8 Other disorders of nervous system Delete: I69.01 Cognitive deficits following nontraumatic subarachnoid hemorrhage Add: I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage Add: I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage Add: I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage Add: I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage Add: I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage Add: I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage Add: I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage Delete: I69.11 Cognitive deficits following nontraumatic intracerebral hemorrhage Add: I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage Add: I69.111 Memory deficit following nontraumatic intracerebral hemorrhage Add: I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage Add: I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage Add: I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage Add: I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage Add: I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage Delete: I69.21 Cognitive deficits following other nontraumatic intracranial hemorrhage Add: I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage Add: I69.211 Memory deficit following other nontraumatic intracranial hemorrhage Add: I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage Add: I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage Add: I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage Add: I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage Add: I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage Delete: I69.31 Cognitive deficits following cerebral infarction Add: I69.310 Attention and concentration deficit following cerebral infarction Add: I69.311 Memory deficit following cerebral infarction Add: I69.312 Visuospatial deficit and spatial neglect following cerebral infarction Add: I69.313 Psychomotor deficit following cerebral infarction Add: I69.314 Frontal lobe and executive function deficit following cerebral infarction Add: I69.315 Cognitive social or emotional deficit following cerebral infarction Add: I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction Delete: I69.81 Cognitive deficits following other cerebrovascular disease Add: I69.810 Attention and concentration deficit following other cerebrovascular disease Add: I69.811 Memory deficit following other cerebrovascular disease Add: I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease Add: I69.813 Psychomotor deficit following other cerebrovascular disease Add: I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease Add: I69.815 Cognitive social or emotional deficit following other cerebrovascular disease Add: I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease Delete: I69.91 Cognitive deficits following unspecified cerebrovascular disease Add: I69.910 Attention and concentration deficit following unspecified cerebrovascular disease Add: I69.911 Memory deficit following unspecified cerebrovascular disease Add: I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease Add: I69.913 Psychomotor deficit following unspecified cerebrovascular disease Page A-48 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease Add: I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease Add: I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Delete: P05.01 Newborn light for gestational age, less than 500 grams Delete: P05.02 Newborn light for gestational age, 500-749 grams Delete: P05.03 Newborn light for gestational age, 750-999 grams Delete: P05.04 Newborn light for gestational age, 1000-1249 grams Delete: P05.05 Newborn light for gestational age, 1250-1499 grams Delete: P05.06 Newborn light for gestational age, 1500-1749 grams Delete: P05.07 Newborn light for gestational age, 1750-1999 grams Delete: P05.08 Newborn light for gestational age, 2000-2499 grams Delete: P05.11 Newborn small for gestational age, less than 500 grams Delete: P05.12 Newborn small for gestational age, 500-749 grams Delete: P05.13 Newborn small for gestational age, 750-999 grams Delete: P05.14 Newborn small for gestational age, 1000-1249 grams Delete: P05.15 Newborn small for gestational age, 1250-1499 grams Delete: P05.16 Newborn small for gestational age, 1500-1749 grams Delete: P05.17 Newborn small for gestational age, 1750-1999 grams Delete: P05.18 Newborn small for gestational age, 2000-2499 grams Delete: P05.2 Newborn affected by fetal (intrauterine) malnutrition not light or small for gestational age Delete: P54.0 Neonatal hematemesis Delete: P55.0 Rh isoimmunization of newborn Add: Q87.82 Arterial tortuosity syndrome Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Line: 299 Condition: CANCER OF BRAIN AND NERVOUS SYSTEM Treatment: LINEAR ACCELERATOR, MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only Add: E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type

Line: 301 Condition: CATARACT Treatment: EXTRACTION OF CATARACT Add: 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia

Line: 309 Condition: VIRAL PNEUMONIA Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 315 Condition: CORNEAL OPACITY AND OTHER DISORDERS OF CORNEA Treatment: KERATOPLASTY Add: 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia Add: 92315 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, 1 eye Add: 92316 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes Add: 92317 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens

Line: 316 Condition: HEARING LOSS - AGE 5 OR UNDER Treatment: MEDICAL THERAPY INCLUDING HEARING AIDS, LIMITED SURGICAL THERAPY Add: H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side Add: H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side Add: H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side

Page A-49 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side Add: H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side Add: H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side

Line: 317 Condition: GENDER DYSPHORIA/TRANSEXUALISM Treatment: MEDICAL AND SURGICAL TREATMENT/PSYCHOTHERAPY Add: F64.0 Transsexualism Add: 17110 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Add: 17111 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions Add: 97001 Physical therapy evaluation Add: 97002 Physical therapy re-evaluation Add: 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Add: 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Add: 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

Line: 318 Condition: DISORDERS INVOLVING THE IMMUNE SYSTEM Treatment: MEDICAL THERAPY Add: D89.40 Mast cell activation, unspecified Add: D89.41 Monoclonal mast cell activation syndrome Add: D89.42 Idiopathic mast cell activation syndrome Add: D89.43 Secondary mast cell activation Add: D89.49 Other mast cell activation disorder Add: M04.1 Periodic fever syndromes Add: M04.2 Cryopyrin-associated periodic syndromes Add: M04.8 Other autoinflammatory syndromes Add: M04.9 Autoinflammatory syndrome, unspecified Add: Z51.6 Encounter for desensitization to allergens

Line: 319 Condition: CANCER OF ESOPHAGUS; BARRETT'S ESOPHAGUS WITH DYSPLASIA Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: C49.A1 Gastrointestinal stromal tumor of esophagus

Line: 320 Condition: CANCER OF LIVER Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: C49.A9 Gastrointestinal stromal tumor of other sites Add: 47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

Line: 322 Condition: STROKE Treatment: MEDICAL THERAPY Add: I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries Add: I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries Add: I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries Add: I63.133 Cerebral infarction due to embolism of bilateral carotid arteries Add: I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries Add: I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries Add: I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries Add: I63.323 Cerebral infarction due to thrombosis of bilateral anterior arteries

Page A-50 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: I63.333 Cerebral infarction to thrombosis of bilateral posterior arteries Add: I63.343 Cerebral infarction to thrombosis of bilateral cerebellar arteries Add: I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries Add: I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries Add: I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries Add: I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries Add: I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries Add: I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries Add: I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries Add: I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries Add: I67.0 Dissection of cerebral arteries, nonruptured

Line: 330 Condition: NON-DISSECTING ANEURYSM WITHOUT RUPTURE Treatment: SURGICAL TREATMENT Add: I72.5 Aneurysm of other precerebral arteries Add: I72.6 Aneurysm of vertebral artery Add: Q25.43 Congenital aneurysm of aorta Add: Q25.44 Congenital dilation of aorta

Line: 331 Condition: SENSORINEURAL HEARING LOSS Treatment: COCHLEAR IMPLANT Add: H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side Add: H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side Add: H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side Add: H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side

Line: 332 Condition: FUNCTIONAL AND MECHANICAL DISORDERS OF THE GENITOURINARY SYSTEM INCLUDING BLADDER OUTLET OBSTRUCTION Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)

Line: 337 Condition: CONDITIONS REQUIRING HYPERBARIC OXYGEN THERAPY Treatment: HYPERBARIC OXYGEN Add: K62.7 Radiation proctitis Add: L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation Add: M27.2 Inflammatory conditions of jaws Delete: M27.8 Other specified diseases of jaws Add: N30.40 Irradiation cystitis without hematuria Add: N30.41 Irradiation cystitis with hematuria Delete: T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Delete: T85.89XD Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter

Line: 350 Condition: NEUROLOGICAL DYSFUNCTION IN COMMUNICATION CAUSED BY CHRONIC CONDITIONS Treatment: MEDICAL THERAPY Add: F80.82 Social pragmatic communication disorder Add: G61.82 Multifocal motor neuropathy Delete: G96.8 Other specified disorders of central nervous system Add: G97.61 Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure Add: G97.62 Postprocedural hematoma of a nervous system organ or structure following other procedure Add: G97.63 Postprocedural seroma of a nervous system organ or structure following a nervous system procedure Add: G97.64 Postprocedural seroma of a nervous system organ or structure following other procedure Delete: G98.8 Other disorders of nervous system

Page A-51 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: I69.01 Cognitive deficits following nontraumatic subarachnoid hemorrhage Add: I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage Add: I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage Add: I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage Add: I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage Add: I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage Add: I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage Add: I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage Delete: I69.11 Cognitive deficits following nontraumatic intracerebral hemorrhage Add: I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage Add: I69.111 Memory deficit following nontraumatic intracerebral hemorrhage Add: I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage Add: I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage Add: I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage Add: I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage Add: I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage Delete: I69.21 Cognitive deficits following other nontraumatic intracranial hemorrhage Add: I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage Add: I69.211 Memory deficit following other nontraumatic intracranial hemorrhage Add: I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage Add: I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage Add: I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage Add: I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage Add: I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage Delete: I69.31 Cognitive deficits following cerebral infarction Add: I69.310 Attention and concentration deficit following cerebral infarction Add: I69.311 Memory deficit following cerebral infarction Add: I69.312 Visuospatial deficit and spatial neglect following cerebral infarction Add: I69.313 Psychomotor deficit following cerebral infarction Add: I69.314 Frontal lobe and executive function deficit following cerebral infarction Add: I69.315 Cognitive social or emotional deficit following cerebral infarction Add: I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction Delete: I69.81 Cognitive deficits following other cerebrovascular disease Add: I69.810 Attention and concentration deficit following other cerebrovascular disease Add: I69.811 Memory deficit following other cerebrovascular disease Add: I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease Add: I69.813 Psychomotor deficit following other cerebrovascular disease Add: I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease Add: I69.815 Cognitive social or emotional deficit following other cerebrovascular disease Add: I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease Delete: I69.91 Cognitive deficits following unspecified cerebrovascular disease Add: I69.910 Attention and concentration deficit following unspecified cerebrovascular disease Add: I69.911 Memory deficit following unspecified cerebrovascular disease Add: I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease Add: I69.913 Psychomotor deficit following unspecified cerebrovascular disease Add: I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease Add: I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease Add: I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Delete: P05.01 Newborn light for gestational age, less than 500 grams Delete: P05.02 Newborn light for gestational age, 500-749 grams Delete: P05.03 Newborn light for gestational age, 750-999 grams Delete: P05.04 Newborn light for gestational age, 1000-1249 grams Delete: P05.05 Newborn light for gestational age, 1250-1499 grams Delete: P05.06 Newborn light for gestational age, 1500-1749 grams Delete: P05.07 Newborn light for gestational age, 1750-1999 grams Delete: P05.08 Newborn light for gestational age, 2000-2499 grams Delete: P05.11 Newborn small for gestational age, less than 500 grams Delete: P05.12 Newborn small for gestational age, 500-749 grams Delete: P05.13 Newborn small for gestational age, 750-999 grams Delete: P05.14 Newborn small for gestational age, 1000-1249 grams Delete: P05.15 Newborn small for gestational age, 1250-1499 grams Delete: P05.16 Newborn small for gestational age, 1500-1749 grams Delete: P05.17 Newborn small for gestational age, 1750-1999 grams Delete: P05.18 Newborn small for gestational age, 2000-2499 grams Delete: P05.2 Newborn affected by fetal (intrauterine) malnutrition not light or small for gestational age

Page A-52 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: P54.0 Neonatal hematemesis Delete: P55.0 Rh isoimmunization of newborn Add: Q87.82 Arterial tortuosity syndrome

Line: 351 Condition: CONDITIONS OF THE BACK AND SPINE WITH URGENT SURGICAL INDICATIONS Treatment: SURGICAL THERAPY Delete: M50.02 Cervical disc disorder with myelopathy, mid-cervical region Add: M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level Add: M50.021 Cervical disc disorder at C4-C5 level with myelopathy Add: M50.022 Cervical disc disorder at C5-C6 level with myelopathy Add: M50.023 Cervical disc disorder at C6-C7 level with myelopathy Add: Q06.8 Other specified congenital malformations of spinal cord Add: 99184 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

Line: 358 Condition: STRUCTURAL CAUSES OF AMENORRHEA Treatment: SURGICAL TREATMENT Delete: Q52.12 Longitudinal vaginal septum Add: Q52.121 Longitudinal vaginal septum, obstructing, right side Add: Q52.122 Longitudinal vaginal septum, obstructing, left side Add: Q52.123 Longitudinal vaginal septum, microperforate, right side Add: Q52.124 Longitudinal vaginal septum, microperforate, left side Add: Q52.129 Other and unspecified longitudinal vaginal septum

Line: 360 Condition: CLOSED FRACTURE OF EXTREMITIES (EXCEPT MINOR TOES) Treatment: OPEN OR CLOSED REDUCTION Delete: M84.359D Stress fracture, hip, unspecified, subsequent encounter for fracture with routine healing Delete: M84.359G Stress fracture, hip, unspecified, subsequent encounter for fracture with delayed healing Delete: M84.659A Pathological fracture in other disease, hip, unspecified, initial encounter for fracture Delete: M84.659D Pathological fracture in other disease, hip, unspecified, subsequent encounter for fracture with routine healing Delete: M84.659G Pathological fracture in other disease, hip, unspecified, subsequent encounter for fracture with delayed healing Add: M84.750A Atypical femoral fracture, unspecified, initial encounter for fracture Add: M84.750D Atypical femoral fracture, unspecified, subsequent encounter for fracture with routine healing Add: M84.750G Atypical femoral fracture, unspecified, subsequent encounter for fracture with delayed healing Add: S92.811A Other fracture of right foot, initial encounter for closed fracture Add: S92.811D Other fracture of right foot, subsequent encounter for fracture with routine healing Add: S92.811G Other fracture of right foot, subsequent encounter for fracture with delayed healing Add: S92.812A Other fracture of left foot, initial encounter for closed fracture Add: S92.812D Other fracture of left foot, subsequent encounter for fracture with routine healing Add: S92.812G Other fracture of left foot, subsequent encounter for fracture with delayed healing Add: S92.819A Other fracture of unspecified foot, initial encounter for closed fracture Add: S92.819D Other fracture of unspecified foot, subsequent encounter for fracture with routine healing Add: S92.819G Other fracture of unspecified foot, subsequent encounter for fracture with delayed healing Add: S99.001A Unspecified physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.001D Unspecified physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.001G Unspecified physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.002A Unspecified physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.002D Unspecified physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.002G Unspecified physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing Add: S99.009A Unspecified physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.009D Unspecified physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.009G Unspecified physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.011A Salter-Harris Type I physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.011D Salter-Harris Type I physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.011G Salter-Harris Type I physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.012A Salter-Harris Type I physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.012D Salter-Harris Type I physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.012G Salter-Harris Type I physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing

Page A-53 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.019A Salter-Harris Type I physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.019D Salter-Harris Type I physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.019G Salter-Harris Type I physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.021A Salter-Harris Type II physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.021D Salter-Harris Type II physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.021G Salter-Harris Type II physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.022A Salter-Harris Type II physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.022D Salter-Harris Type II physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.022G Salter-Harris Type II physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing Add: S99.029A Salter-Harris Type II physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.029D Salter-Harris Type II physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.029G Salter-Harris Type II physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.031A Salter-Harris Type III physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.031D Salter-Harris Type III physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.031G Salter-Harris Type III physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.032A Salter-Harris Type III physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.032D Salter-Harris Type III physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.032G Salter-Harris Type III physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing Add: S99.039A Salter-Harris Type III physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.039D Salter-Harris Type III physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.039G Salter-Harris Type III physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.041A Salter-Harris Type IV physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.041D Salter-Harris Type IV physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.041G Salter-Harris Type IV physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.042A Salter-Harris Type IV physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.042D Salter-Harris Type IV physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.042G Salter-Harris Type IV physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing Add: S99.049A Salter-Harris Type IV physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.049D Salter-Harris Type IV physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.049G Salter-Harris Type IV physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.091A Other physeal fracture of right calcaneus, initial encounter for closed fracture Add: S99.091D Other physeal fracture of right calcaneus, subsequent encounter for fracture with routine healing Add: S99.091G Other physeal fracture of right calcaneus, subsequent encounter for fracture with delayed healing Add: S99.092A Other physeal fracture of left calcaneus, initial encounter for closed fracture Add: S99.092D Other physeal fracture of left calcaneus, subsequent encounter for fracture with routine healing Add: S99.092G Other physeal fracture of left calcaneus, subsequent encounter for fracture with delayed healing Add: S99.099A Other physeal fracture of unspecified calcaneus, initial encounter for closed fracture Add: S99.099D Other physeal fracture of unspecified calcaneus, subsequent encounter for fracture with routine healing Add: S99.099G Other physeal fracture of unspecified calcaneus, subsequent encounter for fracture with delayed healing Add: S99.101A Unspecified physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.101D Unspecified physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.101G Unspecified physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.102A Unspecified physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.102D Unspecified physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.102G Unspecified physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.109A Unspecified physeal fracture of unspecified metatarsal, initial encounter for closed fracture Add: S99.109D Unspecified physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.109G Unspecified physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: S99.111A Salter-Harris Type I physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.111D Salter-Harris Type I physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.111G Salter-Harris Type I physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.112A Salter-Harris Type I physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.112D Salter-Harris Type I physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.112G Salter-Harris Type I physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.119A Salter-Harris Type I physeal fracture of unspecified metatarsal, initial encounter for closed fracture

Page A-54 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.119D Salter-Harris Type I physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.119G Salter-Harris Type I physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: S99.121A Salter-Harris Type II physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.121D Salter-Harris Type II physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.121G Salter-Harris Type II physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.122A Salter-Harris Type II physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.122D Salter-Harris Type II physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.122G Salter-Harris Type II physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.129A Salter-Harris Type II physeal fracture of unspecified metatarsal, initial encounter for closed fracture Add: S99.129D Salter-Harris Type II physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.129G Salter-Harris Type II physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: S99.131A Salter-Harris Type III physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.131D Salter-Harris Type III physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.131G Salter-Harris Type III physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.132A Salter-Harris Type III physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.132D Salter-Harris Type III physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.132G Salter-Harris Type III physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.139A Salter-Harris Type III physeal fracture of unspecified metatarsal, initial encounter for closed fracture Add: S99.139D Salter-Harris Type III physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.139G Salter-Harris Type III physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: S99.141A Salter-Harris Type IV physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.141D Salter-Harris Type IV physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.141G Salter-Harris Type IV physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.142A Salter-Harris Type IV physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.142D Salter-Harris Type IV physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.142G Salter-Harris Type IV physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.149A Salter-Harris Type IV physeal fracture of unspecified metatarsal, initial encounter for closed fracture Add: S99.149D Salter-Harris Type IV physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.149G Salter-Harris Type IV physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: S99.191A Other physeal fracture of right metatarsal, initial encounter for closed fracture Add: S99.191D Other physeal fracture of right metatarsal, subsequent encounter for fracture with routine healing Add: S99.191G Other physeal fracture of right metatarsal, subsequent encounter for fracture with delayed healing Add: S99.192A Other physeal fracture of left metatarsal, initial encounter for closed fracture Add: S99.192D Other physeal fracture of left metatarsal, subsequent encounter for fracture with routine healing Add: S99.192G Other physeal fracture of left metatarsal, subsequent encounter for fracture with delayed healing Add: S99.199A Other physeal fracture of unspecified metatarsal, initial encounter for closed fracture Add: S99.199D Other physeal fracture of unspecified metatarsal, subsequent encounter for fracture with routine healing Add: S99.199G Other physeal fracture of unspecified metatarsal, subsequent encounter for fracture with delayed healing Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Line: 361 Condition: RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE Treatment: ARTHROPLASTY/RECONSTRUCTION Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Line: 363 Condition: BODY INFESTATIONS (EG. LICE, SCABIES) Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Page A-55 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 364 Condition: DEFORMITY/CLOSED DISLOCATION OF MAJOR JOINT AND RECURRENT JOINT DISLOCATIONS Treatment: SURGICAL TREATMENT Delete: Q71.00 Congenital complete absence of unspecified upper limb Delete: Q71.01 Congenital complete absence of right upper limb Delete: Q71.02 Congenital complete absence of left upper limb Delete: Q71.03 Congenital complete absence of upper limb, bilateral Delete: Q71.10 Congenital absence of unspecified upper arm and forearm with hand present Delete: Q71.11 Congenital absence of right upper arm and forearm with hand present Delete: Q71.12 Congenital absence of left upper arm and forearm with hand present Delete: Q71.13 Congenital absence of upper arm and forearm with hand present, bilateral Delete: Q71.20 Congenital absence of both forearm and hand, unspecified upper limb Delete: Q71.21 Congenital absence of both forearm and hand, right upper limb Delete: Q71.22 Congenital absence of both forearm and hand, left upper limb Delete: Q71.23 Congenital absence of both forearm and hand, bilateral Delete: Q71.30 Congenital absence of unspecified hand and finger Delete: Q71.31 Congenital absence of right hand and finger Delete: Q71.32 Congenital absence of left hand and finger Delete: Q71.33 Congenital absence of hand and finger, bilateral Delete: Q72.00 Congenital complete absence of unspecified lower limb Delete: Q72.01 Congenital complete absence of right lower limb Delete: Q72.02 Congenital complete absence of left lower limb Delete: Q72.03 Congenital complete absence of lower limb, bilateral Delete: Q72.10 Congenital absence of unspecified thigh and lower leg with foot present Delete: Q72.11 Congenital absence of right thigh and lower leg with foot present Delete: Q72.12 Congenital absence of left thigh and lower leg with foot present Delete: Q72.13 Congenital absence of thigh and lower leg with foot present, bilateral Delete: Q72.20 Congenital absence of both lower leg and foot, unspecified lower limb Delete: Q72.21 Congenital absence of both lower leg and foot, right lower limb Delete: Q72.22 Congenital absence of both lower leg and foot, left lower limb Delete: Q72.23 Congenital absence of both lower leg and foot, bilateral Delete: Q72.30 Congenital absence of unspecified foot and toe(s) Delete: Q72.31 Congenital absence of right foot and toe(s) Delete: Q72.32 Congenital absence of left foot and toe(s) Delete: Q72.33 Congenital absence of foot and toe(s), bilateral Delete: Q73.0 Congenital absence of unspecified limb(s) Delete: M43.3 Recurrent atlantoaxial dislocation with myelopathy Delete: M43.4 Other recurrent atlantoaxial dislocation Delete: M43.5X2 Other recurrent vertebral dislocation, cervical region Delete: M43.5X3 Other recurrent vertebral dislocation, cervicothoracic region Delete: M43.5X4 Other recurrent vertebral dislocation, thoracic region Delete: M43.5X5 Other recurrent vertebral dislocation, thoracolumbar region Delete: M43.5X6 Other recurrent vertebral dislocation, lumbar region Delete: M43.5X7 Other recurrent vertebral dislocation, lumbosacral region Delete: M43.5X8 Other recurrent vertebral dislocation, sacral and sacrococcygeal region Delete: M43.5X9 Other recurrent vertebral dislocation, site unspecified Delete: M99.16 Subluxation complex (vertebral) of lower extremity Delete: M99.17 Subluxation complex (vertebral) of upper extremity Delete: M99.18 Subluxation complex (vertebral) of rib cage Delete: M99.19 Subluxation complex (vertebral) of abdomen and other regions Delete: Q66.2 Congenital metatarsus (primus) varus Add: Q66.21 Congenital metatarsus primus varus Add: Q66.22 Congenital metatarsus adductus Add: S03.00XA Dislocation of jaw, unspecified side, initial encounter Add: S03.00XD Dislocation of jaw, unspecified side, subsequent encounter Add: S03.01XA Dislocation of jaw, right side, initial encounter Add: S03.01XD Dislocation of jaw, right side, subsequent encounter Add: S03.02XA Dislocation of jaw, left side, initial encounter Add: S03.02XD Dislocation of jaw, left side, subsequent encounter Add: S03.03XA Dislocation of jaw, bilateral, initial encounter Add: S03.03XD Dislocation of jaw, bilateral, subsequent encounter Delete: S03.0XXA Dislocation of jaw, initial encounter Delete: S03.0XXD Dislocation of jaw, subsequent encounter Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Page A-56 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 366 Condition: SCOLIOSIS Treatment: MEDICAL AND SURGICAL THERAPY Delete: 63200 Laminectomy, with release of tethered spinal cord, lumbar Add: 99184 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

Line: 367 Condition: DYSTONIA (UNCONTROLLABLE); LARYNGEAL SPASM Treatment: MEDICAL THERAPY Delete: J38.6 Stenosis of larynx Delete: 31528 Laryngoscopy direct, with or without tracheoscopy; with dilation, initial Delete: 31529 Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent Delete: 31582 Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy

Line: 375 Condition: AMBLYOPIA Treatment: MEDICAL AND SURGICAL TREATMENT Add: 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia

Line: 377 Condition: BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANS Treatment: LOBECTOMY, MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY Delete: 77520 Proton treatment delivery; simple, without compensation Delete: 77522 Proton treatment delivery; simple, with compensation Delete: 77523 Proton treatment delivery; intermediate Delete: 77525 Proton treatment delivery; complex

Line: 378 Condition: ACNE CONGLOBATA (SEVERE CYSTIC ACNE) Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair Delete: 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Delete: 11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair Delete: 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Delete: 11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair Delete: 11471 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 382 Condition: DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF- DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION Treatment: MEDICAL THERAPY (SHORT TERM REHABILITATION WITH DEFINED GOALS) Add: G61.82 Multifocal motor neuropathy Delete: G96.8 Other specified disorders of central nervous system Add: G97.61 Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure Add: G97.62 Postprocedural hematoma of a nervous system organ or structure following other procedure Add: G97.63 Postprocedural seroma of a nervous system organ or structure following a nervous system procedure Add: G97.64 Postprocedural seroma of a nervous system organ or structure following other procedure Delete: G98.8 Other disorders of nervous system Add: Q71.00 Congenital complete absence of unspecified upper limb Add: Q71.01 Congenital complete absence of right upper limb Add: Q71.02 Congenital complete absence of left upper limb Add: Q71.03 Congenital complete absence of upper limb, bilateral Add: Q71.10 Congenital absence of unspecified upper arm and forearm with hand present

Page A-57 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: Q71.11 Congenital absence of right upper arm and forearm with hand present Add: Q71.12 Congenital absence of left upper arm and forearm with hand present Add: Q71.13 Congenital absence of upper arm and forearm with hand present, bilateral Add: Q71.20 Congenital absence of both forearm and hand, unspecified upper limb Add: Q71.21 Congenital absence of both forearm and hand, right upper limb Add: Q71.22 Congenital absence of both forearm and hand, left upper limb Add: Q71.23 Congenital absence of both forearm and hand, bilateral Add: Q71.30 Congenital absence of unspecified hand and finger Add: Q71.31 Congenital absence of right hand and finger Add: Q71.32 Congenital absence of left hand and finger Add: Q71.33 Congenital absence of hand and finger, bilateral Add: Q72.00 Congenital complete absence of unspecified lower limb Add: Q72.01 Congenital complete absence of right lower limb Add: Q72.02 Congenital complete absence of left lower limb Add: Q72.03 Congenital complete absence of lower limb, bilateral Add: Q72.10 Congenital absence of unspecified thigh and lower leg with foot present Add: Q72.11 Congenital absence of right thigh and lower leg with foot present Add: Q72.12 Congenital absence of left thigh and lower leg with foot present Add: Q72.13 Congenital absence of thigh and lower leg with foot present, bilateral Add: Q72.20 Congenital absence of both lower leg and foot, unspecified lower limb Add: Q72.21 Congenital absence of both lower leg and foot, right lower limb Add: Q72.22 Congenital absence of both lower leg and foot, left lower limb Add: Q72.23 Congenital absence of both lower leg and foot, bilateral Add: Q72.30 Congenital absence of unspecified foot and toe(s) Add: Q72.31 Congenital absence of right foot and toe(s) Add: Q72.32 Congenital absence of left foot and toe(s) Add: Q72.33 Congenital absence of foot and toe(s), bilateral Add: Q73.0 Congenital absence of unspecified limb(s) Delete: I69.01 Cognitive deficits following nontraumatic subarachnoid hemorrhage Add: I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage Add: I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage Add: I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage Add: I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage Add: I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage Add: I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage Add: I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage Delete: I69.11 Cognitive deficits following nontraumatic intracerebral hemorrhage Add: I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage Add: I69.111 Memory deficit following nontraumatic intracerebral hemorrhage Add: I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage Add: I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage Add: I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage Add: I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage Add: I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage Delete: I69.21 Cognitive deficits following other nontraumatic intracranial hemorrhage Add: I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage Add: I69.211 Memory deficit following other nontraumatic intracranial hemorrhage Add: I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage Add: I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage Add: I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage Add: I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage Add: I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage Delete: I69.31 Cognitive deficits following cerebral infarction Add: I69.310 Attention and concentration deficit following cerebral infarction Add: I69.311 Memory deficit following cerebral infarction Add: I69.312 Visuospatial deficit and spatial neglect following cerebral infarction Add: I69.313 Psychomotor deficit following cerebral infarction Add: I69.314 Frontal lobe and executive function deficit following cerebral infarction Add: I69.315 Cognitive social or emotional deficit following cerebral infarction Add: I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction Delete: I69.81 Cognitive deficits following other cerebrovascular disease Add: I69.810 Attention and concentration deficit following other cerebrovascular disease Add: I69.811 Memory deficit following other cerebrovascular disease Add: I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease Add: I69.813 Psychomotor deficit following other cerebrovascular disease

Page A-58 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease Add: I69.815 Cognitive social or emotional deficit following other cerebrovascular disease Add: I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease Delete: I69.91 Cognitive deficits following unspecified cerebrovascular disease Add: I69.910 Attention and concentration deficit following unspecified cerebrovascular disease Add: I69.911 Memory deficit following unspecified cerebrovascular disease Add: I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease Add: I69.913 Psychomotor deficit following unspecified cerebrovascular disease Add: I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease Add: I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease Add: I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Delete: P05.01 Newborn light for gestational age, less than 500 grams Delete: P05.02 Newborn light for gestational age, 500-749 grams Delete: P05.03 Newborn light for gestational age, 750-999 grams Delete: P05.04 Newborn light for gestational age, 1000-1249 grams Delete: P05.05 Newborn light for gestational age, 1250-1499 grams Delete: P05.06 Newborn light for gestational age, 1500-1749 grams Delete: P05.07 Newborn light for gestational age, 1750-1999 grams Delete: P05.08 Newborn light for gestational age, 2000-2499 grams Delete: P05.11 Newborn small for gestational age, less than 500 grams Delete: P05.12 Newborn small for gestational age, 500-749 grams Delete: P05.13 Newborn small for gestational age, 750-999 grams Delete: P05.14 Newborn small for gestational age, 1000-1249 grams Delete: P05.15 Newborn small for gestational age, 1250-1499 grams Delete: P05.16 Newborn small for gestational age, 1500-1749 grams Delete: P05.17 Newborn small for gestational age, 1750-1999 grams Delete: P05.18 Newborn small for gestational age, 2000-2499 grams Delete: P05.2 Newborn affected by fetal (intrauterine) malnutrition not light or small for gestational age Delete: P54.0 Neonatal hematemesis Delete: P55.0 Rh isoimmunization of newborn Add: Q87.82 Arterial tortuosity syndrome

Line: 383 Condition: ESOPHAGEAL STRICTURE; ACHALASIA Treatment: MEDICAL AND SURGICAL TREATMENT Add: K20.0 Eosinophilic esophagitis

Line: 384 Condition: CHRONIC ULCER OF SKIN Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

Line: 385 Condition: ESOPHAGITIS; GERD Treatment: SHORT-TERM MEDICAL THERAPY; SURGICAL TREATMENT Delete: K20.0 Eosinophilic esophagitis Add: K22.710 Barrett's esophagus with low grade dysplasia Delete: K44.0 Diaphragmatic hernia with obstruction, without gangrene Delete: K44.1 Diaphragmatic hernia with gangrene Delete: 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Delete: 39540 Repair, diaphragmatic hernia (other than neonatal), traumatic; acute Delete: 39541 Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic Delete: 39560 Resection, diaphragm; with simple repair (eg, primary suture) Delete: 39561 Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap)

Page A-59 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 386 Condition: BULIMIA NERVOSA AND UNSPECIFIED EATING DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: F50.8 Other eating disorders Add: F50.81 Binge eating disorder Add: F50.89 Other specified eating disorder Delete: 99184 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

Line: 397 Condition: PANIC DISORDER; AGORAPHOBIA Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 398 Condition: CROUP SYNDROME, EPIGLOTTITIS, ACUTE LARYNGOTRACHEITIS Treatment: MEDICAL THERAPY, INTUBATION, TRACHEOTOMY Delete: 31603 Tracheostomy, emergency procedure; transtracheal Delete: 31605 Tracheostomy, emergency procedure; cricothyroid membrane

Line: 399 Condition: STRABISMUS WITHOUT AMBLYOPIA AND OTHER DISORDERS OF BINOCULAR EYE MOVEMENTS; CONGENITAL ANOMALIES OF EYE; LACRIMAL DUCT OBSTRUCTION IN CHILDREN Treatment: MEDICAL AND SURGICAL TREATMENT Add: 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia

Line: 402 Condition: ACUTE MYELOID LEUKEMIA Treatment: BONE MARROW TRANSPLANT AND MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY, RADIATION AND RADIONUCLEIDE THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex

Line: 403 Condition: MYELOID DISORDERS Treatment: MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 77520 Proton treatment delivery; simple, without compensation Add: 77522 Proton treatment delivery; simple, with compensation Add: 77523 Proton treatment delivery; intermediate Add: 77525 Proton treatment delivery; complex

Line: 406 Condition: BENIGN CONDITIONS OF BONE AND JOINTS AT HIGH RISK FOR COMPLICATIONS Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: Q79.8 Other congenital malformations of musculoskeletal system Add: Q67.6 Pectus excavatum Add: 21740 Reconstructive repair of pectus excavatum or carinatum; open Add: 21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy Add: 21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy

Page A-60 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 407 Condition: CONDITIONS OF THE BACK AND SPINE Treatment: RISK ASSESSMENT, PHYSICAL MODALITIES, COGNITIVE BEHAVIORAL THERAPY, MEDICAL THERAPY Add: S9451 Exercise classes, non-physician provider, per session Delete: M43.6 Torticollis

Line: 412 Condition: DISSOCIATIVE DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 413 Condition: EPIDERMOLYSIS BULLOSA Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 417 Condition: SCHIZOTYPAL PERSONALITY DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 418 Condition: BALANOPOSTHITIS AND OTHER DISORDERS OF PENIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)

Line: 419 Condition: OVERANXIOUS DISORDER; GENERALIZED ANXIETY DISORDER; ANXIETY DISORDER, UNSPECIFIED Treatment: MEDICAL/PSYCHOTHERAPY Delete: 99184 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

Line: 420 Condition: TRANSIENT CEREBRAL ISCHEMIA; OCCLUSION/STENOSIS OF PRECEREBRAL ARTERIES WITHOUT OCCLUSION Treatment: MEDICAL THERAPY; THROMBOENDARTERECTOMY Add: I77.71 Dissection of carotid artery Add: I77.74 Dissection of vertebral artery Add: I77.75 Dissection of other precerebral arteries

Line: 421 Condition: PERIPHERAL NERVE ENTRAPMENT; PALMAR FASCIAL FIBROMATOSIS Treatment: MEDICAL AND SURGICAL TREATMENT Add: G56.03 Carpal tunnel syndrome, bilateral upper limbs Add: G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs Add: G57.43 Lesion of medial popliteal nerve, bilateral lower limbs Add: G57.53 Tarsal tunnel syndrome, bilateral lower limbs Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Page A-61 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 427 Condition: LYMPHEDEMA Treatment: MEDICAL THERAPY, OTHER OPERATION ON LYMPH CHANNEL Add: 97016 Application of a modality to 1 or more areas; vasopneumatic devices

Line: 428 Condition: COMPLICATIONS OF A PROCEDURE USUALLY REQUIRING TREATMENT Treatment: MEDICAL AND SURGICAL TREATMENT Add: D78.31 Postprocedural hematoma of the spleen following a procedure on the spleen Add: D78.32 Postprocedural hematoma of the spleen following other procedure Add: D78.33 Postprocedural seroma of the spleen following a procedure on the spleen Add: D78.34 Postprocedural seroma of the spleen following other procedure Add: E89.820 Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure Add: E89.821 Postprocedural hematoma of an endocrine system organ or structure following other procedure Add: E89.822 Postprocedural seroma of an endocrine system organ or structure following an endocrine system procedure Add: E89.823 Postprocedural seroma of an endocrine system organ or structure following other procedure Add: T83.091A Other mechanical complication of indwelling urethral catheter, initial encounter Add: T83.091D Other mechanical complication of indwelling urethral catheter, subsequent encounter Add: T83.411A Breakdown (mechanical) of implanted testicular prosthesis, initial encounter Add: T83.411D Breakdown (mechanical) of implanted testicular prosthesis, subsequent encounter Add: T83.421A Displacement of implanted testicular prosthesis, initial encounter Add: T83.421D Displacement of implanted testicular prosthesis, subsequent encounter Add: T83.491A Other mechanical complication of implanted testicular prosthesis, initial encounter Add: T83.491D Other mechanical complication of implanted testicular prosthesis, subsequent encounter Add: L76.31 Postprocedural hematoma of skin and subcutaneous tissue following a dermatologic procedure Add: L76.32 Postprocedural hematoma of skin and subcutaneous tissue following other procedure Add: L76.33 Postprocedural seroma of skin and subcutaneous tissue following a dermatologic procedure Add: L76.34 Postprocedural seroma of skin and subcutaneous tissue following other procedure Add: O89.4 Spinal and epidural anesthesia-induced headache during the puerperium Add: T83.021A Displacement of indwelling urethral catheter, initial encounter Add: T83.021D Displacement of indwelling urethral catheter, subsequent encounter Add: T83.031A Leakage of indwelling urethral catheter, initial encounter Add: T83.031D Leakage of indwelling urethral catheter, subsequent encounter Add: T83.712A Erosion of implanted urethral mesh to surrounding organ or tissue, initial encounter Add: T83.712D Erosion of implanted urethral mesh to surrounding organ or tissue, subsequent encounter Add: T83.713A Erosion of implanted urethral bulking agent to surrounding organ or tissue, initial encounter Add: T83.713D Erosion of implanted urethral bulking agent to surrounding organ or tissue, subsequent encounter Add: T83.714A Erosion of implanted ureteral bulking agent to surrounding organ or tissue, initial encounter Add: T83.714D Erosion of implanted ureteral bulking agent to surrounding organ or tissue, subsequent encounter Add: T83.719A Erosion of other prosthetic materials to surrounding organ or tissue, initial encounter Add: T83.719D Erosion of other prosthetic materials to surrounding organ or tissue, subsequent encounter Add: T83.722A Exposure of implanted urethral mesh into urethra, initial encounter Add: T83.722D Exposure of implanted urethral mesh into urethra, subsequent encounter Add: T83.723A Exposure of implanted urethral bulking agent into urethra, initial encounter Add: T83.723D Exposure of implanted urethral bulking agent into urethra, subsequent encounter Add: T83.724A Exposure of implanted ureteral bulking agent into ureter, initial encounter Add: T83.724D Exposure of implanted ureteral bulking agent into ureter, subsequent encounter Add: T83.729A Exposure of other prosthetic materials into organ or tissue, initial encounter Add: T83.729D Exposure of other prosthetic materials into organ or tissue, subsequent encounter Add: T83.79XA Other specified complications due to other genitourinary prosthetic materials, initial encounter Add: T83.79XD Other specified complications due to other genitourinary prosthetic materials, subsequent encounter Add: T85.840A Pain due to nervous system prosthetic devices, implants and grafts, initial encounter Add: T85.840D Pain due to nervous system prosthetic devices, implants and grafts, subsequent encounter Add: T85.848A Pain due to other internal prosthetic devices, implants and grafts, initial encounter Add: T85.848D Pain due to other internal prosthetic devices, implants and grafts, subsequent encounter Add: T88.53XA Unintended awareness under general anesthesia during procedure, initial encounter Add: T88.53XD Unintended awareness under general anesthesia during procedure, subsequent encounter Delete: 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

Page A-62 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 430 Condition: SEVERE INFLAMMATORY SKIN DISEASE Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 431 Condition: ACUTE PERIPHERAL MOTOR AND DIGITAL NERVE INJURY Treatment: SURGICAL THERAPY Add: G57.23 Lesion of femoral nerve, bilateral lower limbs Delete: 27175 Treatment of slipped femoral epiphysis; by traction, without reduction Delete: 27176 Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Delete: 27177 Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) Delete: 27178 Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning Delete: 27179 Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) Delete: 27181 Open treatment of slipped femoral epiphysis; osteotomy and internal fixation Delete: 27185 Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur

Line: 434 Condition: NONINFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUS; OVARIAN CYSTS; GONADAL DYSGENISIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: N83.0 Follicular cyst of ovary Delete: N83.1 Corpus luteum cyst Delete: N83.20 Unspecified ovarian cysts Delete: N83.29 Other ovarian cysts Delete: N83.4 Prolapse and hernia of ovary and fallopian tube

Line: 436 Condition: INTERNAL DERANGEMENT OF KNEE AND LIGAMENTOUS DISRUPTIONS OF THE KNEE, RESULTING IN SIGNIFICANT INJURY/IMPAIRMENT Treatment: REPAIR, MEDICAL THERAPY Add: 20924 Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)

Line: 438 Condition: HYPOSPADIAS AND EPISPADIAS Treatment: REPAIR Delete: Q54.9 Hypospadias, unspecified Delete: 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)

Line: 442 Condition: STEREOTYPY/HABIT DISORDER AND SELF-ABUSIVE BEHAVIOR DUE TO NEUROLOGICAL DYSFUNCTION Treatment: CONSULTATION/MEDICATION MANAGEMENT/LIMITED BEHAVIORAL MODIFICATION Delete: 99184 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

Line: 445 Condition: VENOUS TRIBUTARY (BRANCH) OCCLUSION; CENTRAL RETINAL VEIN OCCLUSION Treatment: SURGICAL TREATMENT INCLUDING LASER SURGERY, MEDICAL THERAPY INCLUDING INJECTION Delete: H34.811 Central retinal vein occlusion, right eye Add: H34.8110 Central retinal vein occlusion, right eye, with macular edema Add: H34.8111 Central retinal vein occlusion, right eye, with retinal neovascularization Add: H34.8112 Central retinal vein occlusion, right eye, stable Delete: H34.812 Central retinal vein occlusion, left eye Add: H34.8120 Central retinal vein occlusion, left eye, with macular edema Add: H34.8121 Central retinal vein occlusion, left eye, with retinal neovascularization Add: H34.8122 Central retinal vein occlusion, left eye, stable Delete: H34.813 Central retinal vein occlusion, bilateral Page A-63 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: H34.8130 Central retinal vein occlusion, bilateral, with macular edema Add: H34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularization Add: H34.8132 Central retinal vein occlusion, bilateral, stable Delete: H34.819 Central retinal vein occlusion, unspecified eye Add: H34.8190 Central retinal vein occlusion, unspecified eye, with macular edema Add: H34.8191 Central retinal vein occlusion, unspecified eye, with retinal neovascularization Add: H34.8192 Central retinal vein occlusion, unspecified eye, stable Delete: H34.831 Tributary (branch) retinal vein occlusion, right eye Add: H34.8310 Tributary (branch) retinal vein occlusion, right eye, with macular edema Add: H34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization Add: H34.8312 Tributary (branch) retinal vein occlusion, right eye, stable Delete: H34.832 Tributary (branch) retinal vein occlusion, left eye Add: H34.8320 Tributary (branch) retinal vein occlusion, left eye, with macular edema Add: H34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularization Add: H34.8322 Tributary (branch) retinal vein occlusion, left eye, stable Delete: H34.833 Tributary (branch) retinal vein occlusion, bilateral Add: H34.8330 Tributary (branch) retinal vein occlusion, bilateral, with macular edema Add: H34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization Add: H34.8332 Tributary (branch) retinal vein occlusion, bilateral, stable Delete: H34.839 Tributary (branch) retinal vein occlusion, unspecified eye Add: H34.8390 Tributary (branch) retinal vein occlusion, unspecified eye, with macular edema Add: H34.8391 Tributary (branch) retinal vein occlusion, unspecified eye, with retinal neovascularization Add: H34.8392 Tributary (branch) retinal vein occlusion, unspecified eye, stable

Line: 447 Condition: MALUNION AND NONUNION OF FRACTURE Treatment: SURGICAL TREATMENT Add: M84.750K Atypical femoral fracture, unspecified, subsequent encounter for fracture with nonunion Add: M84.750P Atypical femoral fracture, unspecified, subsequent encounter for fracture with malunion Add: M84.751K Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion Add: M84.751P Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with malunion Add: M84.752K Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion Add: M84.752P Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with malunion Add: M84.753K Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion Add: M84.753P Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion Add: M84.754K Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion Add: M84.754P Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with malunion Add: M84.755K Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion Add: M84.755P Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with malunion Add: M84.756K Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion Add: M84.756P Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion Add: M84.757K Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion Add: M84.757P Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with malunion Add: M84.758K Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion Add: M84.758P Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with malunion Add: M84.759K Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion Add: M84.759P Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion Add: S02.101K Fracture of base of skull, right side, subsequent encounter for fracture with nonunion Add: S02.102K Fracture of base of skull, left side, subsequent encounter for fracture with nonunion Add: S02.109K Fracture of base of skull, unspecified side, subsequent encounter for fracture with nonunion Delete: S02.10XK Unspecified fracture of base of skull, subsequent encounter for fracture with nonunion Add: S02.11AK Type I occipital condyle fracture, right side, subsequent encounter for fracture with nonunion Add: S02.11BK Type I occipital condyle fracture, left side, subsequent encounter for fracture with nonunion Add: S02.11CK Type II occipital condyle fracture, right side, subsequent encounter for fracture with nonunion Add: S02.11DK Type II occipital condyle fracture, left side, subsequent encounter for fracture with nonunion Add: S02.11EK Type III occipital condyle fracture, right side, subsequent encounter for fracture with nonunion Add: S02.11FK Type III occipital condyle fracture, left side, subsequent encounter for fracture with nonunion Add: S02.11GK Other fracture of occiput, right side, subsequent encounter for fracture with nonunion Add: S02.11HK Other fracture of occiput, left side, subsequent encounter for fracture with nonunion Add: S02.30XK Fracture of orbital floor, unspecified side, subsequent encounter for fracture with nonunion Add: S02.31XK Fracture of orbital floor, right side, subsequent encounter for fracture with nonunion Add: S02.32XK Fracture of orbital floor, left side, subsequent encounter for fracture with nonunion

Page A-64 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: S02.3XXK Fracture of orbital floor, subsequent encounter for fracture with nonunion Add: S02.40AK Malar fracture, right side, subsequent encounter for fracture with nonunion Add: S02.40BK Malar fracture, left side, subsequent encounter for fracture with nonunion Add: S02.40CK Maxillary fracture, right side, subsequent encounter for fracture with nonunion Add: S02.40DK Maxillary fracture, left side, subsequent encounter for fracture with nonunion Add: S02.40EK Zygomatic fracture, right side, subsequent encounter for fracture with nonunion Add: S02.40FK Zygomatic fracture, left side, subsequent encounter for fracture with nonunion Add: S02.601K Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with nonunion Add: S02.602K Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with nonunion Add: S02.610K Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.611K Fracture of condylar process of right mandible, subsequent encounter for fracture with nonunion Add: S02.612K Fracture of condylar process of left mandible, subsequent encounter for fracture with nonunion Delete: S02.61XK Fracture of condylar process of mandible, subsequent encounter for fracture with nonunion Add: S02.620K Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.621K Fracture of subcondylar process of right mandible, subsequent encounter for fracture with nonunion Add: S02.622K Fracture of subcondylar process of left mandible, subsequent encounter for fracture with nonunion Delete: S02.62XK Fracture of subcondylar process of mandible, subsequent encounter for fracture with nonunion Add: S02.630K Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.631K Fracture of coronoid process of right mandible, subsequent encounter for fracture with nonunion Add: S02.632K Fracture of coronoid process of left mandible, subsequent encounter for fracture with nonunion Delete: S02.63XK Fracture of coronoid process of mandible, subsequent encounter for fracture with nonunion Add: S02.640K Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.641K Fracture of ramus of right mandible, subsequent encounter for fracture with nonunion Add: S02.642K Fracture of ramus of left mandible, subsequent encounter for fracture with nonunion Delete: S02.64XK Fracture of ramus of mandible, subsequent encounter for fracture with nonunion Add: S02.650K Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.651K Fracture of angle of right mandible, subsequent encounter for fracture with nonunion Add: S02.652K Fracture of angle of left mandible, subsequent encounter for fracture with nonunion Delete: S02.65XK Fracture of angle of mandible, subsequent encounter for fracture with nonunion Add: S02.670K Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with nonunion Add: S02.671K Fracture of alveolus of right mandible, subsequent encounter for fracture with nonunion Add: S02.672K Fracture of alveolus of left mandible, subsequent encounter for fracture with nonunion Delete: S02.67XK Fracture of alveolus of mandible, subsequent encounter for fracture with nonunion Add: S02.80XK Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with nonunion Add: S02.81XK Fracture of other specified skull and facial bones, right side, subsequent encounter for fracture with nonunion Add: S02.82XK Fracture of other specified skull and facial bones, left side, subsequent encounter for fracture with nonunion Delete: S02.8XXK Fractures of other specified skull and facial bones, subsequent encounter for fracture with nonunion Add: S92.811K Other fracture of right foot, subsequent encounter for fracture with nonunion Add: S92.811P Other fracture of right foot, subsequent encounter for fracture with malunion Add: S92.812K Other fracture of left foot, subsequent encounter for fracture with nonunion Add: S92.812P Other fracture of left foot, subsequent encounter for fracture with malunion Add: S92.819K Other fracture of unspecified foot, subsequent encounter for fracture with nonunion Add: S92.819P Other fracture of unspecified foot, subsequent encounter for fracture with malunion Add: S99.001K Unspecified physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.001P Unspecified physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.002K Unspecified physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.002P Unspecified physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.009K Unspecified physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.009P Unspecified physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion Add: S99.011K Salter-Harris Type I physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.011P Salter-Harris Type I physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.012K Salter-Harris Type I physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.012P Salter-Harris Type I physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.019K Salter-Harris Type I physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.019P Salter-Harris Type I physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion Add: S99.021K Salter-Harris Type II physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.021P Salter-Harris Type II physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.022K Salter-Harris Type II physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.022P Salter-Harris Type II physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.029K Salter-Harris Type II physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.029P Salter-Harris Type II physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion

Page A-65 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.031K Salter-Harris Type III physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.031P Salter-Harris Type III physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.032K Salter-Harris Type III physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.032P Salter-Harris Type III physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.039K Salter-Harris Type III physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.039P Salter-Harris Type III physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion Add: S99.041K Salter-Harris Type IV physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.041P Salter-Harris Type IV physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.042K Salter-Harris Type IV physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.042P Salter-Harris Type IV physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.049K Salter-Harris Type IV physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.049P Salter-Harris Type IV physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion Add: S99.091K Other physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion Add: S99.091P Other physeal fracture of right calcaneus, subsequent encounter for fracture with malunion Add: S99.092K Other physeal fracture of left calcaneus, subsequent encounter for fracture with nonunion Add: S99.092P Other physeal fracture of left calcaneus, subsequent encounter for fracture with malunion Add: S99.099K Other physeal fracture of unspecified calcaneus, subsequent encounter for fracture with nonunion Add: S99.099P Other physeal fracture of unspecified calcaneus, subsequent encounter for fracture with malunion Add: S99.101K Unspecified physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.101P Unspecified physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.102K Unspecified physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.102P Unspecified physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.109K Unspecified physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion Add: S99.109P Unspecified physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.111K Salter-Harris Type I physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.111P Salter-Harris Type I physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.112K Salter-Harris Type I physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.112P Salter-Harris Type I physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.119K Salter-Harris Type I physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion Add: S99.119P Salter-Harris Type I physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.121K Salter-Harris Type II physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.121P Salter-Harris Type II physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.122K Salter-Harris Type II physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.122P Salter-Harris Type II physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.129K Salter-Harris Type II physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion Add: S99.129P Salter-Harris Type II physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.131K Salter-Harris Type III physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.131P Salter-Harris Type III physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.132K Salter-Harris Type III physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.132P Salter-Harris Type III physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.139K Salter-Harris Type III physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion Add: S99.139P Salter-Harris Type III physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.141K Salter-Harris Type IV physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.141P Salter-Harris Type IV physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.142K Salter-Harris Type IV physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.142P Salter-Harris Type IV physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.149K Salter-Harris Type IV physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion Add: S99.149P Salter-Harris Type IV physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.191K Other physeal fracture of right metatarsal, subsequent encounter for fracture with nonunion Add: S99.191P Other physeal fracture of right metatarsal, subsequent encounter for fracture with malunion Add: S99.192K Other physeal fracture of left metatarsal, subsequent encounter for fracture with nonunion Add: S99.192P Other physeal fracture of left metatarsal, subsequent encounter for fracture with malunion Add: S99.199K Other physeal fracture of unspecified metatarsal, subsequent encounter for fracture with nonunion

Page A-66 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.199P Other physeal fracture of unspecified metatarsal, subsequent encounter for fracture with malunion Add: S99.201K Unspecified physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.201P Unspecified physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.202K Unspecified physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.202P Unspecified physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.209K Unspecified physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.209P Unspecified physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion Add: S99.211K Salter-Harris Type I physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.211P Salter-Harris Type I physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.212K Salter-Harris Type I physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.212P Salter-Harris Type I physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.219K Salter-Harris Type I physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.219P Salter-Harris Type I physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion Add: S99.221K Salter-Harris Type II physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.221P Salter-Harris Type II physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.222K Salter-Harris Type II physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.222P Salter-Harris Type II physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.229K Salter-Harris Type II physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.229P Salter-Harris Type II physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion Add: S99.231K Salter-Harris Type III physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.231P Salter-Harris Type III physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.232K Salter-Harris Type III physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.232P Salter-Harris Type III physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.239K Salter-Harris Type III physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.239P Salter-Harris Type III physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion Add: S99.241K Salter-Harris Type IV physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.241P Salter-Harris Type IV physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.242K Salter-Harris Type IV physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.242P Salter-Harris Type IV physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.249K Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.249P Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion Add: S99.291K Other physeal fracture of phalanx of right toe, subsequent encounter for fracture with nonunion Add: S99.291P Other physeal fracture of phalanx of right toe, subsequent encounter for fracture with malunion Add: S99.292K Other physeal fracture of phalanx of left toe, subsequent encounter for fracture with nonunion Add: S99.292P Other physeal fracture of phalanx of left toe, subsequent encounter for fracture with malunion Add: S99.299K Other physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with nonunion Add: S99.299P Other physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with malunion

Line: 450 Condition: HEARING LOSS - OVER AGE OF FIVE Treatment: MEDICAL THERAPY INCLUDING HEARING AIDS, LIMITED SURGICAL THERAPY Add: H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side Add: H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side Add: H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side Add: H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side Add: H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side Add: H90.A32 Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side Delete: H93.11 Tinnitus, right ear Delete: H93.12 Tinnitus, left ear Delete: H93.13 Tinnitus, bilateral Delete: H93.19 Tinnitus, unspecified ear

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Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 453 Condition: DEGENERATION OF MACULA AND POSTERIOR POLE Treatment: MEDICAL, SURGICAL AND LASER TREATMENT Delete: H35.31 Nonexudative age-related macular degeneration Add: H35.3110 Nonexudative age-related macular degeneration, right eye, stage unspecified Add: H35.3111 Nonexudative age-related macular degeneration, right eye, early dry stage Add: H35.3112 Nonexudative age-related macular degeneration, right eye, intermediate dry stage Add: H35.3113 Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement Add: H35.3114 Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement Add: H35.3120 Nonexudative age-related macular degeneration, left eye, stage unspecified Add: H35.3121 Nonexudative age-related macular degeneration, left eye, early dry stage Add: H35.3122 Nonexudative age-related macular degeneration, left eye, intermediate dry stage Add: H35.3123 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement Add: H35.3124 Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement Add: H35.3130 Nonexudative age-related macular degeneration, bilateral, stage unspecified Add: H35.3131 Nonexudative age-related macular degeneration, bilateral, early dry stage Add: H35.3132 Nonexudative age-related macular degeneration, bilateral, intermediate dry stage Add: H35.3133 Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement Add: H35.3134 Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement Add: H35.3190 Nonexudative age-related macular degeneration, unspecified eye, stage unspecified Add: H35.3191 Nonexudative age-related macular degeneration, unspecified eye, early dry stage Add: H35.3192 Nonexudative age-related macular degeneration, unspecified eye, intermediate dry stage Add: H35.3193 Nonexudative age-related macular degeneration, unspecified eye, advanced atrophic without subfoveal involvement Add: H35.3194 Nonexudative age-related macular degeneration, unspecified eye, advanced atrophic with subfoveal involvement Delete: H35.32 Exudative age-related macular degeneration Add: H35.3210 Exudative age-related macular degeneration, right eye, stage unspecified Add: H35.3211 Exudative age-related macular degeneration, right eye, with active choroidal neovascularization Add: H35.3212 Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization Add: H35.3213 Exudative age-related macular degeneration, right eye, with inactive scar Add: H35.3220 Exudative age-related macular degeneration, left eye, stage unspecified Add: H35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization Add: H35.3222 Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization Add: H35.3223 Exudative age-related macular degeneration, left eye, with inactive scar Add: H35.3230 Exudative age-related macular degeneration, bilateral, stage unspecified Add: H35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization Add: H35.3232 Exudative age-related macular degeneration, bilateral, with inactive choroidal neovascularization Add: H35.3233 Exudative age-related macular degeneration, bilateral, with inactive scar Add: H35.3290 Exudative age-related macular degeneration, unspecified eye, stage unspecified Add: H35.3291 Exudative age-related macular degeneration, unspecified eye, with active choroidal neovascularization Add: H35.3292 Exudative age-related macular degeneration, unspecified eye, with inactive choroidal neovascularization Add: H35.3293 Exudative age-related macular degeneration, unspecified eye, with inactive scar

Line: 455 Condition: DISORDERS OF REFRACTION AND ACCOMMODATION Treatment: MEDICAL THERAPY Delete: E50.5 Vitamin A deficiency with night blindness Add: 92314 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia

Line: 456 Condition: EXOPHTHALMOS AND CYSTS OF THE EYE AND ORBIT Treatment: SURGICAL TREATMENT Delete: E50.0 Vitamin A deficiency with conjunctival xerosis Delete: E50.1 Vitamin A deficiency with Bitot's spot and conjunctival xerosis Delete: E50.2 Vitamin A deficiency with corneal xerosis Delete: E50.3 Vitamin A deficiency with corneal ulceration and xerosis

Page A-68 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 463 Condition: ACUTE BRONCHITIS AND BRONCHIOLITIS Treatment: MEDICAL THERAPY Delete: 31603 Tracheostomy, emergency procedure; transtracheal

Line: 466 Condition: OBSESSIVE-COMPULSIVE DISORDERS Treatment: MEDICAL/PSYCHOTHERAPY Delete: F42 Obsessive-compulsive disorder Add: F42.2 Mixed obsessional thoughts and acts Add: F42.3 Hoarding disorder Add: F42.4 Excoriation (skin-picking) disorder Add: F42.8 Other obsessive-compulsive disorder Add: F42.9 Obsessive-compulsive disorder, unspecified

Line: 467 Condition: OSTEOARTHRITIS AND ALLIED DISORDERS Treatment: MEDICAL THERAPY, INJECTIONS Delete: M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region Delete: M48.8X2 Other specified spondylopathies, cervical region Delete: M48.8X3 Other specified spondylopathies, cervicothoracic region Delete: M48.8X4 Other specified spondylopathies, thoracic region Delete: M48.8X5 Other specified spondylopathies, thoracolumbar region Delete: M48.8X6 Other specified spondylopathies, lumbar region Delete: M48.8X7 Other specified spondylopathies, lumbosacral region Delete: M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region Delete: M48.8X9 Other specified spondylopathies, site unspecified Add: 97018 Application of a modality to 1 or more areas; paraffin bath

Line: 471 Condition: BRACHIAL PLEXUS LESIONS Treatment: MEDICAL THERAPY Delete: 97024 Application of a modality to 1 or more areas; diathermy (eg, microwave)

Line: 473 Condition: GONADAL DYSFUNCTION, MENOPAUSAL MANAGEMENT Treatment: OOPHORECTOMY, ORCHIECTOMY, HORMONAL REPLACEMENT FOR PURPOSES OTHER THAN INFERTILITY Delete: N83.31 Acquired atrophy of ovary Delete: N83.32 Acquired atrophy of fallopian tube Delete: N83.33 Acquired atrophy of ovary and fallopian tube

Line: 482 Condition: CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT NEUROLOGIC INJURY OR STRUCTURAL INSTABILITY Treatment: MEDICAL AND SURGICAL TREATMENT Add: M43.5X4 Other recurrent vertebral dislocation, thoracic region Add: M43.5X5 Other recurrent vertebral dislocation, thoracolumbar region Add: M43.5X6 Other recurrent vertebral dislocation, lumbar region Add: M43.5X7 Other recurrent vertebral dislocation, lumbosacral region Add: M43.5X8 Other recurrent vertebral dislocation, sacral and sacrococcygeal region Add: M43.5X9 Other recurrent vertebral dislocation, site unspecified Delete: M99.14 Subluxation complex (vertebral) of sacral region Delete: M99.15 Subluxation complex (vertebral) of pelvic region Add: S23.101A Dislocation of unspecified thoracic vertebra, initial encounter Add: S23.101D Dislocation of unspecified thoracic vertebra, subsequent encounter Add: S23.111A Dislocation of T1/T2 thoracic vertebra, initial encounter Add: S23.111D Dislocation of T1/T2 thoracic vertebra, subsequent encounter Add: S23.121A Dislocation of T2/T3 thoracic vertebra, initial encounter Add: S23.121D Dislocation of T2/T3 thoracic vertebra, subsequent encounter Add: S23.123A Dislocation of T3/T4 thoracic vertebra, initial encounter

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Add: S23.123D Dislocation of T3/T4 thoracic vertebra, subsequent encounter Add: S23.131A Dislocation of T4/T5 thoracic vertebra, initial encounter Add: S23.131D Dislocation of T4/T5 thoracic vertebra, subsequent encounter Add: S23.133A Dislocation of T5/T6 thoracic vertebra, initial encounter Add: S23.133D Dislocation of T5/T6 thoracic vertebra, subsequent encounter Add: S23.141A Dislocation of T6/T7 thoracic vertebra, initial encounter Add: S23.141D Dislocation of T6/T7 thoracic vertebra, subsequent encounter Add: S23.143A Dislocation of T7/T8 thoracic vertebra, initial encounter Add: S23.143D Dislocation of T7/T8 thoracic vertebra, subsequent encounter Add: S23.151A Dislocation of T8/T9 thoracic vertebra, initial encounter Add: S23.151D Dislocation of T8/T9 thoracic vertebra, subsequent encounter Add: S23.153A Dislocation of T9/T10 thoracic vertebra, initial encounter Add: S23.153D Dislocation of T9/T10 thoracic vertebra, subsequent encounter Add: S23.161A Dislocation of T10/T11 thoracic vertebra, initial encounter Add: S23.161D Dislocation of T10/T11 thoracic vertebra, subsequent encounter Add: S23.163A Dislocation of T11/T12 thoracic vertebra, initial encounter Add: S23.163D Dislocation of T11/T12 thoracic vertebra, subsequent encounter Add: S23.171A Dislocation of T12/L1 thoracic vertebra, initial encounter Add: S23.171D Dislocation of T12/L1 thoracic vertebra, subsequent encounter Add: S33.101A Dislocation of unspecified lumbar vertebra, initial encounter Add: S33.101D Dislocation of unspecified lumbar vertebra, subsequent encounter Add: S33.111A Dislocation of L1/L2 lumbar vertebra, initial encounter Add: S33.111D Dislocation of L1/L2 lumbar vertebra, subsequent encounter Add: S33.121A Dislocation of L2/L3 lumbar vertebra, initial encounter Add: S33.121D Dislocation of L2/L3 lumbar vertebra, subsequent encounter Add: S33.131A Dislocation of L3/L4 lumbar vertebra, initial encounter Add: S33.131D Dislocation of L3/L4 lumbar vertebra, subsequent encounter Add: S33.141A Dislocation of L4/L5 lumbar vertebra, initial encounter Add: S33.141D Dislocation of L4/L5 lumbar vertebra, subsequent encounter

Line: 484 Condition: BREAST CYSTS AND OTHER DISORDERS OF THE BREAST Treatment: MEDICAL AND SURGICAL TREATMENT Delete: N61 Inflammatory disorders of breast

Line: 492 Condition: CLOSED FRACTURE OF ONE OR MORE PHALANGES OF THE FOOT, NOT INCLUDING THE GREAT TOE Treatment: MEDICAL AND SURGICAL TREATMENT Add: S99.201A Unspecified physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.201D Unspecified physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.201G Unspecified physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.202A Unspecified physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.202D Unspecified physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.202G Unspecified physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.209A Unspecified physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.209D Unspecified physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.209G Unspecified physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing Add: S99.211A Salter-Harris Type I physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.211D Salter-Harris Type I physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.211G Salter-Harris Type I physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.212A Salter-Harris Type I physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.212D Salter-Harris Type I physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.212G Salter-Harris Type I physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.219A Salter-Harris Type I physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.219D Salter-Harris Type I physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.219G Salter-Harris Type I physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing Page A-70 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Add: S99.221A Salter-Harris Type II physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.221D Salter-Harris Type II physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.221G Salter-Harris Type II physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.222A Salter-Harris Type II physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.222D Salter-Harris Type II physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.222G Salter-Harris Type II physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.229A Salter-Harris Type II physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.229D Salter-Harris Type II physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.229G Salter-Harris Type II physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing Add: S99.231A Salter-Harris Type III physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.231D Salter-Harris Type III physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.231G Salter-Harris Type III physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.232A Salter-Harris Type III physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.232D Salter-Harris Type III physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.232G Salter-Harris Type III physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.239A Salter-Harris Type III physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.239D Salter-Harris Type III physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.239G Salter-Harris Type III physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing Add: S99.241A Salter-Harris Type IV physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.241D Salter-Harris Type IV physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.241G Salter-Harris Type IV physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.242A Salter-Harris Type IV physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.242D Salter-Harris Type IV physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.242G Salter-Harris Type IV physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.249A Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.249D Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.249G Salter-Harris Type IV physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing Add: S99.291A Other physeal fracture of phalanx of right toe, initial encounter for closed fracture Add: S99.291D Other physeal fracture of phalanx of right toe, subsequent encounter for fracture with routine healing Add: S99.291G Other physeal fracture of phalanx of right toe, subsequent encounter for fracture with delayed healing Add: S99.292A Other physeal fracture of phalanx of left toe, initial encounter for closed fracture Add: S99.292D Other physeal fracture of phalanx of left toe, subsequent encounter for fracture with routine healing Add: S99.292G Other physeal fracture of phalanx of left toe, subsequent encounter for fracture with delayed healing Add: S99.299A Other physeal fracture of phalanx of unspecified toe, initial encounter for closed fracture Add: S99.299D Other physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with routine healing Add: S99.299G Other physeal fracture of phalanx of unspecified toe, subsequent encounter for fracture with delayed healing

Line: 493 Condition: DERMATOPHYTOSIS OF NAIL, GROIN, AND FOOT AND OTHER DERMATOMYCOSIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

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Line: 501 Condition: CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD) AND HYDROXYAPETITE DEPOSITION DISEASE Treatment: MEDICAL THERAPY Delete: 99184 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 Delete: 99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) Delete: 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99224 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 physicians, other qualified health care professionals, 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. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99225 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 physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.

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Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: 99226 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 physicians, other qualified health care professionals, 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. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99232 Subsequent hospital 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 physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99233 Subsequent hospital 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 physicians, other qualified health care professionals, 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. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99236 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit. Delete: 99238 Hospital discharge day management; 30 minutes or less Delete: 99239 Hospital discharge day management; more than 30 minutes Delete: 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Delete: 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) Delete: 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit.

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Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99308 Subsequent nursing facility 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 low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99309 Subsequent nursing facility 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 moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99315 Nursing facility discharge day management; 30 minutes or less Delete: 99316 Nursing facility discharge day management; more than 30 minutes Delete: 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient's facility floor or unit. Delete: 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. Delete: 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. Delete: 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. Delete: 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver.

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Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. Delete: 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. Delete: 99335 Domiciliary or rest home visit for the evaluation and management of an established 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 low complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. Delete: 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. Delete: 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or 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 patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Delete: 99339 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Delete: 99340 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Delete: 99379 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Delete: 99380 Supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Delete: 99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger Delete: 99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger Delete: 99471 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

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Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: 99472 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 of age Delete: 99475 Initial 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 Delete: 99476 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 Delete: 99477 Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services Delete: 99478 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams) Delete: 99479 Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams) Delete: 99480 Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams)

Line: 507 Condition: ERYTHEMATOUS CONDITIONS Treatment: MEDICAL THERAPY Delete: L71.1 Rhinophyma Delete: L71.8 Other rosacea Delete: L71.9 Rosacea, unspecified

Line: 508 Condition: PERIPHERAL ENTHESOPATHIES Treatment: SURGICAL TREATMENT Delete: 27175 Treatment of slipped femoral epiphysis; by traction, without reduction Delete: 27176 Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Delete: 27177 Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) Delete: 27178 Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning Delete: 27179 Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) Delete: 27181 Open treatment of slipped femoral epiphysis; osteotomy and internal fixation Delete: 27185 Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur

Line: 512 Condition: PERIPHERAL NERVE DISORDERS Treatment: MEDICAL THERAPY Add: G56.13 Other lesions of median nerve, bilateral upper limbs Add: G56.23 Lesion of ulnar nerve, bilateral upper limbs Add: G56.33 Lesion of radial nerve, bilateral upper limbs Add: G56.43 Causalgia of bilateral upper limbs Add: G56.83 Other specified mononeuropathies of bilateral upper limbs Add: G56.93 Unspecified mononeuropathy of bilateral upper limbs Add: G57.03 Lesion of sciatic nerve, bilateral lower limbs Add: G57.13 Meralgia paresthetica, bilateral lower limbs Add: G57.23 Lesion of femoral nerve, bilateral lower limbs Add: G57.73 Causalgia of bilateral lower limbs Add: G57.83 Other specified mononeuropathies of bilateral lower limbs Add: G57.93 Unspecified mononeuropathy of bilateral lower limbs Add: G61.82 Multifocal motor neuropathy Delete: 97024 Application of a modality to 1 or more areas; diathermy (eg, microwave)

Line: 516 Condition: ESOPHAGITIS AND GERD; ESOPHAGEAL SPASM; ASYMPTOMATIC DIAPHRAGMATIC HERNIA Treatment: MEDICAL THERAPY Delete: K20.0 Eosinophilic esophagitis Delete: K22.70 Barrett's esophagus without dysplasia Delete: K22.710 Barrett's esophagus with low grade dysplasia Delete: K22.711 Barrett's esophagus with high grade dysplasia Delete: K22.719 Barrett's esophagus with dysplasia, unspecified

Page A-76 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 517 Condition: HIDRADENITIS SUPPURATIVA; DISSECTING CELLULITIS OF THE SCALP Treatment: MEDICAL THERAPY Add: L66.2 Folliculitis decalvans Add: L66.8 Other cicatricial alopecia Add: L66.9 Cicatricial alopecia, unspecified

Line: 518 Condition: CHRONIC PROSTATITIS, OTHER DISORDERS OF PROSTATE Treatment: MEDICAL THERAPY Delete: N42.3 Dysplasia of prostate

Line: 520 Condition: DISORDERS OF SWEAT GLANDS Treatment: MEDICAL THERAPY Delete: S13.0XXA Traumatic rupture of cervical intervertebral disc, initial encounter

Line: 521 Condition: PARALYSIS OF VOCAL CORDS OR LARYNX Treatment: INCISION/EXCISION/ENDOSCOPY Add: J38.6 Stenosis of larynx Add: 31513 Laryngoscopy, indirect; with vocal cord injection Add: 31570 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; Add: 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope Add: 31590 Laryngeal reinnervation by neuromuscular pedicle Add: 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Add: 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals Add: 92524 Behavioral and qualitative analysis of voice and resonance

Line: 525 Condition: ROSACEA; ACNE Treatment: MEDICAL AND SURGICAL TREATMENT Add: L71.1 Rhinophyma Add: L71.8 Other rosacea Add: L71.9 Rosacea, unspecified Delete: 11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair Delete: 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Delete: 11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair Delete: 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Delete: 11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair Delete: 11471 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 526 Condition: SEXUAL DYSFUNCTION Treatment: PSYCHOTHERAPY, MEDICAL AND SURGICAL TREATMENT Add: 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)

Line: 530 Condition: DEFORMITIES OF UPPER BODY AND ALL LIMBS Treatment: REPAIR/REVISION/RECONSTRUCTION/RELOCATION/MEDICAL THERAPY Delete: M21.6X1 Other acquired deformities of right foot Delete: M21.6X2 Other acquired deformities of left foot Delete: M21.6X9 Other acquired deformities of unspecified foot Delete: M42.10 Adult osteochondrosis of spine, site unspecified Delete: M42.11 Adult osteochondrosis of spine, occipito-atlanto-axial region Delete: M42.12 Adult osteochondrosis of spine, cervical region Page A-77 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Delete: M42.13 Adult osteochondrosis of spine, cervicothoracic region Delete: M42.14 Adult osteochondrosis of spine, thoracic region Delete: M42.15 Adult osteochondrosis of spine, thoracolumbar region Delete: M42.16 Adult osteochondrosis of spine, lumbar region Delete: M42.17 Adult osteochondrosis of spine, lumbosacral region Delete: M42.18 Adult osteochondrosis of spine, sacral and sacrococcygeal region Delete: M42.19 Adult osteochondrosis of spine, multiple sites in spine Delete: M42.9 Spinal osteochondrosis, unspecified Add: Q67.6 Pectus excavatum

Line: 531 Condition: DISORDERS OF FUNCTION OF STOMACH AND OTHER FUNCTIONAL DIGESTIVE DISORDERS Treatment: MEDICAL AND SURGICAL THERAPY Add: K58.1 Irritable bowel syndrome with constipation Add: K58.2 Mixed irritable bowel syndrome Add: K58.8 Other irritable bowel syndrome Add: K59.03 Drug induced constipation Add: K59.04 Chronic idiopathic constipation

Line: 532 Condition: CONDITIONS OF THE BACK AND SPINE WITHOUT URGENT SURGICAL INDICATIONS Treatment: SURGICAL THERAPY Delete: M50.12 Cervical disc disorder with radiculopathy, mid-cervical region Add: M50.120 Mid-cervical disc disorder, unspecified Add: M50.121 Cervical disc disorder at C4-C5 level with radiculopathy Add: M50.122 Cervical disc disorder at C5-C6 level with radiculopathy Add: M50.123 Cervical disc disorder at C6-C7 level with radiculopathy Delete: M50.22 Other cervical disc displacement, mid-cervical region Add: M50.220 Other cervical disc displacement, mid-cervical region, unspecified level Add: M50.221 Other cervical disc displacement at C4-C5 level Add: M50.222 Other cervical disc displacement at C5-C6 level Add: M50.223 Other cervical disc displacement at C6-C7 level Delete: M50.32 Other cervical disc degeneration, mid-cervical region Add: M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level Add: M50.321 Other cervical disc degeneration at C4-C5 level Add: M50.322 Other cervical disc degeneration at C5-C6 level Add: M50.323 Other cervical disc degeneration at C6-C7 level Delete: M50.82 Other cervical disc disorders, mid-cervical region Add: M50.820 Other cervical disc disorders, mid-cervical region, unspecified level Add: M50.821 Other cervical disc disorders at C4-C5 level Add: M50.822 Other cervical disc disorders at C5-C6 level Add: M50.823 Other cervical disc disorders at C6-C7 level Delete: M50.92 Cervical disc disorder, unspecified, mid-cervical region Add: M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level Add: M50.921 Unspecified cervical disc disorder at C4-C5 level Add: M50.922 Unspecified cervical disc disorder at C5-C6 level Add: M50.923 Unspecified cervical disc disorder at C6-C7 level fied Add: 99184 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

Line: 534 Condition: CHRONIC PELVIC INFLAMMATORY DISEASE, PELVIC PAIN SYNDROME, DYSPAREUNIA Treatment: MEDICAL AND SURGICAL TREATMENT Delete: N94.1 Dyspareunia

Page A-78 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 535 Condition: ATOPIC DERMATITIS Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 536 Condition: CONTACT DERMATITIS AND OTHER ECZEMA Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 539 Condition: PERIPHERAL NERVE DISORDERS Treatment: SURGICAL TREATMENT Add: G56.13 Other lesions of median nerve, bilateral upper limbs Add: G56.23 Lesion of ulnar nerve, bilateral upper limbs Add: G56.33 Lesion of radial nerve, bilateral upper limbs Add: G56.43 Causalgia of bilateral upper limbs Add: G56.83 Other specified mononeuropathies of bilateral upper limbs Add: G56.93 Unspecified mononeuropathy of bilateral upper limbs Add: G57.03 Lesion of sciatic nerve, bilateral lower limbs Add: G57.13 Meralgia paresthetica, bilateral lower limbs Add: G57.23 Lesion of femoral nerve, bilateral lower limbs Add: G57.73 Causalgia of bilateral lower limbs Add: G57.83 Other specified mononeuropathies of bilateral lower limbs Add: G57.93 Unspecified mononeuropathy of bilateral lower limbs

Line: 542 Condition: LESION OF PLANTAR NERVE; PLANTAR FASCIAL FIBROMATOSIS Treatment: MEDICAL THERAPY, EXCISION Add: G57.63 Lesion of plantar nerve, bilateral lower limbs

Line: 543 Condition: TENSION HEADACHES Treatment: MEDICAL THERAPY Add: M99.80 Other biomechanical lesions of head region

Line: 544 Condition: MILD PSORIASIS ; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 545 Condition: DEFORMITIES OF FOOT Treatment: FASCIOTOMY/INCISION/REPAIR/ARTHRODESIS Add: M21.611 Bunion of right foot Add: M21.612 Bunion of left foot Add: M21.619 Bunion of unspecified foot Add: M21.621 Bunionette of right foot Add: M21.622 Bunionette of left foot Add: M21.629 Bunionette of unspecified foot Add: M21.6X1 Other acquired deformities of right foot Add: M21.6X2 Other acquired deformities of left foot Add: M21.6X9 Other acquired deformities of unspecified foot

Page A-79 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 547 Condition: HYDROCELE Treatment: MEDICAL THERAPY, EXCISION Delete: N50.8 Other specified disorders of male genital organs

Line: 548 Condition: SYMPTOMATIC URTICARIA Treatment: MEDICAL THERAPY Delete: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 552 Condition: TMJ DISORDER Treatment: TMJ SPLINTS Delete: M26.60 Temporomandibular joint disorder, unspecified Add: M26.601 Right temporomandibular joint disorder, unspecified Add: M26.602 Left temporomandibular joint disorder, unspecified Add: M26.603 Bilateral temporomandibular joint disorder, unspecified Add: M26.609 Unspecified temporomandibular joint disorder, unspecified side Delete: M26.61 Adhesions and ankylosis of temporomandibular joint Add: M26.611 Adhesions and ankylosis of right temporomandibular joint Add: M26.612 Adhesions and ankylosis of left temporomandibular joint Add: M26.613 Adhesions and ankylosis of bilateral temporomandibular joint Add: M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side Delete: M26.62 Arthralgia of temporomandibular joint Add: M26.621 Arthralgia of right temporomandibular joint Add: M26.622 Arthralgia of left temporomandibular joint Add: M26.623 Arthralgia of bilateral temporomandibular joint Add: M26.629 Arthralgia of temporomandibular joint, unspecified side Delete: M26.63 Articular disc disorder of temporomandibular joint Add: M26.631 Articular disc disorder of right temporomandibular joint Add: M26.632 Articular disc disorder of left temporomandibular joint Add: M26.633 Articular disc disorder of bilateral temporomandibular joint Add: M26.639 Articular disc disorder of temporomandibular joint, unspecified side Add: S03.40XA Sprain of jaw, unspecified side, initial encounter Add: S03.40XD Sprain of jaw, unspecified side, subsequent encounter Add: S03.41XA Sprain of jaw, right side, initial encounter Add: S03.41XD Sprain of jaw, right side, subsequent encounter Add: S03.42XA Sprain of jaw, left side, initial encounter Add: S03.42XD Sprain of jaw, left side, subsequent encounter Add: S03.43XA Sprain of jaw, bilateral, initial encounter Add: S03.43XD Sprain of jaw, bilateral, subsequent encounter Delete: S03.4XXA Sprain of jaw, initial encounter Delete: S03.4XXD Sprain of jaw, subsequent encounter

Line: 555 Condition: OTHER NONINFECTIOUS GASTROENTERITIS AND COLITIS Treatment: MEDICAL THERAPY Delete: K52.2 Allergic and dietetic gastroenteritis and colitis Add: K52.21 Food protein-induced enterocolitis syndrome Add: K52.22 Food protein-induced enteropathy Add: K52.29 Other allergic and dietetic gastroenteritis and colitis Add: K52.831 Collagenous colitis Add: K52.832 Lymphocytic colitis Add: K52.838 Other microscopic colitis Add: K52.839 Microscopic colitis, unspecified Add: Z51.6 Encounter for desensitization to allergens

Page A-80 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 564 Condition: ALLERGIC RHINITIS AND CONJUNCTIVITIS, CHRONIC RHINITIS Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens

Line: 571 Condition: DERMATITIS DUE TO SUBSTANCES TAKEN INTERNALLY Treatment: MEDICAL THERAPY Add: Z51.6 Encounter for desensitization to allergens

Line: 578 Condition: DEVIATED NASAL SEPTUM, ACQUIRED DEFORMITY OF NOSE, OTHER DISEASES OF UPPER RESPIRATORY TRACT Treatment: EXCISION OF CYST/RHINECTOMY/PROSTHESIS Add: S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing Add: S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing

Line: 579 Condition: STOMATITIS AND OTHER DISEASES OF ORAL SOFT TISSUES Treatment: INCISION AND DRAINAGE, MEDICAL THERAPY Add: K13.22 Minimal keratinized residual ridge mucosa Add: K13.23 Excessive keratinized residual ridge mucosa Add: K13.24 Leukokeratosis nicotina palati

Line: 588 Condition: DISEASE OF NAILS, HAIR AND HAIR FOLLICLES Treatment: MEDICAL THERAPY Delete: L66.2 Folliculitis decalvans Delete: L66.3 Perifolliculitis capitis abscedens Delete: L66.8 Other cicatricial alopecia Delete: L66.9 Cicatricial alopecia, unspecified

Line: 607 Condition: DISORDERS OF SOFT TISSUE Treatment: MEDICAL THERAPY Delete: 62369 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 Delete: 62370 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 skill of a physician or other qualified health care professional) Delete: 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill Delete: 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming

Line: 611 Condition: SPRAINS AND STRAINS OF ADJACENT MUSCLES AND JOINTS, MINOR Treatment: MEDICAL THERAPY Delete: S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter Delete: S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter

Line: 614 Condition: ABUSE OF NONADDICTIVE SUBSTANCES Treatment: MEDICAL THERAPY Add: H0032 Mental health service plan development by non-physician Delete: 99184 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 Page A-81 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 615 Condition: MINOR HEAD INJURY: HEMATOMA/EDEMA WITH NO PERSISTENT SYMPTOMS Treatment: MEDICAL THERAPY Add: S02.101A Fracture of base of skull, right side, initial encounter for closed fracture Add: S02.101D Fracture of base of skull, right side, subsequent encounter for fracture with routine healing Add: S02.101G Fracture of base of skull, right side, subsequent encounter for fracture with delayed healing Add: S02.101S Fracture of base of skull, right side, sequela Add: S02.102A Fracture of base of skull, left side, initial encounter for closed fracture Add: S02.102D Fracture of base of skull, left side, subsequent encounter for fracture with routine healing Add: S02.102G Fracture of base of skull, left side, subsequent encounter for fracture with delayed healing Add: S02.109A Fracture of base of skull, unspecified side, initial encounter for closed fracture Add: S02.109D Fracture of base of skull, unspecified side, subsequent encounter for fracture with routine healing Add: S02.109G Fracture of base of skull, unspecified side, subsequent encounter for fracture with delayed healing Delete: S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture Add: S02.11AA Type I occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11AD Type I occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11AG Type I occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.11BA Type I occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11BD Type I occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11BG Type I occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11CA Type II occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11CD Type II occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11CG Type II occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.11DA Type II occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11DD Type II occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11DG Type II occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11EA Type III occipital condyle fracture, right side, initial encounter for closed fracture Add: S02.11ED Type III occipital condyle fracture, right side, subsequent encounter for fracture with routine healing Add: S02.11EG Type III occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing Add: S02.11FA Type III occipital condyle fracture, left side, initial encounter for closed fracture Add: S02.11FD Type III occipital condyle fracture, left side, subsequent encounter for fracture with routine healing Add: S02.11FG Type III occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing Add: S02.11GA Other fracture of occiput, right side, initial encounter for closed fracture Add: S02.11GD Other fracture of occiput, right side, subsequent encounter for fracture with routine healing Add: S02.11GG Other fracture of occiput, right side, subsequent encounter for fracture with delayed healing Add: S02.11HA Other fracture of occiput, left side, initial encounter for closed fracture Add: S02.11HD Other fracture of occiput, left side, subsequent encounter for fracture with routine healing Add: S02.11HG Other fracture of occiput, left side, subsequent encounter for fracture with delayed healing Add: S02.80XA Fracture of other specified skull and facial bones, unspecified side, initial encounter for closed fracture Add: S02.80XB Fracture of other specified skull and facial bones, unspecified side, initial encounter for open fracture Add: S02.80XD Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with routine healing Add: S02.80XG Fracture of other specified skull and facial bones, unspecified side, subsequent encounter for fracture with delayed healing

Line: 623 Condition: BENIGN LESIONS OF TONGUE Treatment: EXCISION Delete: K13.22 Minimal keratinized residual ridge mucosa

Line: 625 Condition: PREVENTION SERVICES WITH LIMITED OR NO EVIDENCE OF EFFECTIVENESS Treatment: MEDICAL THERAPY Delete: Z22.50 Carrier of unspecified viral hepatitis Delete: Z22.51 Carrier of viral hepatitis B Delete: Z22.52 Carrier of viral hepatitis C Delete: Z22.59 Carrier of other viral hepatitis

Page A-82 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 631 Condition: BENIGN NEOPLASMS OF SKIN AND OTHER SOFT TISSUES Treatment: MEDICAL THERAPY Delete: 11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair Delete: 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Delete: 11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair Delete: 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Delete: 11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair Delete: 11471 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair Add: 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma

Line: 633 Condition: BENIGN CERVICAL CONDITIONS Treatment: MEDICAL THERAPY Delete: N90.6 Hypertrophy of vulva

Line: 635 Condition: PICA Treatment: MEDICAL/PSYCHOTHERAPY Delete: F50.8 Other eating disorders

Line: 647 Condition: TMJ DISORDERS Treatment: TMJ SURGERY Delete: M26.60 Temporomandibular joint disorder, unspecified Add: M26.601 Right temporomandibular joint disorder, unspecified Add: M26.602 Left temporomandibular joint disorder, unspecified Add: M26.603 Bilateral temporomandibular joint disorder, unspecified Add: M26.609 Unspecified temporomandibular joint disorder, unspecified side Delete: M26.61 Adhesions and ankylosis of temporomandibular joint Add: M26.611 Adhesions and ankylosis of right temporomandibular joint Add: M26.612 Adhesions and ankylosis of left temporomandibular joint Add: M26.613 Adhesions and ankylosis of bilateral temporomandibular joint Add: M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side Delete: M26.62 Arthralgia of temporomandibular joint Add: M26.621 Arthralgia of right temporomandibular joint Add: M26.622 Arthralgia of left temporomandibular joint Add: M26.623 Arthralgia of bilateral temporomandibular joint Add: M26.629 Arthralgia of temporomandibular joint, unspecified side Delete: M26.63 Articular disc disorder of temporomandibular joint Add: M26.631 Articular disc disorder of right temporomandibular joint Add: M26.632 Articular disc disorder of left temporomandibular joint Add: M26.633 Articular disc disorder of bilateral temporomandibular joint Add: M26.639 Articular disc disorder of temporomandibular joint, unspecified side

Line: 650 Condition: DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT Treatment: ELECTIVE DENTAL SERVICES Delete: K08.8 Other specified disorders of teeth and supporting structures Add: K08.81 Primary occlusal trauma Add: K08.82 Secondary occlusal trauma Add: K08.89 Other specified disorders of teeth and supporting structures

Page A-83 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 656 Condition: ENDOCRINE AND METABOLIC CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: E80.4 Gilbert syndrome Add: E80.6 Other disorders of bilirubin metabolism Add: E80.7 Disorder of bilirubin metabolism, unspecified

Line: 657 Condition: CARDIOVASCULAR CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: Q25.47 Right aortic arch

Line: 658 Condition: SENSORY ORGAN CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: H93.11 Tinnitus, right ear Add: H93.12 Tinnitus, left ear Add: H93.13 Tinnitus, bilateral Add: H93.19 Tinnitus, unspecified ear

Line: 660 Condition: DERMATOLOGICAL CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: L98.7 Excessive and redundant skin and subcutaneous tissue Delete: Q82.3 Incontinentia pigmenti

Line: 661 Condition: RESPIRATORY CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Delete: J98.5 Diseases of mediastinum, not elsewhere classified Add: J98.51 Mediastinitis Add: J98.59 Other diseases of mediastinum, not elsewhere classified

Line: 662 Condition: GENITOURINARY CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Delete: N42.3 Dysplasia of prostate Delete: N50.8 Other specified disorders of male genital organs Add: Q52.120 Longitudinal vaginal septum, nonobstructing

Line: 663 Condition: MUSCULOSKELETAL CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Delete: M53.2X9 Spinal instabilities, site unspecified Add: M62.84 Sarcopenia Delete: M99.81 Other biomechanical lesions of cervical region Delete: M99.82 Other biomechanical lesions of thoracic region

Page A-84 Attachment A

Coding Changes to Condition-Treatment Pairs on the Prioritized List of Health Services Approved on January 14, 2016 through August 11, 2016 by the Health Evidence Review Commission

Line: 664 Condition: GASTROINTESTINAL CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: K90.41 Non-celiac gluten sensitivity

Line: 665 Condition: MISCELLANEOUS CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Delete: Q67.5 Congenital deformity of spine Delete: Q67.6 Pectus excavatum

Page A-85 Attachment B

Interim Modifications Affecting Numerous Lines

Remove code 92310 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92311 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, 1 eye) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92312 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92313 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,323,324,340-342,353,356,359,365,370,372,375,379,388, 399,410,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92325 (Modification of contact lens (separate procedure), with medical supervision of adaptation) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92326 (Replacement of contact lens) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92340 (Fitting of spectacles, except for aphakia; monofocal) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92341 (Fitting of spectacles, except for aphakia; bifocal) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92342 (Fitting of spectacles, except for aphakia; multifocal, other than bifocal) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92352 (Fitting of spectacle prosthesis for aphakia; monofocal) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92353 (Fitting of spectacle prosthesis for aphakia; multifocal) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92358 (Prosthesis service for aphakia, temporary (disposable or loan, including materials)) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 92370 (Repair and refitting spectacles; except for aphakia) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,302,304,313,323,324,340-342,353,356,359,365,370,372,379,388,410,441, 445,453,456,464,475,488,499,505,564,567,572,597,630,636,644

Remove code 92371 (Repair and refitting spectacles; spectacle prosthesis for aphakia) from the following lines: 100,117,143,159,171,175,248,249,252,270,274,278,284,301,302,304,313,315,323,324,340-342,353,356,359,365,370,372,375,379, 388,399,441,445,453,455,456,464,475,476,488,499,505,564,567,572,597,630,636,644

Remove code 97022 (Application of a modality to 1 or more areas; whirlpool) from the following lines: 34,50,61,72,75,76,85,95,96,135,136,140,154,157,164,187,188,200,201,205,212,259,261,276,290,297,306,314,322,346,350,351,353, 360,361,364,366,381,382,392,406,407,413,421,428,431,436,447,467,471,482,490,512,532,558,561,574,592,611

Add code 99354 (Prolonged evaluation and management or psychotherapy 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 hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)) to the following lines:

Page B-1 Attachment B

Interim Modifications Affecting Numerous Lines

4,5,7,26,29,66,101,126,153,177,197,206,208,216,257,282,287,295,351,366,386,394,397,412,417,419,425,437,442,449,451,454,462, 466,474,477,483,498,532,549,554,576,614,635,653

Add code 99355 (Prolonged evaluation and management or psychotherapy 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 for prolonged service)) to the following lines: 4,5,7,26,29,66,101,126,153,177,197,206,208,216,257,282,287,295,351,366,386,394,397,412,417,419,425,437,442,449,451,454,462, 466,474,477,483,498,532,549,554,576,614,635,653

Add code 99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)) to the following lines: 4,7,26,29,66,101,122,153,177,206,208,282,287,295,351,366,386,397,412,417,442,454,474,532,614

Remove code 99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)) from the following lines: 407,501

Add code 99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)) to the following lines: 4,7,26,29,66,101,122,153,177,206,208,282,287,295,351,366,386,397,412,417,442,454,474,532,614

Remove code 99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)) from the following lines: 407,501

Page B-2 Attachment C

Obsolete Codes Removed from Prioritized List

The following invalid ICD-10-CM Codes codes have been deleted from the Prioritized List of Health Services:

E08321,E08329,E08331,E08339,E08341,E08349,E08351,E08359,E09321,E09329,E09331,E09339,E09341,E09349,E09351,E09359, E10321,E10329,E10331,E10339,E10341,E10349,E10351,E10359,E11321,E11329,E11331,E11339,E11341,E11349,E11351,E11359, E13321,E13329,E13331,E13339,E13341,E13349,E13351,E13359,E780,F328,F348,F42,F508,H34811,H34812,H34813,H34819, H34831,H34832,H34833,H34839,H3531,H3532,H4011X0,H4011X1,H4011X2,H4011X3,H4011X4,I6020,I6021,I6022,I6901,I6911, I6921,I6931,I6981,I6991,I9762,J985,K040,K0521,K0522,K0531,K0532,K088,K522,K550,K593,K850,K851,K852,K853,K858,K859, K868,K904,M2660,M2661,M2662,M2663,M5002,M5012,M5022,M5032,M5082,M5092,N423,N508,N61,N830,N831,N8320,N8329, N8331,N8332,N8333,N834,N8351,N8352,N906,N941,O000,O001,O002,O008,O009,O337,O3421,O702,Q252,Q254,Q5212,Q662, S0210XA,S0210XB,S0210XD,S0210XG,S0210XK,S023XXA,S023XXB,S023XXD,S023XXG,S023XXK,S0261XA,S0261XB,S0261XD, S0261XG,S0261XK,S0262XA,S0262XB,S0262XD,S0262XG,S0262XK,S0263XA,S0263XB,S0263XD,S0263XG,S0263XK,S0264XA, S0264XB,S0264XD,S0264XG,S0264XK,S0265XA,S0265XB,S0265XD,S0265XG,S0265XK,S0267XA,S0267XB,S0267XD,S0267XG, S0267XK,S028XXA,S028XXB,S028XXD,S028XXG,S028XXK,S030XXA,S030XXD,S034XXA,S034XXD,S060X2A,S060X2D,S060X3A, S060X3D,S060X4A,S060X4D,S060X5A,S060X5D,S060X6A,S060X6D,S060X7A,S060X7D,S060X8A,S060X8D,T8351XA,T8351XD, T8359XA,T8359XD,T836XXA,T836XXD,T84040A,T84040D,T84041A,T84041D,T84042A,T84042D,T84043A,T84043D,T84048A, T84048D,T84049A,T84049D,T8581XA,T8581XD,T8582XA,T8582XD,T8583XA,T8583XD,T8584XA,T8584XD,T8585XA,T8585XD, T8586XA,T8586XD,T8589XA,T8589XD,Z2250,Z2251,Z2252,Z2259.

Page C-1 ATTACHMENT D New Guidelines Effective October 1, 2016

DIAGNOSTIC GUIDELINE D2, IMPLANTABLE CARDIAC LOOP RECORDERS Use of an implantable cardiac loop recorder (ICLR) is a covered service only when the patient meets all of the following criteria: 1. The evaluation is for recurrent transient loss of consciousness (TLoC); and 2. A comprehensive evaluation including 30 days of noninvasive ambulatory cardiac monitoring did not demonstrate a cause of the TLoC; and 3. A cardiac arrhythmia is suspected to be the cause of the TLoC; and 4. There is a likely recurrence of the TLoC within the battery longevity of the device.

ICLRs are not a covered service for evaluation of cryptogenic stroke or any other indication.

GUIDELINE NOTE 16, PROTON BEAM THERAPY FOR CANCER Lines 97,117,130,133,195,205,242,280,292,299,377,402,403 Proton beam therapy is included on Lines 117 CANCER OF EYE AND ORBIT, 130 BENIGN NEOPLASM OF THE BRAIN AND SPINAL CORD and 299 CANCER OF BRAIN AND NERVOUS SYSTEM.

Proton beam therapy is included on Lines 133, 205 and 292 only for: malignant skull base, paranasal sinus (including lethal midline granuloma), spinal, and juxtaspinal tumors.

Proton beam therapy is additionally included on Lines 97, 195, 242, 280, 402 and 403 only for pediatric malignant tumors (incident cancer under age 21).

GUIDELINE NOTE 33, NITROUS OXIDE FOR LABOR PAIN Line 1 Nitrous oxide for labor pain is included on this line.

GUIDELINE NOTE 72, CONGENITAL UROLOGIC CONDITIONS Lines 91,98,438,662 The following conditions are included on these Lines 91, 98 and 438 only for children aged 18 and younger. For adults, these conditions are included on Line 662.  ICD-10 Q54.0 (Hypospadias, balanic)  ICD-10 Q55.22 (Retractile testicle)  ICD-10 Q60.3 (Renal hypoplasia, unilateral)  ICD-10 Q62.4 (Agenesis of ureter)  ICD-10 Q62.5 (Duplication of ureter)  ICD-10 Q62.60 (Accessory kidney)  ICD-10 Q62.61 (Deviation of ureter)  ICD-10 Q62.62 (Displacement of ureter)  ICD-10 Q63 (Other congenital malformations of kidney)

GUIDELINE NOTE 94, PECTUS EXCAVATUM Lines 406,530 Pectus excavatum (ICD-10 Q67.6) is included on Line 406 only for patients with all of the following:

1. Severe deformity (Haller index >3.25) AND 2. Documented pulmonary or cardiac dysfunction demonstrated by either a. Cardiac effects to include cardiac compression or displacement, bundle branch block or other cardiac pathology secondary to compression of the heart, OR b. Pulmonary function studies demonstrating at least a moderately severe restrictive lung defect, AND 3. These conditions are reasonably expected to be relieved with surgery.

Otherwise, this condition is included on Line 530.

ICD-10 Q79.8 is included on Line 406 only for Poland syndrome. Other diagnoses using this code are on Line 530. Surgical reconstruction of musculoskeletal chest wall deformities associated with Poland's syndrome are only included on Line 406 when causing functional deficits.

D-1

ATTACHMENT D New Guidelines Effective October 1, 2016

GUIDELINE NOTE 105, MEDIASTINITIS Lines 290,661 ICD-10 J98.51 (Mediastinitis) is included on Line 290 for acute mediastinitis and on Line 661 for chronic or fibrosing mediastinitis.

GUIDELINE NOTE 155, ELECTRIC TUMOR TREATMENT FIELDS FOR GLIOBLASTOMA Line 299 Electric tumor treatment fields (codes HCPCS A4555 and E0766) are included on this line only when 1. Used for the initial treatment of supratentorial glioblastoma 2. Used in combination with temozolomide

Electric tumor treatment fields are not included on this line for recurrent glioblastoma or any other indication.

GUIDELINE NOTE 156, ENCOUNTER FOR DESENSITIZATION TO ALLERGENS Lines 9,107,128,227,318,535,536,555,564,571 ICD-10 Z51.6 (Encounter for desensitization to allergens) is only included on these lines when used to treat a diagnosis appearing on a line above the current funding line.

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ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

GUIDELINE NOTE 3, PROPHYLACTIC TREATMENT FOR PREVENTION OF BREAST CANCER IN HIGH RISK WOMEN Line 195 Bilateral prophylactic breast removal and/or oophorectomy are included on Line 195 for women without a personal history of invasive breast cancer who meet the criteria in the NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Risk Reduction. V.1.2014 (1/20/142016 (2/23/16). www.nccn.org. Prior to surgery, women without a personal history of breast cancer must have a genetics consultation as defined in section A2 of the DIAGNOSTIC GUIDELINE D1, NON-PRENATAL GENETIC TESTING GUIDELINE.

Contralateral prophylactic mastectomy is included on Line 195 for women with a personal history of breast cancer.

GUIDELINE NOTE 4, TOBACCO DEPENDENCE, INCLUDING DURING PREGNANCY Line Lines 1,5 Pharmacotherapy and behavioral counseling are included on this line, alone or in combination, for at least 2 quit attempts per year. A minimum of four counseling sessions of at least 10 minutes each (group or individual, telephonic or in person) are included for each quit attempt. More intensive interventions and group therapy are likely to be the most effective behavioral interventions. During pregnancy, additional intensive behavioral counseling is strongly encouraged. All tobacco cessation interventions during pregnancy are not subject to limits.

Inclusion on this line follows the minimum standard criteria as defined in the Oregon Public Health Division “Standard Tobacco Cessation Coverage” (based on the Patient Protection and Affordable Care Act), available here: https://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Pages/pubs.aspx. The USPSTF has also made “A” recommendations for screening, counseling, and treatment of pregnant and nonpregnant adults, included in Guideline Note 106.

The development of the pregnancy-related portions of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-reduce-tobacco-use-pregnancy.aspx

Guideline Note 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE Lines 366,407 Patients seeking care for back pain should be assessed for potentially serious conditions (“red flag”)” symptoms requiring immediate diagnostic testing), as defined in Diagnostic Guideline D4. Patients lacking red flag symptoms should be assessed using a validated assessment tool (e.g. STarT Back Assessment Tool) in order to determine their risk level for poor functional prognosis based on psychosocial indicators. For patients who are determined to be low risk on the assessment tool, the following services are included on these lines:  Office evaluation and education,  Up to 4 total visits, consisting of the following treatments: OMT/CMT, acupuncture, and PT/OT. Massage, if available, may be considered.  First line medications: NSAIDs, acetaminophen, and/or muscle relaxers. Opioids may be considered as a second line treatment, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOID PRESCRIBINGOPIOIDS FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.

For patients who are determined to be medium- or high risk on the validated assessment tool, as well as patients undergoing opioid tapers as in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE, the following treatments are included on these lines:  Office evaluation, consultation and education  Cognitive behavioral therapy. The necessity for cognitive behavioral therapy should be re-evaluated every 90 days and coverage will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement.  Prescription and over-the-counter medications,; opioid medications subject to the limitations on coverage of opioids in Guideline Note 60 OPIOID PRESCRIBINGOPIOIDS FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.  The following evidence-based therapies, when available, are encouraged: yoga, massage, supervised exercise therapy, intensive interdisciplinary rehabilitation. HCPCS S9451 is only included on Line 407 for the provision of yoga or supervised exercise therapy.  A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only included on these lines if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant progress toward the therapy plan of care goals and objectives using evidence based objective tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ). 1) Rehabilitative therapy (physical and/or occupational therapy), if provided according to Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES. Rehabilitation services provided under this guideline also count towards visit totals in Guideline Note 6 2) Chiropractic or osteopathic manipulation 3) Acupuncture E-1

ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

Mechanical traction (CPT 97012) is not included on these lines, due to evidence of lack of effectiveness for treatment of back and neck conditions. Transcutaneous electrical nerve stimulation (TENS; CPT 64550, 97014 and 97032) is not included on the Prioritized List for any condition due to lack of evidence of effectiveness.

The development of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-low-back-non-pharmacologic-intervention.aspx.

Evidence Table of Effective Treatments for the Management of Low Back Pain

GUIDELINE NOTE 60 OPIOID PRESCRIBING, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE Lines 351,366,407,532 The following restrictions on opioid treatment apply to all diagnosesOpioid medications are only included on these lines. under the following criteria:

For acute injury, acute flare of chronic pain, or after surgery:

E-2

ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

1) During the first 6 weeks after the acute injury, flare or surgery, opioid treatment is included on these lines ONLY: a) When each prescription is limited to 7 days of treatment, AND b) For short acting opioids only, AND c) When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND d) When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND e) There is documented lack of current or priorverification that the patient is not high risk for opioid misuse or abuse. 2) Treatment with opioids after 6 weeks, up to 90 days, requires after the followinginitial injury/flare/surgery is included on these lines ONLY: a) DocumentedWith documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ). b) Must beWhen prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture. c) VerificationWith verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve i) Documented verification from the state's prescription monitoring program database that the controlled substance history is consistent with the prescribing record ii) Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abuse iii) Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids. d) Each prescription must be limited to 7 days of treatment and for short acting opioids only

3) Further opioid treatment after 90 days may be considered ONLY when there is a significant change in status, such as a clinically significant verifiable new injury or surgery. In such cases, use of opioids is limited to a maximum of an additional 7 days. In exceptional cases, use up to 28 days may be covered, subject to the criteria in #2 above.

For patients with chronic pain from diagnoses on these lines currently treated with long term opioid therapy, opioids must be tapered off using an individualized treatment plan developed by January 1, 2017 with a quit date no later than January 1, 2018. Taper plans must include nonpharmacological treatment strategies for managing the patient’s pain based on Guideline note 56. Chronic opioid treatment (>90 days) after the initial injury/flare/surgery is not included on these lines except for the taper process described below.

Transitional coverage for patients on long-term opioid therapy as of July 1, 2016:

For patients on covered chronic opioid therapy as of July 1, 2016, opioid medication is included on these lines only from July 1, 2016 to December 31, 2016. During the period from January 1, 2017 to December 31, 2017, continued coverage of opioid medications requires an individual treatment plan developed by January 1, 2017 which includes a taper with an end to opioid therapy no later than January 1, 2018. Taper plans must include nonpharmacological treatment strategies for managing the patient’s pain based on Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. If a patient has developed dependence and/or addiction related to their opioids, treatment is available on Line 4 SUBSTANCE USE DISORDER.

GUIDELINE NOTE 65, TELEPHONE AND EMAIL CONSULTATIONS Included on all lines with evaluation & management (E&M) codes Telephone and email consultations (CPT 98966-98969) must meet the following criteria: 1) Patient must have a pre-existing relationship with the provider as demonstrated by at least one prior office visit within the past 12 months. 2) E-visits must be provided by a physician or licensed provider within their scope of practice. 3) Documentation should model SOAP charting; must include patient history, provider assessment, and treatment plan; follow up instructions; be adequate so that the information provided supports the assessment and plan; must be retained in the patient’s medical record and be retrievable. 4) Telephone and email consultations must involve permanent storage (electronic or hard copy) of the encounter. 5) Telephone and email consultations must meet HIPAA standards for privacy. 6) There needs to be a patient-clinician agreement of informed consent for E-visits by email. This should be discussed with and signed by the patient and documented in the medical record.

Examples of reimbursable telephone and email consultations include but are not limited to: 1) Extended counseling when person-to-person contact would involve an unwise delay. 2) Treatment of relapses that require significant investment of provider time and judgment. 3) Counseling and education for patients with complex chronic conditions.

Examples of non-reimbursable telephone and email consultations include but are not limited to: 1) Prescription renewal. 2) Scheduling a test. 3) Scheduling an appointment. E-3

ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

4) Reporting normal test results. 5) Requesting a referral. 6) Follow up of medical procedure to confirm stable condition, without indication of complication or new condition. 7) Brief discussion to confirm stability of chronic problem and continuity of present management.

Guideline Note 92, ACUPUNCTURE Lines 1,5,208,366,407,415,467,543 Inclusion of acupuncture (CPT 97810-97814) on the Prioritized List has the following limitations:

Line 1 PREGNANCY Acupuncture pairs on Line 1 for the following conditions and codes. Hyperemesis gravidarum ICD-10-CM: O21.0, O21.1 Acupuncture pairs with hyperemesis gravidarum when a diagnosis is made by the maternity care provider and referred for acupuncture treatment for up to 12 sessions of acupressure/acupuncture per pregnancy. Breech presentation ICD-10-CM: O32.1 Acupuncture (and moxibustion) is paired with breech presentation when a referral with a diagnosis of breech presentation is made by the maternity care provider, the patient is between 33 and 38 weeks gestation, for up to 6 visits per pregnancy. Back and pelvic pain of pregnancy ICD-10-CM: O99.89 Acupuncture is paired with back and pelvic pain of pregnancy when referred by maternity care provider/primary care provider for up to 12 sessions per pregnancy. Line 5 TOBACCO DEPENDENCE Acupuncture is included on this line for a maximum of 12 sessions. Line 208 DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE Acupuncture is paired with the treatment of post-stroke depression only. Treatments may be billed to a maximum of 30 minutes face-to-face time and limited to 12 total sessions per year, with documentation of meaningful improvement. Line 366 SCOLIOSIS Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. Line 407 CONDITIONS OF THE BACK AND SPINE Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. Line 415 MIGRAINE HEADACHES Acupuncture pairs on Line 415 for migraine (ICD-10-CM G43.0, G43.1, G43.5, G43.7, G43.8, G43.9), for up to 12 sessions per year. Line 467 OSTEOARTHRITIS AND ALLIED DISORDERS Acupuncture pairs on Line 467 for osteoarthritis of the knee only (ICD-10-CM M17), for up to 12 sessions per year. *Line 543 TENSION HEADACHES Acupuncture is included on Line 543 for treatment of tension headaches (ICD-10-CM G44.2), for up to 12 sessions per year.

The development of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-low-back-non-pharmacologic-intervention.aspx

*Below the current funding line.

GUIDELINE NOTE 99, ROUTINE PRENATAL ULTRASOUND Lines 1,39,41,67 Routine ultrasound for the average risk pregnant woman is included on these lines for: A) One ultrasound in the first trimester for the purpose of identifying fetal aneuploidy or anomaly (between 11 and 13 weeks of gestation) and /or dating confirmation. In some instances, if a patient’s LMP is truly unknown, a dating ultrasound may be indicated prior to an aneuploidy screen B) One ultrasound for the purpose of anatomy screening after 18 weeks gestation. For those using tobacco during pregnancy, additional counseling around smoking impacts on the fetus is included during this ultrasound

Only one type of routine prenatal ultrasound should be covered in a single day (i.e., transvaginal or abdominal).

The development of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-routine-ultrasound-pregnancy.aspx

E-4

ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

GUIDELINE NOTE 106, PREVENTIVE SERVICES Line 3 Included on this line are the following preventive services as required by federal law: 1. US Preventive Services Task Force (USPSTF) “A” and “B” Recommendations (as of May 2012): http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/ 2. American Academy of Pediatrics (AAP) Bright Futures Guidelines (published 2008):: http://brightfutures.aap.org. Periodicity schedule available at http://www.aap.org/en-us/professional- resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf. 3. Health Resources and Services Administration (HRSA) Women’s Preventive Services - Required Health Plan Coverage Guidelines: (approved with Affordable Care Act on March 23, 2010) http://www.hrsa.gov/womensguidelines/ 4. Immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP): http://www.cdc.gov/vaccines/schedules/hcp/index.html

GUIDELINE NOTE 107, HYPERBARIC OXYGEN Line 337 A course of hyperbaric oxygen treatment is included on this line subject to the following limitations:  Codes appearing on this line from ICD-10-CM E08-E13 are included only when they are diabetic wound ulcers of the lower extremities which are Wagner grade 3 or higher (that is, involving bone or gangrenous) and show no measurable signs of healing after 30 days of adequate standard wound therapies including arterial assessment. Courses of treatment for wounds or ulcers are limited to 30 days after the initial treatment; additional 30 day treatment courses are only covered for patients with incomplete wound/infection resolution AND measurable signs of healing  ICD-10-CM M27.2 is included on this line for osteoradionecrosis of the jaw only  ICD-10-CM O08.0 and M60.0 are included on this line only if the infection is a necrotizing soft-tissue infection  ICD-10-CM S07, S17, S38, S47.1, S47.2, S47.9, S57, S67, S77, S87, S97, T79.A are included on this line only for posttraumatic crush injury of Gustilo type III B and C  ICD-10-CM T66.XXXA-T66.XXXD and L59.8 are included on this line only for osteoradionecrosis and soft tissue radiation injury  ICD-10-CM T86.82, T82.898, T82.9, T83.89, T83.9, T84.89, T84.9, T85.89, T85.9 are included on this line only for compromised myocutaneous flaps Hyperbaric oxygen is a covered service only under the following circumstances:  when paired with diabetic wounds of the lower extremities extremities without gangrene (ICD-10-CM E08.621, E09.621, E10.621, E11.621, E13.621, E08.622, E09.622, E10.622, E11.622, and E13.622) in patients who meet all of the following criteria: o Patient has a wound classified as Wagner grade III or higher, AND o Patient has failed an adequate course of standard wound therapy including arterial assessment, with no measurable signs of healing after at least thirty days, AND o Wounds must be evaluated at least every 30 days during administration of hyperbaric oxygen therapy. Continued treatment with hyperbaric oxygen therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  when paired with ICD-10-CM M27.8 for osteoradionecrosis of the jaw only  when paired with ICD-10-CM O08.0 and M60.0 only if the infection is a necrotizing soft-tissue infection  when paired with diagnosis codes included on this line from ICD-10-CM S07, S17, S38, S47.1, S47.2, S47.9, S57, S67, S77, S87, S97, T79.A only for posttraumatic crush injury of Gustilo type III B and C  when paired with ICD-10-CM T66.XXXA-T66.XXXD only for osteoradionecrosis and soft tissue radiation injury  when paired with ICD-10-CM T86.82, T82.898, T82.9, T83.89, T83.9, T84.89, T84.9, T85.89, T85.9 only for compromised myocutaneous flaps

GUIDELINE NOTE 113, DISEASES OF LIPS Lines 210,585 ICD-10-CM code K13.0 (Diseases of lips) is included on Line 210 only for treatment of abscess or cellulitis of the lips. All other sub- diagnoses under this codecoded using K13.0 are included on Line 585.

GUIDELINE NOTE 127, GENDER DYSPHORIA Line 317 Hormone treatment with GnRH analogues for delaying the onset of puberty and/or continued pubertal development is included on this line for gender questioning children and adolescents. This therapy should be initiated at the first physical changes of puberty, confirmed by pubertal levels of estradiol or testosterone, but no earlier than Tanner stages 2-3. Prior to initiation of puberty suppression therapy, adolescents must fulfill eligibility and readiness criteria and must have a comprehensive mental health evaluation. Ongoing psychological care is strongly encouraged for continued puberty suppression therapy. E-5

ATTACHMENT E REVISIONS TO EXISTING GUIDELINE NOTES Effective October 1, 2016

Cross-sex hormone therapy is included on this line for treatment of adolescents and adults with gender dysphoria who meet appropriate eligibility and readiness criteria. To qualify for cross-sex hormone therapy, the patient must: 1. have persistent, well-documented gender dysphoria 2. have the capacity to make a fully informed decision and to give consent for treatment 3. have any significant medical or mental health concerns reasonably well controlled 4. have a comprehensive mental health evaluation provided in accordance with Version 7 of the World Professional Association for Transgender Health (WPATH) Standards of Care (www.wpath.org). Sex reassignment surgery is included for patients who are sufficiently physically fit and meet eligibility criteria. To qualify for surgery, the patient must: 1. have persistent, well documented gender dysphoria 2. for genital surgeries, have completed twelve months of continuous hormone therapy as appropriate to the member’s gender goals unless hormones are not clinically indicated for the individual 3. have completed twelve months of living in a gender role that is congruent with their gender identity unless a medical and a mental health professional both determine that this requirement is not safe for the patient 4. have the capacity to make a fully informed decision and to give consent for treatment 5. have any significant medical or mental health concerns reasonably well controlled 6. for breast/chest surgeries, have one referral from a mental health professional provided in accordance with version 7 of the WPATH Standards of Care. 7. For genital surgeries, have two referrals from mental health professionals provided in accordance with version 7 of the WPATH Standards of Care.

Electrolysis (CPT 17380) isand laser hair removal (CPT 17110,17111) are only included on this line for surgical site electrolysis as part of pre-surgical preparation for chest or genital surgical procedures also included on this line. It isThese procedures are not included on this line for facial or other cosmetic procedures or as pre-surgical preparation for a procedure not included on this line.

Mammoplasty (CPT 19316, 19324-19325, 19340, 19342, 19350, 19357-19380) is only included on this line when 12 continuous months of hormonal (estrogen) therapy has failed to result in breast tissue growth of Tanner Stage 5 on the puberty scale OR there is a medicalany contraindication to, intolerance of or patient refusal of hormonal therapy.

Revisions to surgeries for the treatment of gender dysphoria are only covered in cases where the revision is required to address complications of the surgery (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.). Revisions are not covered solely for cosmetic issues.

Pelvic physical therapy (CPT 97001, 97001, 97110, 97140, and 97530) is included on this line only for pre- and post-operative therapy related to genital surgeries also included on this line and as limited in Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES.

GUIDELINE NOTE 141, LARYNGEAL STENOSIS OR PARALYSIS WITH AIRWAY COMPLICATIONS; DYSPHONIA LineLines 70,521 Laryngeal and vocal cord paralysis is covered(ICD-10-CM J38.01 and J38.02) are included on this line Line 70 if associated with recurrent aspiration pneumonia (unilateral or bilateral) or airway obstruction (bilateral). Hoarseness is Vocal cord paralysis is included on line 70 for children 18 and under with dysphonia or dysphagia persisting for at least twelve months. Treatment of hoarseness and dysphonia in adults are included only on Line 521. Laryngeal stenosis (ICD-10-CM J38.6) is included on this lineLine 70 only if it causes airway obstruction; otherwise it is included on Line 521.

GUIDELINE NOTE 144, PROTON PUMP INHIBITOR THERAPY FOR GASTROESOPHAGEAL REFLUX DISEASE (GERD) Lines 385,516 Short term treatment (up to 8 weeks) of GERD without Barrett’s (ICD-10 K20.8, K20.9, K21.0, K21.9) with proton pump inhibitor therapy is included on Line 385. Long term treatment is included on Line 516.

Long term proton pump inhibitor therapy is included on Line 516 for Barrett’s esophagus (ICD-10 K22.70).

.

E-6

ATTACHMENT F Deleted Guidelines Effective October 1, 2016

DIAGNOSTIC GUIDELINE D2, TUBERCULOSIS TESTING GUIDELINE Quanti-FERON TB Gold (QFT-G), a blood test for detecting infection with Mycobacterium tuberculosis, may be used in the following circumstances: A) Instead of Tuberculin Skin Test (TST) for investigation of contacts to confirmed cases of active tuberculosis (TB) disease. B) Instead of TST for screening for latent TB in persons with definitive history or BCG or who have immigrated from countries with high prevalence (>10%) of latent TB where BCG is commonly given. C) As a supplementary test to TST in foreign-born persons with a positive TST, history of BCG vaccination against tuberculosis, and no clinical evidence of current TB disease. D) As a supplementary test in persons with a positive TST who are members of otherwise low-risk populations (e.g., U.S.- born persons and others who have immigrated to the U.S. > 5 years previously or more recently from low TB prevalence countries; absence of immunosuppressive conditions such as HIV infection, renal failure, diabetes mellitus or alcoholism; homelessness; known exposure to someone with active TB), and no clinical evidence of current TB disease. E) In populations that need rapid (within 24 hours) diagnosis in order to guide appropriate public health interventions such as isolation for infectious tuberculosis or contact evaluation. F) In a high-risk patient (e.g. homelessness, immune suppression or deficiency, recent immigrant) who the treating clinician believes is unlikely to return on time for the TST reading.

GUIDELINE NOTE 16, CYSTIC FIBROSIS CARRIER SCREENING Lines 1,625 Cystic fibrosis carrier testing is covered for 1) non-pregnant adults if indicated in the genetic testing algorithm or 2) pregnant women.

GUIDELINE NOTE 33, CANCERS OF ESOPHAGUS, LIVER, PANCREAS, GALLBLADDER AND OTHER BILIARY Lines 319-321,439 Retreatment with chemotherapy after failure from the first full course of chemotherapy places the patient in the category of treatment of cancer with little or no benefit. See Guideline Note 12.

Guideline Note 72, ELECTRONIC ANALYSIS OF INTRATHECAL PUMPS Lines 351,366,532,607 Electronic analysis of intrathecal pumps, with or without programming (CPT codes 62367-62370), is included on these lines only for pumps implanted prior to April 1, 2009.

Guideline Note 105 EPIDURAL STEROID INJECTIONS FOR BACK PAIN Line 407 Epidural lumbar steroid injections (CPT 62311, 64483, 64484) are included on this line for patients with persistent radiculopathy due to herniated lumbar disc, where radiculopathy is defined as lower extremity pain in a nerve root distribution, with or without weakness or sensory deficits.

One epidural steroid injection is included on this line; a second epidural steroid injection may be provided after 3-6 months only if objective evidence of 3 months of sustained pain relief was provided by the first injection. It is recommended that shared decision- making regarding epidural steroid injection include a specific discussion about inconsistent evidence showing moderate short-term benefits, and lack of long-term benefits. Epidural steroid injections are not included on this line for spinal stenosis or for patients with low back pain without radiculopathy. Epidural steroid injections are only included on this line when the patient is also participating in an active therapy such as physical therapy or home exercise therapy.

The development of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-percutaneous-low-back.aspx

F-1

ATTACHMENT G Revised Multisector Interventions Effective October 1, 2016

MULTISECTOR INTERVENTIONS 1,: TOBACCO PREVENTION AND CESSATION, INCLUDING DURING PREGNANCY Benefit coverage for smoking cessation on Line 5 and in Guideline Note 4, TOBACCO DEPENDENCE, INCLUDING DURING PREGNANCY is intended to be offered with minimal barriers, in order to encourage utilization. To further prevent tobacco use and help people quit, additional evidence-based policy and programmatic interventions from a population perspective are available here:  Oregon Public Health Division’s Health Promotion and Chronic Disease Prevention Section: Evidence-Based Strategies for Reducing Tobacco Use A Guide for CCOs https://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/evidence- based_strategies_reduce_tob_use_guide_cco.pdf  Community Preventive Services Task Force (supported by the CDC) - What Works: Tobacco Use http://www.thecommunityguide.org/about/What-Works-Tobacco-factsheet-and-insert.pdf The Community Preventive Services Task Force identified the following evidence-based strategies:

To reduce the use of tobacco during pregnancy and improve associated outcomes, the evidence supports the following interventions:  Financial incentives (incentives contingent upon laboratory tests confirming tobacco abstinence are the most effective)  Smoke-free legislation  Tobacco excise taxes

G-1

Attachment H Errata to the 1/1/2016 Prioritized List

1. On August 18, 2016 the following corrections were posted a. Move ICD-10-CM E51.2 Wernicke's encephalopathy from line 205 to line 206 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS. 2. On July 12, 2016 the following corrections were posted a. Add ICD-10-CM codes S32.002A, S32.012A, S32.022A, S32.032A, S32.042A and S32.052A (Unstable burst fractures of the vertebrae) to line 154 CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; O THER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR UNSTABLE; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY b. Remove S32.002A, S32.002D,S32.002G,S32.012A, ,S32.012D,S32.012G,S32.022A, S32.022D,S32.022G,S32.032A, S32.032D,S32.032G,S32.042A, S32.042D,S32.042G,S32.052A, S32.052D and S32.052G (Unstable burst fractures of the vertebrae) from line 482 CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT NEUROLOGIC INJURY OR STRUCTURAL INSTABILITY c. Modify GN136 removing reference to unstable burst fracture. d. Modify GN 97, removing ICD-10-CM codes S43.60 and S43.62 (Sprains of sternoclavicular joint). e. Move ICD-10-CM codes M76.20-M76.22 (iliac crest spur) from line 381 DISRUPTIONS OF THE LIGAMENTS AND TENDONS OF THE ARMS AND LEGS, EXCLUDING THE KNEE, RESULTING IN SIGNIFICANT INJURY/IMPAIRMENT and add to line 361 RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE f. Add a reference to M76.2 (iliac crest spur) to GN 114. g. Connected GL 126 APPLIED BEHAVIOR ANALYSIS INTERVENTIONS FOR SELF-INJURIOUS BEHAVIOR to line 442 STEREOTYPY/HABIT DISORDER AND SELF-ABUSIVE BEHAVIOR DUE TO NEUROLOGICAL DYSFUNCTION rather than line 197 AUTISM SPECTRUM DISORDER h. Corrected link in Guideline Note D6 to link to the correct coverage guidance. i. Remove 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved from Line 415 MIGRAINE HEADACHES. 3. The following corrections were posted 3/16/2016 a. ICD-10-CM code P36.1-P36.9 Sepsis of newborn were moved from line 2 BIRTH OF INFANT to line 186 SEPTICIMIA. b. HCPCS G0458 Low dose rate (ldr) prostate brachytherapy services, composite rate was removed from lines 8,30,51,84,210,212,240,290,384,428 and added to line 334 CANCER OF PROSTATE GLAND. c. Corrected Guideline Note 42 , CHEMODENERVATION FOR CHRONIC MIGRAINE, changing the last paragraph to read as shown below (changes in bold): i. Treatment is limited to two treatments given 3 months apart. Additional treatment requires documented positive response to therapy. Positive response to therapy is defined as a reduction of at least 7 headache days per month compared to baseline headache frequency. d. Corrected Guideline Note 36, ADENOTONSILLECTOMY FOR INDICATIONS OTHER THAN OBSTRUCTIVE SLEEP APNEA. Line number references in the second=to-last paragraph were corrected to read as follows (changes in bold) i. ICD-10-CM J35.1 and J35.3 are included on Line 373 only for 1) unilateral tonsillar hypertrophy in adults and 2) unilateral tonsillar hypertrophy in children

H-1

Attachment H Errata to the 1/1/2016 Prioritized List

with other symptoms suggestive of malignancy. Bilateral tonsillar hypertrophy and unilateral tonsillar hypertrophy in children without other symptoms suggestive of malignancy are included only on Line 553. 4. The following corrections were posted February 18, 2016: a. CPT codes 64505-64530 (Injection, anesthetic agent) were removed from all lines on which they appear and recommended for placement on the Ancillary file. (Lines 1, 3, 6, 8, 9, 11, 20, 24, 25, 28, 30, 32, 37, 38, 39, 40, 41, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 59, 60, 61, 62, 63, 65, 67, 68, 70, 71, 72, 73, 74, 75, 76, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 102, 103, 104, 105, 107, 109, 110, 111, 112, 115, 116, 117, 118, 119, 120, 121, 123, 124, 125, 129, 130, 131, 132, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 147, 148, 154, 156, 157, 158, 159, 160, 161, 162, 163, 164, 166, 167, 168, 169, 170, 172, 173, 174, 175, 178, 180, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 198, 199, 200, 201, 202, 204, 205, 207, 209, 210, 212, 213, 214, 215, 217, 218, 219, 220, 221, 222, 224, 226, 227, 228, 229, 231, 233, 234, 235, 236, 237, 238, 239, 240, 242, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 254, 255, 256, 258, 259, 260, 261, 262, 263, 264, 265, 266, 267, 268, 270, 274, 275, 276, 278, 279, 280, 281, 284, 285, 286, 289, 290, 291, 292, 293, 294, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 308, 309, 310, 311, 312, 313, 314, 315, 316, 319, 320, 321, 322, 323, 324, 327, 328, 330, 331, 332, 333, 334, 335, 336, 338, 339, 340, 341, 342, 344, 345, 347, 350, 351, 352, 354, 356, 357, 358, 359, 360, 361, 362, 364, 365, 366, 367, 368, 369, 370, 371, 372, 373, 375, 376, 377, 379, 380, 381, 382, 383, 384, 385, 387, 390, 392, 393, 395, 398, 399, 400, 401, 402, 403, 405, 408, 409, 410, 411, 413, 418, 420, 421, 422, 423, 424, 426, 428, 429, 431, 432, 433, 434, 435, 436, 438, 439, 440, 441, 443, 444, 445, 446, 447, 450, 452, 453, 456, 458, 459, 463, 464, 465, 467, 468, 469, 470, 471, 473, 475, 476, 478, 479, 480, 481, 482, 484, 485, 494, 501, 516, 523, 524, 529, 531, 546, 566, 625) b. Speech therapy-related CPT codes 92507-92508, 92526, 92607-92609 and 92633 were removed from line 501 CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD) AND HYDROXYAPETITE DEPOSITION DISEASE c. ICD-10-CM code Z51.0 Encounter for antineoplastic radiation therapy was added to all radiation therapy lines (Lines 97, 116, 117, 119, 129, 130, 133, 137, 139, 161, 162, 195, 204, 205, 213, 215, 219, 220, 234, 239, 242, 243, 263, 264, 266, 267, 275, 280, 291, 292, 299, 319, 320, 321, 334, 347, 377, 402, 403, 406, 424, 439, 446, 464, 561, 606). d. ICD-10-CM code Z51.12 Encounter for antineoplastic immunotherapy was added to all chemotherapy lines (Lines 97, 116, 117, 119, 130, 137, 139, 161, 162, 195, 204, 205, 213, 215, 219, 220, 234, 239, 242, 243, 263, 264, 266, 267, 275, 280, 291, 292, 299, 319, 320, 321, 334, 402, 403, 406, 424, 439, 561). e. Move ICD-10-CM M93.01-M93.03 (slipped upper femoral epiphysis of the hip) from line 85 FRACTURE OF HIP to line 360 CLOSED FRACTURE OF EXTREMITIES (EXCEPT MINOR TOES). 5. The following corrections were posted February 1, 2016 a. ICD-10-CM code M79.7 Fibromyalgia was removed from line 607 DISORDERS OF SOFT TISSUE b. ICD-10-CM code P36.0 Sepsis of newborn due to streptococcus, group B was moved from line 2 BIRTH OF INFANT to line 186 SEPTICIMIA. c. ICD-10-CM CODE P78.89 Other specified perinatal digestive system disorders was moved from line 2 BIRTH OF INFANT to line 105 CONGENITAL ANOMALIES OF DIGESTIVE

H-2

Attachment H Errata to the 1/1/2016 Prioritized List

SYSTEM AND ABDOMINAL WALL EXCLUDING NECROSIS; CHRONIC INTESTINAL PSEUDO- OBSTRUCTION d. ICD-10-CM code Q30.0 Choanal atresia was moved from line 665 ISCELLANEOUS CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY to line 124 CHOANAL ATRESIA 6. The following corrections were posted January 19, 2016 a. ICD-10-CM codes K44.0 Diaphragmatic hernia with obstruction, without gangrene and K44.1 Diaphragmatic hernia with gangrene were added to line 385 ESOPHAGITIS; ESOPHAGEAL AND INTRAESOPHAGEAL HERNIAS. b. ICD-10-CM codes P07.30 Preterm newborn, unspecified weeks of gestation and P07.32 Preterm newborn, gestational age 29 completed weeks were added to line 17 VERY LOW BIRTH WEIGHT (UNDER 1500 GRAMS). c. ICD-10 code L20.9 Atopic dermatitis, unspecified was added to line 535 ATOPIC DERMATITIS. d. ICD-10-CM code E51.2 Wernicke's encephalopathy was moved from line 122 NUTRITIONAL DEFICIENCIES to line 205 CANCER OF BONES. 7. The following corrections were posted December 31, 2015: a. Q28.3 (Other malformations of cerebral vessels) and Q28.2 (Arteriovenous malformation of cerebral vessels) were removed from line 322 STROKE and placed on line 200 SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE/HEMATOMA; CEREBRAL ANEURYSM; COMPRESSION OF BRAIN. b. K22.71 (Barrett’s esophagus with dysplasia) was added to line 319 CANCER OF THE ESOPHAGUS and K22.70 (Barrett’s esophagus) was temporarily added to line 385 ESOPHAGITIS; ESOPHAGEAL AND INTRAESOPHAGEAL HERNIAS c. Guideline Note 92 (Acupuncture) was modified to change the ICD-10-CM code for pelvic pain in pregnancy from O33.0 (Maternal care for disproportion due to deformity of maternal pelvic bones) to O99.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) d. ICD-10-CM code E50.5 (Vitamin A deficiency with night blindness) was placed on lines 122 NUTRITIONAL DEFICIENCIES and line 455 DISORDERS OF REFRACTION AND ACCOMMODATION. (It was removed from lines 115 and 442). e. ICD-10-CM E50.6 (Vitamin A deficiency with xerophthalmic scars of cornea) was moved to line 122 and line 505 CHRONIC CONJUNCTIVITIS, BLEPHAROCONJUNCTIVITIS and removed from lines 115 AND 490. 8. The following corrections occurred since the Notice of Interim Modifications for the 1/1/16 list was generated. Therefore in these cases, guideline note text may differ from the appendices of the notice. a. A reference was added in Guideline notes 6, 94, 100 indicating that certain associated lines are from the October, 2015 Prioritized List due to the delay in implementation of the changes involving conditions of the back and spine. b. In guideline note 28, the reference to enthesopathy of the hip was removed to correctly identify ICD-10-CM M70.6 and M70.7. c. In guideline note 60 a typographical error was corrected (“included” was replaced with “including”). d. The method of referring to ICD-10-CM categories and subcategories has been corrected so that a lowercase “x” no longer represents multiple codes, and the listing of an ICD-10- CM representing a category or subcategory means all billable codes in that category or

H-3

Attachment H Errata to the 1/1/2016 Prioritized List

subcategory are included. For example, guideline note 81 now refers to “ICD-10-CM I73.1” (representing the single billable code I73.1). In guideline note 89, the reference to “ICD-10-CM I20.x” is replaced with “ICD-10-CM I20” (representing all billable codes in the range I20.0-I20.9 that appear on the line associated with the guideline note). For all such changes the meaning has not changed. e. In Guideline note 107 HYPERBARIC OXYGEN, a range of ICD-10-CM was removed from the first bullet. The meaning is not changed since all ICD-10-CM included on the line for diabetic wounds of the lower extremities were previously referenced. f. Coding changes as shown in Table A.

H-4

Attachment H Errata to the 1/1/2016 Prioritized List

Table A.

Code Additions Deletions C92.01 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS 242 ACUTE PROMYELOCYTIC LEUKEMIA 232 INTESTINAL MALABSORPTION 402 ACUTE MYELOID LEUKEMIA 379 RETINAL TEAR 403 MYELOID DISORDERS 380 CHOLESTEATOMA; INFECTIONS OF THE PINNA C92.02 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS 242 ACUTE PROMYELOCYTIC LEUKEMIA 232 INTESTINAL MALABSORPTION 402 ACUTE MYELOID LEUKEMIA 379 RETINAL TEAR 403 MYELOID DISORDERS 380 CHOLESTEATOMA; INFECTIONS OF THE PINNA C92.90 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C92.91 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C92.92 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C92.Z0 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C92.Z1 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C92.Z2 403 MYELOID DISORDERS 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVE... C93.30 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS C93.31 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS C93.32 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS C94.20 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C94.21 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C94.22 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C94.30 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C94.31 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C94.32 402 ACUTE MYELOID LEUKEMIA 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO 403 MYELOID DISORDERS MAXIMIZE LEVE... C95.01 97 CHILDHOOD LEUKEMIAS 93 DISCORDANT CARDIOVASCULAR CONNECTIONS 183 ACUTE LEUKEMIA, MYELODYSPLASTIC 179 POLYARTERITIS NODOSA AND ALLIED CONDITIONS SYNDROME 232 INTESTINAL MALABSORPTION 242 ACUTE PROMYELOCYTIC LEUKEMIA 380 CHOLESTEATOMA; INFECTIONS OF THE PINNA 403 MYELOID DISORDERS H40.031 248 PRIMARY ANGLE-CLOSURE GLAUCOMA 249 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA H40.032 248 PRIMARY ANGLE-CLOSURE GLAUCOMA 249 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA H40.033 248 PRIMARY ANGLE-CLOSURE GLAUCOMA 249 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA H40.039 248 PRIMARY ANGLE-CLOSURE GLAUCOMA 249 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA

H-5