BLUE CROSS AND BLUE SHIELD OF TEXAS (BCBSTX) 2021 OUTPATIENT PRIOR AUTHORIZATION REQUIREMENTS BY PROCEDURE CODE FOR ADMINISTRATIVE SERVICES ONLY (ASO) MEMBERS General Information: Procedures on the following pages may require prior authorization. These lists are not exhaustive. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply. ASO groups may have specific prior authorization requirements. Providers should check eligibility and benefits through Availity® or their preferred vendor to determine if a prior authorization is required. Not all requirements apply to each BCBSTX network (Blue Choice PPOSM, Blue EssentialsSM, Blue PremierSM, Blue Advantage HMOSM, MyBlue HealthSM and Blue High PerformanceSM). For inactive Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), the new code(s) is required to be submitted.
Updates to this list are announced routinely in the News and Updates section of the bcbstx.com/provider website. Selected procedures codes, within the outpatient service categories listed on the Utilization Management - Prior Authorization & Predeterminations page on the BCBSTX provider website, may not be included in this procedure code list. It is imperative that providers check eligibility and benefits and verify prior authorization requirements through Availity or their preferred vendor for these categories. Refer to Utilization Management -Prior Authorization & Predeterminations page on the BCBSTX provider website for any specific ASO group prior authorization information. 2021 Medical Surgical Procedures Requiring Prior Authorization for ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Surgical Deactivation of Cosmetic Surgery 15824 RHYTIDECTOMY FOREHEAD SUR712.031 _ Headache Trigger Sites
Surgical Deactivation of Cosmetic Surgery 15826 RHYTIDECTOMY GLABELLAR FROWN LINES SUR712.031 _ Headache Trigger Sites
Cosmetic Surgery 19316 MASTOPEXY SUR716.010 Mastopexy _
Cosmetic Surgery 19318 REDUCTION MAMMAPLASTY SUR716.012 Reduction Mammaplasty _
AIM Specialty Health®(AIM) Joint & Spine Surgery 20930 SP BONE ALGRFT MORSEL ADD-ON Guidelines _
Joint & Spine Surgery 20931 SP BONE ALGRFT STRUCT ADD-ON AIM Guidelines _
Joint & Spine Surgery 20936 SP BONE AGRFT LOCAL ADD-ON AIM Guidelines _
Joint & Spine Surgery 20937 SP BONE AGRFT MORSEL ADD-ON AIM Guidelines _
Joint & Spine Surgery 20938 SP BONE AGRFT STRUCT ADD-ON AIM Guidelines _
Joint & Spine Surgery 20974 ELECTRICAL BONE STIMULATION AIM Guidelines _
Joint & Spine Surgery 20975 ELECTRICAL BONE STIMULATION AIM Guidelines _
Oral Surgery 21085 IMPRESSION & PREPARATION ORAL SURGICAL SPLINT SUR705.030 Orthognathic Surgery _
Oral Surgery 21110 APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC SUR705.030 Orthognathic Surgery _
Oral Surgery 21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL SUR705.030 Orthognathic Surgery _
Oral Surgery 21127 AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL SUR705.030 Orthognathic Surgery _
Oral Surgery 21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT SUR705.030 Orthognathic Surgery _
Oral Surgery 21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT SUR705.030 Orthognathic Surgery _
Oral Surgery 21143 RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT SUR705.030 Orthognathic Surgery _ 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Oral Surgery 21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS SUR705.030 Orthognathic Surgery _
Oral Surgery 21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS SUR705.030 Orthognathic Surgery _
Oral Surgery 21147 RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS SUR705.030 Orthognathic Surgery _
Oral Surgery 21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION SUR705.030 Orthognathic Surgery _
Oral Surgery 21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS SUR705.030 Orthognathic Surgery _
Oral Surgery 21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I SUR705.030 Orthognathic Surgery _
Oral Surgery 21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I SUR705.030 Orthognathic Surgery _
Oral Surgery 21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I SUR705.030 Orthognathic Surgery _
Oral Surgery 21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I SUR705.030 Orthognathic Surgery _
Oral Surgery 21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT & BONE GRAFTS SUR705.030 Orthognathic Surgery _
Oral Surgery 21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF SUR705.030 Orthognathic Surgery _
Oral Surgery 21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT SUR705.030 Orthognathic Surgery _
Oral Surgery 21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD SUR705.030 Orthognathic Surgery _
Oral Surgery 21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI SUR705.030 Orthognathic Surgery _
Oral Surgery 21198 OSTEOTOMY MANDIBLE SEGMENTAL SUR705.030 Orthognathic Surgery _
OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT Oral Surgery 21199 SUR705.030 Orthognathic Surgery _
Oral Surgery 21206 OSTEOTOMY MAXILLA SEGMENTAL SUR705.030 Orthognathic Surgery _
Oral Surgery 21208 OSTEOPLASTY FACIAL BONES AUGMENTATION SUR705.030 Orthognathic Surgery _
Oral Surgery 21209 OSTEOPLASTY FACIAL BONES REDUCTION SUR705.030 Orthognathic Surgery _
Oral Surgery 21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS SUR705.030 Orthognathic Surgery _
Oral Surgery 21215 GRAFT BONE MANDIBLE SUR705.030 Orthognathic Surgery _
Oral Surgery 21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR SUR705.030 Orthognathic Surgery _
Joint & Spine Surgery 22510 PERQ CERVICOTHORACIC INJECT AIM Guidelines _
Joint & Spine Surgery 22511 PERQ LUMBOSACRAL INJECTION AIM Guidelines _
Joint & Spine Surgery 22512 VERTEBROPLASTY ADDL INJECT AIM Guidelines _
Joint & Spine Surgery 22513 PERQ VERTEBRAL AUGMENTATION AIM Guidelines _
Joint & Spine Surgery 22514 PERQ VERTEBRAL AUGMENTATION AIM Guidelines _
10/23/2020 2/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Joint & Spine Surgery 22515 PERQ VERTEBRAL AUGMENTATION AIM Guidelines _
Pain Management 22526 IDET SINGLE LEVEL AIM Guidelines _
Pain Management 22527 IDET 1 OR MORE LEVELS AIM Guidelines _
Joint & Spine Surgery 22533 LAT LUMBAR SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22534 LAT THOR/LUMB ADDL SEG AIM Guidelines _
Joint & Spine Surgery 22551 NECK SPINE FUSE&REMOV BEL C2 AIM Guidelines _
Joint & Spine Surgery 22552 ADDL NECK SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22554 NECK SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22558 LUMBAR SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22585 ADDITIONAL SPINAL FUSION AIM Guidelines _
Joint & Spine Surgery 22595 NECK SPINAL FUSION AIM Guidelines _
Joint & Spine Surgery 22600 NECK SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22612 LUMBAR SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22614 SPINE FUSION EXTRA SEGMENT AIM Guidelines _
Joint & Spine Surgery 22630 LUMBAR SPINE FUSION AIM Guidelines _
Joint & Spine Surgery 22632 SPINE FUSION EXTRA SEGMENT AIM Guidelines _
Joint & Spine Surgery 22633 LUMBAR SPINE FUSION COMBINED AIM Guidelines _
Joint & Spine Surgery 22634 SPINE FUSION EXTRA SEGMENT AIM Guidelines _
Genetic Lab 0203U AI IBD MRNA XPRSN PRFL 17 AIM Guidelines Added 01/01/2021
Genetic Lab 0204U ONC THYR MRNA XPRSN ALYS 593 AIM Guidelines Added 01/01/2021
Genetic Lab 0205U OPH AMD ALYS 3 GENE VARIANTS AIM Guidelines Added 01/01/2021
Genetic Lab 0208U ONC MTC MRNA XPRSN ALYS 108 AIM Guidelines Added 01/01/2021
Genetic Lab 0209U CYTOG CONST ALYS INTERROG AIM Guidelines Added 01/01/2021
Genetic Lab 0211U ONC PAN-TUM DNA&RNA GNRJ SEQ AIM Guidelines Added 01/01/2021
Joint & Spine Surgery 22840 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22841 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22842 INSERT SPINE FIXATION DEVICE AIM Guidelines _
10/23/2020 3/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Joint & Spine Surgery 22843 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22844 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22845 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22846 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22847 INSERT SPINE FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22848 INSERT PELV FIXATION DEVICE AIM Guidelines _
Joint & Spine Surgery 22853 INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W/ARTHRD AIM Guidelines _
Joint & Spine Surgery 22854 INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W/ARTHRD AIM Guidelines _
Joint & Spine Surgery 22856 CERV ARTIFIC DISKECTOMY AIM Guidelines _
Joint & Spine Surgery 22857 LUMBAR ARTIF DISKECTOMY AIM Guidelines _
Joint & Spine Surgery 22858 SECOND LEVEL CER DISKECTOMY AIM Guidelines _
Joint & Spine Surgery 22859 INSJ BIOMCHN DEV NTRVRT DISC SPACE W/O ARTHRD AIM Guidelines _
Joint & Spine Surgery 22861 REVISE CERV ARTIFIC DISC AIM Guidelines _
Joint & Spine Surgery 22862 REVISE LUMBAR ARTIF DISC AIM Guidelines _
Genetic Lab 0212U RARE DS GEN DNA ALYS PROBAND AIM Guidelines Added 01/01/2021
Genetic Lab 0213U RARE DS GEN DNA ALYS EA COMP AIM Guidelines Added 01/01/2021
Joint & Spine Surgery 22867 INSJ STABLJ DEV W/DCMPRN AIM Guidelines _
Joint & Spine Surgery 22868 INSJ STABLJ DEV W/DCMPRN AIM Guidelines _
Joint & Spine Surgery 22869 INSJ STABLJ DEV W/O DCMPRN AIM Guidelines _
Joint & Spine Surgery 22870 INSJ STABLJ DEV W/O DCMPRN AIM Guidelines _
Joint & Spine Surgery 23000 REMOVAL OF CALCIUM DEPOSITS AIM Guidelines _
Joint & Spine Surgery 23020 RELEASE SHOULDER JOINT AIM Guidelines _
Joint & Spine Surgery 23120 PARTIAL REMOVAL COLLAR BONE AIM Guidelines _
Joint & Spine Surgery 23130 REMOVE SHOULDER BONE PART AIM Guidelines _
Joint & Spine Surgery 23410 REPAIR ROTATOR CUFF ACUTE AIM Guidelines _
Joint & Spine Surgery 23412 REPAIR ROTATOR CUFF CHRONIC AIM Guidelines _
Joint & Spine Surgery 23415 RELEASE OF SHOULDER LIGAMENT AIM Guidelines _
10/23/2020 4/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Joint & Spine Surgery 23420 REPAIR OF SHOULDER AIM Guidelines _
Joint & Spine Surgery 23430 REPAIR BICEPS TENDON AIM Guidelines _
Joint & Spine Surgery 23440 REMOVE/TRANSPLANT TENDON AIM Guidelines _
Joint & Spine Surgery 23450 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23455 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23460 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23462 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23465 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23466 REPAIR SHOULDER CAPSULE AIM Guidelines _
Joint & Spine Surgery 23470 RECONSTRUCT SHOULDER JOINT AIM Guidelines _
Joint & Spine Surgery 23472 RECONSTRUCT SHOULDER JOINT AIM Guidelines _
Joint & Spine Surgery 23473 REVIS RECONST SHOULDER JOINT AIM Guidelines _
Joint & Spine Surgery 23474 REVIS RECONST SHOULDER JOINT AIM Guidelines _
Pain Management 27096 INJECT SACROILIAC JOINT AIM Guidelines _
Joint & Spine Surgery 27125 PARTIAL HIP REPLACEMENT AIM Guidelines _
Joint & Spine Surgery 27130 TOTAL HIP ARTHROPLASTY AIM Guidelines _
Joint & Spine Surgery 27132 TOTAL HIP ARTHROPLASTY AIM Guidelines _
Joint & Spine Surgery 27134 REVISE HIP JOINT REPLACEMENT AIM Guidelines _
Joint & Spine Surgery 27137 REVISE HIP JOINT REPLACEMENT AIM Guidelines _
Joint & Spine Surgery 27138 REVISE HIP JOINT REPLACEMENT AIM Guidelines _
Joint & Spine Surgery 27279 ARTHRODESIS SACROILIAC JOINT AIM Guidelines _
Joint & Spine Surgery 27280 FUSION OF SACROILIAC JOINT AIM Guidelines _
Genetic Lab 0214U RARE DS XOM DNA ALYS PROBAND AIM Guidelines Added 01/01/2021
Joint & Spine Surgery 27332 REMOVAL OF KNEE CARTILAGE AIM Guidelines _
Joint & Spine Surgery 27333 REMOVAL OF KNEE CARTILAGE AIM Guidelines _
Joint & Spine Surgery 27334 REMOVE KNEE JOINT LINING AIM Guidelines _
Joint & Spine Surgery 27335 REMOVE KNEE JOINT LINING AIM Guidelines _
10/23/2020 5/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Joint & Spine Surgery 27403 REPAIR OF KNEE CARTILAGE AIM Guidelines _
Joint & Spine Surgery 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE AIM Guidelines _
Joint & Spine Surgery 27415 OSTEOCHONDRAL KNEE ALLOGRAFT AIM Guidelines _
Joint & Spine Surgery 27416 OSTEOCHONDRAL KNEE AUTOGRAFT AIM Guidelines _
Joint & Spine Surgery 27418 REPAIR DEGENERATED KNEECAP AIM Guidelines _
Joint & Spine Surgery 27420 REVISION OF UNSTABLE KNEECAP AIM Guidelines _
Joint & Spine Surgery 27422 REVISION OF UNSTABLE KNEECAP AIM Guidelines _
Joint & Spine Surgery 27424 REVISION/REMOVAL OF KNEECAP AIM Guidelines _
Joint & Spine Surgery 27425 LAT RETINACULAR RELEASE OPEN AIM Guidelines _
Joint & Spine Surgery 27427 RECONSTRUCTION KNEE AIM Guidelines _
Joint & Spine Surgery 27428 RECONSTRUCTION KNEE AIM Guidelines _
Joint & Spine Surgery 27429 RECONSTRUCTION KNEE AIM Guidelines _
Joint & Spine Surgery 27430 REVISION OF THIGH MUSCLES AIM Guidelines _
Joint & Spine Surgery 27438 REVISE KNEECAP WITH IMPLANT AIM Guidelines _
Joint & Spine Surgery 27440 REVISION OF KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27441 REVISION OF KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27442 REVISION OF KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27443 REVISION OF KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27446 REVISION OF KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27447 TOTAL KNEE ARTHROPLASTY AIM Guidelines _
Joint & Spine Surgery 27486 REVISE/REPLACE KNEE JOINT AIM Guidelines _
Joint & Spine Surgery 27487 REVISE/REPLACE KNEE JOINT AIM Guidelines _
Genetic Lab 0215U RARE DS XOM DNA ALYS EA COMP AIM Guidelines Added 01/01/2021
Genetic Lab 0216U NEURO INH ATAXIA DNA 12 COM AIM Guidelines Added 01/01/2021
Genetic Lab 0217U NEURO INH ATAXIA DNA 51 GENE AIM Guidelines Added 01/01/2021
Joint & Spine Surgery 22800 POST FUSION
Joint & Spine Surgery 22802 POST FUSION 7-12 VERT SEG SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
10/23/2020 6/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Ear, Nose & Throat 30120 EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30124 EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS N/A Nasal and Sinus Surgery _
Surgical Deactivation of EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE Ear, Nose & Throat 30130 SUR712.031 Headache Trigger Sites _
Surgical Deactivation of SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL Ear, Nose & Throat 30140 SUR712.031 Headache Trigger Sites _
Ear, Nose & Throat 30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NASAL TI SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30410 RHINP PRIM COMPLETE XTRNL PARTS SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30430 RHINOPLASTY SECONDARY MINOR REVISION SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30450 RHINOPLASTY SECONDARY MAJOR REVISION SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 30465 REPAIR NASAL VESTIBULAR STENOSIS N/A Nasal and Sinus Surgery _
Surgical Deactivation of SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF Ear, Nose & Throat 30520 SUR712.031 Headache Trigger Sites _
Ear, Nose & Throat 30999 UNLISTED PROCEDURE NOSE SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 31296 NASAL/SINUS NDSC SURG W/DILATION FRONTAL SINUS SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 31297 NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS SUR706.001 Nasal and Sinus Surgery _
Ear, Nose & Throat 31299 UNLISTED PROCEDURE ACCESSORY SINUSES SUR706.001 Nasal and Sinus Surgery _
Cardiology 36516 THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION THE802.003 Lipid Apheresis _
Orthopedic Applications of Stem- HARVEST AUTO STEM CELLS Transplant 38206 SUR703.051 Cell Therapy _
Orthopedic Applications of Stem- BONE MARROW HARVEST ALLOGEN Transplant 38230 SUR703.051 Cell Therapy _
Orthopedic Applications of Stem- BONE MARROW TRANSPLANTATION; AUTOLOGOUS Transplant 38241 SUR703.051 Cell Therapy _
Gastric Electrical Stimulation LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM Gastroenterology 43647 SUR709.031 (GES) _
Gastric Electrical Stimulation LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM Gastroenterology 43648 SUR709.031 (GES) _
Gastric Electrical Stimulation IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN Gastroenterology 43881 SUR709.031 (GES) _
Neurology 61850 TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL SUR712.025 Deep Brain Stimulation _
Neurology 61863 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY SUR712.025 Deep Brain Stimulation _
Neurology 61864 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY SUR712.025 Deep Brain Stimulation _
Neurology 61867 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY SUR712.025 Deep Brain Stimulation _
10/23/2020 7/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Neurology 61868 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY SUR712.025 Deep Brain Stimulation _
Joint & Spine Surgery 22804 POST FUSION 13/> VERT SEG SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
Joint & Spine Surgery 22808 ANT FUSION 2-3 VERT SEG SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
Pain Management 62263 EPIDURAL LYSIS MULT SESSIONS AIM Guidelines _
Pain Management 62264 EPIDURAL LYSIS ON SINGLE DAY AIM Guidelines _
Pain Management 62280 TREAT SPINAL CORD LESION AIM Guidelines _
Pain Management 62281 TREAT SPINAL CORD LESION AIM Guidelines _
Pain Management 62282 TREAT SPINAL CANAL LESION AIM Guidelines _
Pain Management 62287 PERCUTANEOUS DISKECTOMY AIM Guidelines _
Pain Management 62292 NJX CHEMONUCLEOLYSIS LMBR AIM Guidelines _
Pain Management 62320 NJX INTERLAMINAR CRV/THRC AIM Guidelines _
Pain Management 62321 NJX INTERLAMINAR CRV/THRC AIM Guidelines _
Pain Management 62322 NJX INTERLAMINAR LMBR/SAC AIM Guidelines _
Pain Management 62323 NJX INTERLAMINAR LMBR/SAC AIM Guidelines _
Pain Management 62324 NJX INTERLAMINAR CRV/THRC AIM Guidelines _
Pain Management 62325 NJX INTERLAMINAR CRV/THRC AIM Guidelines _
Pain Management 62326 NJX INTERLAMINAR LMBR/SAC AIM Guidelines _
Pain Management 62327 NJX INTERLAMINAR LMBR/SAC AIM Guidelines _
Pain Management 62350 IMPLANT SPINAL CANAL CATH AIM Guidelines _
Pain Management 62351 IMPLANT SPINAL CANAL CATH AIM Guidelines _
Pain Management 62360 INSERT SPINE INFUSION DEVICE AIM Guidelines _
Pain Management 62361 IMPLANT SPINE INFUSION PUMP AIM Guidelines _
Pain Management 62362 IMPLANT SPINE INFUSION PUMP AIM Guidelines _
Joint & Spine Surgery 62380 NDSC DCMPRN 1 NTRSPC LUMBAR AIM Guidelines _
Joint & Spine Surgery 63001 REMOVE SPINE LAMINA 1/2 CRVL AIM Guidelines _
Joint & Spine Surgery 63005 REMOVE SPINE LAMINA 1/2 LMBR AIM Guidelines _
Joint & Spine Surgery 63012 REMOVE LAMINA/FACETS LUMBAR AIM Guidelines _
10/23/2020 8/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Joint & Spine Surgery 63015 REMOVE SPINE LAMINA >2 CRVCL AIM Guidelines _
Joint & Spine Surgery 63017 REMOVE SPINE LAMINA >2 LMBR AIM Guidelines _
Joint & Spine Surgery 63020 NECK SPINE DISK SURGERY AIM Guidelines _
Joint & Spine Surgery 63030 LOW BACK DISK SURGERY AIM Guidelines _
Joint & Spine Surgery 63035 SPINAL DISK SURGERY ADD-ON AIM Guidelines _
Joint & Spine Surgery 63040 LAMINOTOMY SINGLE CERVICAL AIM Guidelines _
Joint & Spine Surgery 63042 LAMINOTOMY SINGLE LUMBAR AIM Guidelines _
Joint & Spine Surgery 63043 LAMINOTOMY ADDL CERVICAL AIM Guidelines _
Joint & Spine Surgery 63044 LAMINOTOMY ADDL LUMBAR AIM Guidelines _
Joint & Spine Surgery 63045 REMOVE SPINE LAMINA 1 CRVL AIM Guidelines _
Joint & Spine Surgery 63047 REMOVE SPINE LAMINA 1 LMBR AIM Guidelines _
Joint & Spine Surgery 63048 REMOVE SPINAL LAMINA ADD-ON AIM Guidelines _
Joint & Spine Surgery 63050 CERVICAL LAMINOPLSTY 2/> SEG AIM Guidelines _
Joint & Spine Surgery 63051 C-LAMINOPLASTY W/GRAFT/PLATE AIM Guidelines _
Joint & Spine Surgery 63056 DECOMPRESS SPINAL CORD LMBR AIM Guidelines _
Joint & Spine Surgery 63057 DECOMPRESS SPINE CORD ADD-ON AIM Guidelines _
Joint & Spine Surgery 63075 NECK SPINE DISK SURGERY AIM Guidelines _
Joint & Spine Surgery 63076 NECK SPINE DISK SURGERY AIM Guidelines _
Joint & Spine Surgery 63081 REMOVE VERT BODY DCMPRN CRVL AIM Guidelines _
Joint & Spine Surgery 63082 REMOVE VERTEBRAL BODY ADD-ON AIM Guidelines _
Pain Management 63650 IMPLANT NEUROELECTRODES AIM Guidelines _
Pain Management 63655 IMPLANT NEUROELECTRODES AIM Guidelines _
Pain Management 63685 INSRT/REDO SPINE N GENERATOR AIM Guidelines _
Pain Management 64451 NJX AA&/STRD NRV NRVTG SI JT AIM Guidelines _
Pain Management 64479 INJ FORAMEN EPIDURAL C/T AIM Guidelines _
Pain Management 64480 INJ FORAMEN EPIDURAL ADD-ON AIM Guidelines _
Pain Management 64483 INJ FORAMEN EPIDURAL L/S AIM Guidelines _
10/23/2020 9/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Pain Management 64484 INJ FORAMEN EPIDURAL ADD-ON AIM Guidelines _
Pain Management 64490 INJ PARAVERT F JNT C/T 1 LEV AIM Guidelines _
Pain Management 64491 INJ PARAVERT F JNT C/T 2 LEV AIM Guidelines _
Pain Management 64492 INJ PARAVERT F JNT C/T 3 LEV AIM Guidelines _
Pain Management 64493 INJ PARAVERT F JNT L/S 1 LEV AIM Guidelines _
Pain Management 64494 INJ PARAVERT F JNT L/S 2 LEV AIM Guidelines _
Pain Management 64495 INJ PARAVERT F JNT L/S 3 LEV AIM Guidelines _
Pain Management 64510 N BLOCK STELLATE GANGLION AIM Guidelines _
Pain Management 64520 N BLOCK LUMBAR/THORACIC AIM Guidelines _
Joint & Spine Surgery 22810 ANT FUSION 4-7 VERT SEG SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
Joint & Spine Surgery 22812 ANT FUSION 8/> VERT SEG SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
Sacral Nerve Neurology 64561 SUR710.018 _ PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING Neuromodulation/Stimulation
Joint & Spine Surgery 22864 REMOVE CERV ARTIF DISC SUR712.028 Artificial Intervertebral Disc Added 01/01/2021
Joint & Spine Surgery 22865 REMOVE LUMB ARTIF DISC SUR712.028 Artificial Intervertebral Disc Added 01/01/2021
Joint & Spine Surgery 27299 UNLISTED PROCEDURE PELVIS/HIP JOINT SUR712.036 Lumbar Spinal Fusion Added 01/01/2021
Sacral Nerve Neurology 64581 SUR710.018 _ INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE Neuromodulation/Stimulation Autologous Chondrocyte Joint & Spine Surgery 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST SUR705.035 Implantation (ACI) for Focal Added 01/01/2021 Articular Cartilage Lesions
Pain Management 64625 RF ABLTJ NRV NRVTG SI JT AIM Guidelines _
Pain Management 64633 DESTROY CERV/THOR FACET JNT AIM Guidelines _
Pain Management 64634 DESTROY C/TH FACET JNT ADDL AIM Guidelines _
Pain Management 64635 DESTROY LUMB/SAC FACET JNT AIM Guidelines _
Pain Management 64636 DESTROY L/S FACET JNT ADDL AIM Guidelines _
Surgical Deactivation of Neurology 64716 SUR712.031 _ NEUROPLASTY &/TRANSPOSITION CRANIAL NERVE Headache Trigger Sites
Surgical Deactivation of Neurology 64732 SUR712.031 _ TRANSECTION/AVULSION SUPRAORBITAL NERVE Headache Trigger Sites
Surgical Deactivation of Neurology 64734 SUR712.031 _ TRANSECTION/AVULSION INFRAORBITAL NERVE Headache Trigger Sites
Surgical Deactivation of Neurology 64771 SUR712.031 _ TRANSECTION/AVULSION OTH CRANIAL NRV XDRL Headache Trigger Sites
Surgical Deactivation of Neurology 64999 SUR712.031 _ NERVOUS SYSTEM SURGERY Headache Trigger Sites
10/23/2020 10/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Surgical Deactivation of Neurology 67900 SUR712.031 _ REPAIR BROW PTOSIS Headache Trigger Sites
Ear, Nose & Throat 69714 IMPLTJ OSSEOINTEGRATED TEMPORAL BONE W/MASTOID SUR714.003 Bone Conduction Hearing Aids _
Ear, Nose & Throat 69715 IMPLJ OSSEOINTEGRATED TEMPORAL BONE W/O MASTOID SUR714.003 Bone Conduction Hearing Aids _
Ear, Nose & Throat 69717 RPLMCT OSSEOINTEGRATE IMPLNT W/O MASTOIDECTOMY SUR714.003 Bone Conduction Hearing Aids _
Ear, Nose & Throat 69718 RPLMCT OSSEOINTEGRATE IMPLNT W/MASTOIDECTOMY SUR714.003 Bone Conduction Hearing Aids _
Ear, Nose & Throat 69930 COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY SUR714.004 Cochlear Implant _
Advanced Imaging 70336 MAGNETIC IMAGE JAW JOINT AIM Guidelines _
Advanced Imaging 70450 CT HEAD/BRAIN W/O DYE AIM Guidelines _
Advanced Imaging 70460 CT HEAD/BRAIN W/DYE AIM Guidelines _
Advanced Imaging 70470 CT HEAD/BRAIN W/O & W/DYE AIM Guidelines _
Advanced Imaging 70480 CT ORBIT/EAR/FOSSA W/O DYE AIM Guidelines _
Advanced Imaging 70481 CT ORBIT/EAR/FOSSA W/DYE AIM Guidelines _
Advanced Imaging 70482 CT ORBIT/EAR/FOSSA W/O&W/DYE AIM Guidelines _
Advanced Imaging 70486 CT MAXILLOFACIAL W/O DYE AIM Guidelines _
Advanced Imaging 70487 CT MAXILLOFACIAL W/DYE AIM Guidelines _
Advanced Imaging 70488 CT MAXILLOFACIAL W/O & W/DYE AIM Guidelines _
Advanced Imaging 70490 CT SOFT TISSUE NECK W/O DYE AIM Guidelines _
Advanced Imaging 70491 CT SOFT TISSUE NECK W/DYE AIM Guidelines _
Advanced Imaging 70492 CT SFT TSUE NCK W/O & W/DYE AIM Guidelines _
Advanced Imaging 70496 CT ANGIOGRAPHY HEAD AIM Guidelines _
Advanced Imaging 70498 CT ANGIOGRAPHY NECK AIM Guidelines _
Advanced Imaging 70540 MRI ORBIT/FACE/NECK W/O DYE AIM Guidelines _
Advanced Imaging 70542 MRI ORBIT/FACE/NECK W/DYE AIM Guidelines _
Advanced Imaging 70543 MRI ORBT/FAC/NCK W/O &W/DYE AIM Guidelines _
Advanced Imaging 70544 MR ANGIOGRAPHY HEAD W/O DYE AIM Guidelines _
Advanced Imaging 70545 MR ANGIOGRAPHY HEAD W/DYE AIM Guidelines _
Advanced Imaging 70546 MR ANGIOGRAPH HEAD W/O&W/DYE AIM Guidelines _
10/23/2020 11/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 70547 MR ANGIOGRAPHY NECK W/O DYE AIM Guidelines _
Advanced Imaging 70548 MR ANGIOGRAPHY NECK W/DYE AIM Guidelines _
Advanced Imaging 70549 MR ANGIOGRAPH NECK W/O&W/DYE AIM Guidelines _
Advanced Imaging 70551 MRI BRAIN STEM W/O DYE AIM Guidelines _
Advanced Imaging 70552 MRI BRAIN STEM W/DYE AIM Guidelines _
Advanced Imaging 70553 MRI BRAIN STEM W/O & W/DYE AIM Guidelines _
Advanced Imaging 70554 FMRI BRAIN BY TECH AIM Guidelines _
Advanced Imaging 70555 FMRI BRAIN BY PHYS/PSYCH AIM Guidelines _
Advanced Imaging 71250 CT THORAX W/O DYE AIM Guidelines _
Advanced Imaging 71260 CT THORAX W/DYE AIM Guidelines _
Advanced Imaging 71270 CT THORAX W/O & W/DYE AIM Guidelines _
Advanced Imaging 71275 CT ANGIOGRAPHY CHEST AIM Guidelines _
Advanced Imaging 71550 MRI CHEST W/O DYE AIM Guidelines _
Advanced Imaging 71551 MRI CHEST W/DYE AIM Guidelines _
Advanced Imaging 71552 MRI CHEST W/O & W/DYE AIM Guidelines _
Advanced Imaging 71555 MRI ANGIO CHEST W OR W/O DYE AIM Guidelines _
Advanced Imaging 72125 CT NECK SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72126 CT NECK SPINE W/DYE AIM Guidelines _
Advanced Imaging 72127 CT NECK SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72128 CT CHEST SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72129 CT CHEST SPINE W/DYE AIM Guidelines _
Advanced Imaging 72130 CT CHEST SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72131 CT LUMBAR SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72132 CT LUMBAR SPINE W/DYE AIM Guidelines _
Advanced Imaging 72133 CT LUMBAR SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72141 MRI NECK SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72142 MRI NECK SPINE W/DYE AIM Guidelines _
10/23/2020 12/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 72146 MRI CHEST SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72147 MRI CHEST SPINE W/DYE AIM Guidelines _
Advanced Imaging 72148 MRI LUMBAR SPINE W/O DYE AIM Guidelines _
Advanced Imaging 72149 MRI LUMBAR SPINE W/DYE AIM Guidelines _
Advanced Imaging 72156 MRI NECK SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72157 MRI CHEST SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72158 MRI LUMBAR SPINE W/O & W/DYE AIM Guidelines _
Advanced Imaging 72159 MR ANGIO SPINE W/O&W/DYE AIM Guidelines _
Advanced Imaging 72191 CT ANGIOGRAPH PELV W/O&W/DYE AIM Guidelines _
Advanced Imaging 72192 CT PELVIS W/O DYE AIM Guidelines _
Advanced Imaging 72193 CT PELVIS W/DYE AIM Guidelines _
Advanced Imaging 72194 CT PELVIS W/O & W/DYE AIM Guidelines _
Advanced Imaging 72195 MRI PELVIS W/O DYE AIM Guidelines _
Advanced Imaging 72196 MRI PELVIS W/DYE AIM Guidelines _
Advanced Imaging 72197 MRI PELVIS W/O & W/DYE AIM Guidelines _
Advanced Imaging 72198 MR ANGIO PELVIS W/O & W/DYE AIM Guidelines _
Advanced Imaging 73200 CT UPPER EXTREMITY W/O DYE AIM Guidelines _
Advanced Imaging 73201 CT UPPER EXTREMITY W/DYE AIM Guidelines _
Advanced Imaging 73202 CT UPPR EXTREMITY W/O&W/DYE AIM Guidelines _
Advanced Imaging 73206 CT ANGIO UPR EXTRM W/O&W/DYE AIM Guidelines _
Advanced Imaging 73218 MRI UPPER EXTREMITY W/O DYE AIM Guidelines _
Advanced Imaging 73219 MRI UPPER EXTREMITY W/DYE AIM Guidelines _
Advanced Imaging 73220 MRI UPPR EXTREMITY W/O&W/DYE AIM Guidelines _
Advanced Imaging 73221 MRI JOINT UPR EXTREM W/O DYE AIM Guidelines _
Advanced Imaging 73222 MRI JOINT UPR EXTREM W/DYE AIM Guidelines _
Advanced Imaging 73223 MRI JOINT UPR EXTR W/O&W/DYE AIM Guidelines _
Advanced Imaging 73225 MR ANGIO UPR EXTR W/O&W/DYE AIM Guidelines _
10/23/2020 13/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 73700 CT LOWER EXTREMITY W/O DYE AIM Guidelines _
Advanced Imaging 73701 CT LOWER EXTREMITY W/DYE AIM Guidelines _
Advanced Imaging 73702 CT LWR EXTREMITY W/O&W/DYE AIM Guidelines _
Advanced Imaging 73706 CT ANGIO LWR EXTR W/O&W/DYE AIM Guidelines _
Advanced Imaging 73718 MRI LOWER EXTREMITY W/O DYE AIM Guidelines _
Advanced Imaging 73719 MRI LOWER EXTREMITY W/DYE AIM Guidelines _
Advanced Imaging 73720 MRI LWR EXTREMITY W/O&W/DYE AIM Guidelines _
Advanced Imaging 73721 MRI JNT OF LWR EXTRE W/O DYE AIM Guidelines _
Advanced Imaging 73722 MRI JOINT OF LWR EXTR W/DYE AIM Guidelines _
Advanced Imaging 73723 MRI JOINT LWR EXTR W/O&W/DYE AIM Guidelines _
Advanced Imaging 73725 MR ANG LWR EXT W OR W/O DYE AIM Guidelines _
Advanced Imaging 74150 CT ABDOMEN W/O DYE AIM Guidelines _
Advanced Imaging 74160 CT ABDOMEN W/DYE AIM Guidelines _
Advanced Imaging 74170 CT ABDOMEN W/O & W/DYE AIM Guidelines _
Advanced Imaging 74174 CT ANGIO ABD&PELV W/O&W/DYE AIM Guidelines _
Advanced Imaging 74175 CT ANGIO ABDOM W/O & W/DYE AIM Guidelines _
Advanced Imaging 74176 CT ABD & PELVIS W/O CONTRAST AIM Guidelines _
Advanced Imaging 74177 CT ABD & PELV W/CONTRAST AIM Guidelines _
Advanced Imaging 74178 CT ABD & PELV 1/> REGNS AIM Guidelines _
Advanced Imaging 74181 MRI ABDOMEN W/O DYE AIM Guidelines _
Advanced Imaging 74182 MRI ABDOMEN W/DYE AIM Guidelines _
Advanced Imaging 74183 MRI ABDOMEN W/O & W/DYE AIM Guidelines _
Advanced Imaging 74185 MRI ANGIO ABDOM W ORW/O DYE AIM Guidelines _
Advanced Imaging 74261 CT COLONOGRAPHY DX AIM Guidelines _
Advanced Imaging 74262 CT COLONOGRAPHY DX W/DYE AIM Guidelines _
Advanced Imaging 74263 CT COLONOGRAPHY SCREENING AIM Guidelines _
Advanced Imaging 74712 MRI FETAL SNGL/1ST GESTATION AIM Guidelines _
10/23/2020 14/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 74713 MRI FETAL EA ADDL GESTATION AIM Guidelines _
Cardiology 75557 CARDIAC MRI FOR MORPH AIM Guidelines _
Cardiology 75559 CARDIAC MRI W/STRESS IMG AIM Guidelines _
Cardiology 75561 CARDIAC MRI FOR MORPH W/DYE AIM Guidelines _
Cardiology 75563 CARD MRI W/STRESS IMG & DYE AIM Guidelines _
Cardiology 75565 CARD MRI VELOC FLOW MAPPING AIM Guidelines _
Cardiology 75571 CT HRT W/O DYE W/CA TEST AIM Guidelines _
Cardiology 75572 CT HRT W/3D IMAGE AIM Guidelines _
Cardiology 75573 CT HRT W/3D IMAGE CONGEN AIM Guidelines _
Cardiology 75574 CT ANGIO HRT W/3D IMAGE AIM Guidelines _
Advanced Imaging 75635 CT ANGIO ABDOMINAL ARTERIES AIM Guidelines _
Advanced Imaging 76376 3D RENDER W/INTRP POSTPROCES AIM Guidelines _
Advanced Imaging 76377 3D RENDER W/INTRP POSTPROCES AIM Guidelines _
Advanced Imaging 76380 CAT SCAN FOLLOW-UP STUDY AIM Guidelines _
Advanced Imaging 76390 MR SPECTROSCOPY AIM Guidelines _
Advanced Imaging 76391 MR ELASTOGRAPHY AIM Guidelines _
Advanced Imaging 76497 CT PROCEDURE AIM Guidelines _
Advanced Imaging 76498 MRI PROCEDURE AIM Guidelines _
Advanced Imaging 76975 GI ENDOSCOPIC ULTRASOUND AIM Guidelines _
Radiation Oncology 77014 CT SCAN FOR THERAPY GUIDE AIM Guidelines _
Advanced Imaging 77021 MRI GUIDANCE NDL PLMT RS&I AIM Guidelines _
Advanced Imaging 77022 MRI GDN PARNCHYMA TISS ABLTJ AIM Guidelines _
Advanced Imaging 77046 MRI BREAST C- UNILATERAL AIM Guidelines _
Advanced Imaging 77047 MRI BREAST C- BILATERAL AIM Guidelines _
Advanced Imaging 77048 MRI BREAST C-+ W/CAD UNI AIM Guidelines _
Advanced Imaging 77049 MRI BREAST C-+ W/CAD BI AIM Guidelines _
Advanced Imaging 77078 CT BONE DENSITY AXIAL AIM Guidelines _
10/23/2020 15/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 77084 MAGNETIC IMAGE BONE MARROW AIM Guidelines _
AIM Guidelines Radiation Oncology 77371 SRS MULTISOURCE _
Radiation Oncology 77372 SRS LINEAR BASED AIM Guidelines _
Radiation Oncology 77373 SBRT DELIVERY AIM Guidelines _
Radiation Oncology 77385 NTSTY MODUL RAD TX DLVR SMPL AIM Guidelines _
Radiation Oncology 77386 NTSTY MODUL RAD TX DLVR CPLX AIM Guidelines _
Radiation Oncology 77387 GUIDANCE FOR RADJ TX DLVR AIM Guidelines _
Radiation Oncology 77401 RADIATION TREATMENT DELIVERY AIM Guidelines _
Radiation Oncology 77402 RADIATION TREATMENT DELIVERY AIM Guidelines _
Radiation Oncology 77407 RADIATION TREATMENT DELIVERY AIM Guidelines _
Radiation Oncology 77412 RADIATION TREATMENT DELIVERY AIM Guidelines _
Radiation Oncology 77423 NEUTRON BEAM TX COMPLEX AIM Guidelines _
Radiation Oncology 77424 IO RAD TX DELIVERY BY X-RAY AIM Guidelines _
Radiation Oncology 77425 IO RAD TX DELIVER BY ELCTRNS AIM Guidelines _
Radiation Oncology 77520 PROTON TRMT SIMPLE W/O COMP AIM Guidelines _
Radiation Oncology 77522 PROTON TRMT SIMPLE W/COMP AIM Guidelines _
Radiation Oncology 77523 PROTON TRMT INTERMEDIATE AIM Guidelines _
Radiation Oncology 77525 PROTON TREATMENT COMPLEX AIM Guidelines _
Radiation Oncology 77600 HYPERTHERMIA TREATMENT AIM Guidelines _
Radiation Oncology 77605 HYPERTHERMIA TREATMENT AIM Guidelines _
Radiation Oncology 77610 HYPERTHERMIA TREATMENT AIM Guidelines _
Radiation Oncology 77615 HYPERTHERMIA TREATMENT AIM Guidelines _
Radiation Oncology 77620 HYPERTHERMIA TREATMENT AIM Guidelines _
Radiation Oncology 77750 INFUSE RADIOACTIVE MATERIALS AIM Guidelines _
Radiation Oncology 77761 APPLY INTRCAV RADIAT SIMPLE AIM Guidelines _
Radiation Oncology 77762 APPLY INTRCAV RADIAT INTERM AIM Guidelines _
Radiation Oncology 77763 APPLY INTRCAV RADIAT COMPL AIM Guidelines _
10/23/2020 16/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Radiation Oncology 77767 HDR RDNCL SKN SURF BRACHYTX AIM Guidelines _
Radiation Oncology 77768 HDR RDNCL SKN SURF BRACHYTX AIM Guidelines _
Radiation Oncology 77770 HDR RDNCL NTRSTL/ICAV BRCHTX AIM Guidelines _
Radiation Oncology 77771 HDR RDNCL NTRSTL/ICAV BRCHTX AIM Guidelines _
Radiation Oncology 77772 HDR RDNCL NTRSTL/ICAV BRCHTX AIM Guidelines _
Radiation Oncology 77778 APPLY INTERSTIT RADIAT COMPL AIM Guidelines _
Advanced Imaging 78012 THYROID UPTAKE MEASUREMENT AIM Guidelines _
Advanced Imaging 78013 THYROID IMAGING W/BLOOD FLOW AIM Guidelines _
Advanced Imaging 78014 THYROID IMAGING W/BLOOD FLOW AIM Guidelines _
Advanced Imaging 78015 THYROID MET IMAGING AIM Guidelines _
Advanced Imaging 78016 THYROID MET IMAGING/STUDIES AIM Guidelines _
Advanced Imaging 78018 THYROID MET IMAGING BODY AIM Guidelines _
Advanced Imaging 78020 THYROID MET UPTAKE AIM Guidelines _
Advanced Imaging 78070 PARATHYROID PLANAR IMAGING AIM Guidelines _
Advanced Imaging 78071 PARATHYRD PLANAR W/WO SUBTRJ AIM Guidelines _
Advanced Imaging 78072 PARATHYRD PLANAR W/SPECT&CT AIM Guidelines _
Advanced Imaging 78075 ADRENAL CORTEX & MEDULLA IMG AIM Guidelines _
Advanced Imaging 78102 BONE MARROW IMAGING LTD AIM Guidelines _
Advanced Imaging 78103 BONE MARROW IMAGING MULT AIM Guidelines _
Advanced Imaging 78104 BONE MARROW IMAGING BODY AIM Guidelines _
Advanced Imaging 78185 SPLEEN IMAGING AIM Guidelines _
Advanced Imaging 78195 LYMPH SYSTEM IMAGING AIM Guidelines _
Advanced Imaging 78201 LIVER IMAGING AIM Guidelines _
Advanced Imaging 78202 LIVER IMAGING WITH FLOW AIM Guidelines _
Advanced Imaging 78215 LIVER AND SPLEEN IMAGING AIM Guidelines _
Advanced Imaging 78216 LIVER & SPLEEN IMAGE/FLOW AIM Guidelines _
Advanced Imaging 78226 HEPATOBILIARY SYSTEM IMAGING AIM Guidelines _
10/23/2020 17/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 78227 HEPATOBIL SYST IMAGE W/DRUG AIM Guidelines _
Advanced Imaging 78230 SALIVARY GLAND IMAGING AIM Guidelines _
Advanced Imaging 78231 SERIAL SALIVARY IMAGING AIM Guidelines _
Advanced Imaging 78232 SALIVARY GLAND FUNCTION EXAM AIM Guidelines _
Advanced Imaging 78258 ESOPHAGEAL MOTILITY STUDY AIM Guidelines _
Advanced Imaging 78261 GASTRIC MUCOSA IMAGING AIM Guidelines _
Advanced Imaging 78262 GASTROESOPHAGEAL REFLUX EXAM AIM Guidelines _
Advanced Imaging 78264 GASTRIC EMPTYING IMAG STUDY AIM Guidelines _
Advanced Imaging 78265 GASTRIC EMPTYING IMAG STUDY AIM Guidelines _
Advanced Imaging 78266 GASTRIC EMPTYING IMAG STUDY AIM Guidelines _
Advanced Imaging 78278 ACUTE GI BLOOD LOSS IMAGING AIM Guidelines _
Advanced Imaging 78290 MECKELS DIVERT EXAM AIM Guidelines _
Advanced Imaging 78291 LEVEEN/SHUNT PATENCY EXAM AIM Guidelines _
Advanced Imaging 78300 BONE IMAGING LIMITED AREA AIM Guidelines _
Advanced Imaging 78305 BONE IMAGING MULTIPLE AREAS AIM Guidelines _
Advanced Imaging 78306 BONE IMAGING WHOLE BODY AIM Guidelines _
Advanced Imaging 78315 BONE IMAGING 3 PHASE AIM Guidelines _
Cardiology 78414 NON-IMAGING HEART FUNCTION AIM Guidelines _
Cardiology 78428 CARDIAC SHUNT IMAGING AIM Guidelines _
Cardiology 78429 MYOCRD IMG PET 1 STD W/CT AIM Guidelines _
Cardiology 78430 MYOCRD IMG PET RST/STRS W/CT AIM Guidelines _
Cardiology 78431 MYOCRD IMG PET RST&STRS CT AIM Guidelines _
Cardiology 78432 MYOCRD IMG PET 2RTRACER AIM Guidelines _
Cardiology 78433 MYOCRD IMG PET 2RTRACER CT AIM Guidelines _
Advanced Imaging 78445 VASCULAR FLOW IMAGING AIM Guidelines _
Cardiology 78451 HT MUSCLE IMAGE SPECT SING AIM Guidelines _
Cardiology 78452 HT MUSCLE IMAGE SPECT MULT AIM Guidelines _
10/23/2020 18/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Cardiology 78453 HT MUSCLE IMAGE PLANAR SING AIM Guidelines _
Cardiology 78454 HT MUSC IMAGE PLANAR MULT AIM Guidelines _
Advanced Imaging 78456 ACUTE VENOUS THROMBUS IMAGE AIM Guidelines _
Advanced Imaging 78457 VENOUS THROMBOSIS IMAGING AIM Guidelines _
Advanced Imaging 78458 VEN THROMBOSIS IMAGES BILAT AIM Guidelines _
Cardiology 78459 MYOCRD IMG PET SINGLE STUDY AIM Guidelines _
Cardiology 78466 HEART INFARCT IMAGE AIM Guidelines _
Cardiology 78468 HEART INFARCT IMAGE (EF) AIM Guidelines _
Cardiology 78469 HEART INFARCT IMAGE (3D) AIM Guidelines _
Cardiology 78472 GATED HEART PLANAR SINGLE AIM Guidelines _
Cardiology 78473 GATED HEART MULTIPLE AIM Guidelines _
Cardiology 78481 HEART FIRST PASS SINGLE AIM Guidelines _
Cardiology 78483 HEART FIRST PASS MULTIPLE AIM Guidelines _
Cardiology 78491 MYOCRD IMG PET 1STD RST/STRS AIM Guidelines _
Cardiology 78492 MYOCRD IMG PET MLT RST&STRS AIM Guidelines _
Cardiology 78494 HEART IMAGE SPECT AIM Guidelines _
Cardiology 78496 HEART FIRST PASS ADD-ON AIM Guidelines _
Cardiology 78499 CARDIOVASCULAR NUCLEAR EXAM AIM Guidelines _
Advanced Imaging 78579 LUNG VENTILATION IMAGING AIM Guidelines _
Advanced Imaging 78580 LUNG PERFUSION IMAGING AIM Guidelines _
Advanced Imaging 78582 LUNG VENTILAT&PERFUS IMAGING AIM Guidelines _
Advanced Imaging 78597 LUNG PERFUSION DIFFERENTIAL AIM Guidelines _
Advanced Imaging 78598 LUNG PERF&VENTILAT DIFERENTL AIM Guidelines _
Advanced Imaging 78600 BRAIN IMAGE < 4 VIEWS AIM Guidelines _
Advanced Imaging 78601 BRAIN IMAGE W/FLOW < 4 VIEWS AIM Guidelines _
Advanced Imaging 78605 BRAIN IMAGE 4+ VIEWS AIM Guidelines _
Advanced Imaging 78606 BRAIN IMAGE W/FLOW 4 + VIEWS AIM Guidelines _
10/23/2020 19/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 78608 BRAIN IMAGING (PET) AIM Guidelines _
Advanced Imaging 78609 BRAIN IMAGING (PET) AIM Guidelines _
Advanced Imaging 78610 BRAIN FLOW IMAGING ONLY AIM Guidelines _
Advanced Imaging 78630 CEREBROSPINAL FLUID SCAN AIM Guidelines _
Advanced Imaging 78635 CSF VENTRICULOGRAPHY AIM Guidelines _
Advanced Imaging 78645 CSF SHUNT EVALUATION AIM Guidelines _
Advanced Imaging 78650 CSF LEAKAGE IMAGING AIM Guidelines _
Advanced Imaging 78660 NUCLEAR EXAM OF TEAR FLOW AIM Guidelines _
Advanced Imaging 78700 KIDNEY IMAGING MORPHOL AIM Guidelines _
Advanced Imaging 78701 KIDNEY IMAGING WITH FLOW AIM Guidelines _
Advanced Imaging 78707 K FLOW/FUNCT IMAGE W/O DRUG AIM Guidelines _
Advanced Imaging 78708 K FLOW/FUNCT IMAGE W/DRUG AIM Guidelines _
Advanced Imaging 78709 K FLOW/FUNCT IMAGE MULTIPLE AIM Guidelines _
Advanced Imaging 78725 KIDNEY FUNCTION STUDY AIM Guidelines _
Advanced Imaging 78730 URINARY BLADDER RETENTION AIM Guidelines _
Advanced Imaging 78740 URETERAL REFLUX STUDY AIM Guidelines _
Advanced Imaging 78761 TESTICULAR IMAGING W/FLOW AIM Guidelines _
Advanced Imaging 78800 RP LOCLZJ TUM 1 AREA 1 D IMG AIM Guidelines _
Advanced Imaging 78801 RP LOCLZJ TUM 2+AREA 1+D IMG AIM Guidelines _
Advanced Imaging 78802 RP LOCLZJ TUM WHBDY 1 D IMG AIM Guidelines _
Advanced Imaging 78803 RP LOCLZJ TUM SPECT 1 AREA AIM Guidelines _
Advanced Imaging 78804 RP LOCLZJ TUM WHBDY 2+D IMG AIM Guidelines _
Advanced Imaging 78811 PET IMAGE LTD AREA AIM Guidelines _
Advanced Imaging 78812 PET IMAGE SKULL-THIGH AIM Guidelines _
Advanced Imaging 78813 PET IMAGE FULL BODY AIM Guidelines _
Advanced Imaging 78814 PET IMAGE W/CT LMTD AIM Guidelines _
Advanced Imaging 78815 PET IMAGE W/CT SKULL-THIGH AIM Guidelines _
10/23/2020 20/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Advanced Imaging 78816 PET IMAGE W/CT FULL BODY AIM Guidelines _
Advanced Imaging 78830 RP LOCLZJ TUM SPECT W/CT 1 AIM Guidelines _
Advanced Imaging 78831 RP LOCLZJ TUM SPECT 2 AREAS AIM Guidelines _
Advanced Imaging 78832 RP LOCLZJ TUM SPECT W/CT 2 AIM Guidelines _
Advanced Imaging 78999 NUCLEAR DIAGNOSTIC EXAM AIM Guidelines _
Radiation Oncology 79005 NUCLEAR RX ORAL ADMIN AIM Guidelines _
Radiation Oncology 79101 NUCLEAR RX IV ADMIN AIM Guidelines _
Radiation Oncology 79403 HEMATOPOIETIC NUCLEAR TX AIM Guidelines _
Genetic Lab 81162 BRCA1&2 GEN FULL SEQ DUP/DEL AIM Guidelines _
Genetic Lab 81163 BRCA1&2 GENE FULL SEQ ALYS AIM Guidelines _
Genetic Lab 81164 BRCA1&2 GEN FUL DUP/DEL ALYS AIM Guidelines _
Genetic Lab 81165 BRCA1 GENE FULL SEQ ALYS AIM Guidelines _
Genetic Lab 81166 BRCA1 GENE FULL DUP/DEL ALYS AIM Guidelines _
Genetic Lab 81167 BRCA2 GENE FULL DUP/DEL ALYS AIM Guidelines _
Genetic Lab 81173 AR GENE FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81174 AR GENE KNOWN FAMIL VARIANT AIM Guidelines _
Genetic Lab 81185 CACNA1A GENE FULL GENE SEQ AIM Guidelines _
Genetic Lab 81186 CACNA1A GEN KNOWN FAMIL VRNT AIM Guidelines _
Genetic Lab 81189 CSTB GENE FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81190 CSTB GENE KNOWN FAMIL VRNT AIM Guidelines _
Genetic Lab 81201 APC GENE FULL SEQUENCE AIM Guidelines _
Genetic Lab 81202 APC GENE KNOWN FAM VARIANTS AIM Guidelines _
Genetic Lab 81203 APC GENE DUP/DELET VARIANTS AIM Guidelines _
Genetic Lab 81212 BRCA1&2 185&5385&6174 VRNT AIM Guidelines _
Genetic Lab 81215 BRCA1 GENE KNOWN FAMIL VRNT AIM Guidelines _
Genetic Lab 81216 BRCA2 GENE FULL SEQ ALYS AIM Guidelines _
Genetic Lab 81217 BRCA2 GENE KNOWN FAMIL VRNT AIM Guidelines _
10/23/2020 21/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Genetic Lab 81221 CFTR GENE KNOWN FAM VARIANTS AIM Guidelines _
Genetic Lab 81222 CFTR GENE DUP/DELET VARIANTS AIM Guidelines _
Genetic Lab 81223 CFTR GENE FULL SEQUENCE AIM Guidelines _
Genetic Lab 81225 CYP2C19 GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81226 CYP2D6 GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81227 CYP2C9 GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81228 CYTOGEN MICRARRAY COPY NMBR AIM Guidelines _
Genetic Lab 81229 CYTOGEN M ARRAY COPY NO&SNP AIM Guidelines _
Genetic Lab 81230 CYP3A4 GENE COMMON VARIANTS AIM Guidelines _
Genetic Lab 81231 CYP3A5 GENE COMMON VARIANTS AIM Guidelines _
Genetic Lab 81232 DPYD GENE COMMON VARIANTS AIM Guidelines _
Genetic Lab 81238 F9 FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81248 G6PD KNOWN FAMILIAL VARIANT AIM Guidelines _
Genetic Lab 81249 G6PD FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81252 GJB2 GENE FULL SEQUENCE AIM Guidelines _
Genetic Lab 81253 GJB2 GENE KNOWN FAM VARIANTS AIM Guidelines _
Genetic Lab 81257 HBA1/HBA2 GENE AIM Guidelines _
Genetic Lab 81258 HBA1/HBA2 GENE FAM VRNT AIM Guidelines _
Genetic Lab 81259 HBA1/HBA2 FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81269 HBA1/HBA2 GENE DUP/DEL VRNTS AIM Guidelines _
Genetic Lab 81277 CYTOGENOMIC NEO MICRORA ALYS AIM Guidelines _
Genetic Lab 81283 IFNL3 GENE AIM Guidelines _
Genetic Lab 81286 FXN GENE FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81289 FXN GENE KNOWN FAMIL VARIANT AIM Guidelines _
Genetic Lab 81291 MTHFR GENE AIM Guidelines _
Genetic Lab 81292 MLH1 GENE FULL SEQ AIM Guidelines _
Genetic Lab 81293 MLH1 GENE KNOWN VARIANTS AIM Guidelines _
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Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Genetic Lab 81294 MLH1 GENE DUP/DELETE VARIANT AIM Guidelines _
Genetic Lab 81295 MSH2 GENE FULL SEQ AIM Guidelines _
Genetic Lab 81296 MSH2 GENE KNOWN VARIANTS AIM Guidelines _
Genetic Lab 81297 MSH2 GENE DUP/DELETE VARIANT AIM Guidelines _
Genetic Lab 81298 MSH6 GENE FULL SEQ AIM Guidelines _
Genetic Lab 81299 MSH6 GENE KNOWN VARIANTS AIM Guidelines _
Genetic Lab 81300 MSH6 GENE DUP/DELETE VARIANT AIM Guidelines _
Genetic Lab 81302 MECP2 GENE FULL SEQ AIM Guidelines _
Genetic Lab 81303 MECP2 GENE KNOWN VARIANT AIM Guidelines _
Genetic Lab 81304 MECP2 GENE DUP/DELET VARIANT AIM Guidelines _
Genetic Lab 81306 NUDT15 GENE COMMON VARIANTS AIM Guidelines _
Genetic Lab 81307 PALB2 GENE FULL GENE SEQ AIM Guidelines _
Genetic Lab 81308 PALB2 GENE KNOWN FAMIL VRNT AIM Guidelines _
Genetic Lab 81313 PCA3/KLK3 ANTIGEN AIM Guidelines _
Genetic Lab 81317 PMS2 GENE FULL SEQ ANALYSIS AIM Guidelines _
Genetic Lab 81318 PMS2 KNOWN FAMILIAL VARIANTS AIM Guidelines _
Genetic Lab 81319 PMS2 GENE DUP/DELET VARIANTS AIM Guidelines _
Genetic Lab 81321 PTEN GENE FULL SEQUENCE AIM Guidelines _
Genetic Lab 81322 PTEN GENE KNOWN FAM VARIANT AIM Guidelines _
Genetic Lab 81323 PTEN GENE DUP/DELET VARIANT AIM Guidelines _
Genetic Lab 81325 PMP22 GENE FULL SEQUENCE AIM Guidelines _
Genetic Lab 81326 PMP22 GENE KNOWN FAM VARIANT AIM Guidelines _
Genetic Lab 81327 SEPT9 GEN PRMTR MTHYLTN ALYS AIM Guidelines _
Genetic Lab 81328 SLCO1B1 GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81335 TPMT GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81336 SMN1 GENE FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81337 SMN1 GEN NOWN FAMIL SEQ VRNT AIM Guidelines _
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Genetic Lab 81346 TYMS GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81350 UGT1A1 GENE COMMON VARIANTS AIM Guidelines _
Genetic Lab 81355 VKORC1 GENE AIM Guidelines _
Genetic Lab 81361 HBB GENE COM VARIANTS AIM Guidelines _
Genetic Lab 81362 HBB GENE KNOWN FAM VARIANT AIM Guidelines _
Genetic Lab 81363 HBB GENE DUP/DEL VARIANTS AIM Guidelines _
Genetic Lab 81364 HBB FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 81400 MOPATH PROCEDURE LEVEL 1 AIM Guidelines _
Genetic Lab 81401 MOPATH PROCEDURE LEVEL 2 AIM Guidelines _
Genetic Lab 81402 MOPATH PROCEDURE LEVEL 3 AIM Guidelines _
Genetic Lab 81403 MOPATH PROCEDURE LEVEL 4 AIM Guidelines _
Genetic Lab 81404 MOPATH PROCEDURE LEVEL 5 AIM Guidelines _
Genetic Lab 81405 MOPATH PROCEDURE LEVEL 6 AIM Guidelines _
Genetic Lab 81406 MOPATH PROCEDURE LEVEL 7 AIM Guidelines _
Genetic Lab 81407 MOPATH PROCEDURE LEVEL 8 AIM Guidelines _
Genetic Lab 81408 MOPATH PROCEDURE LEVEL 9 AIM Guidelines _
Genetic Lab 81410 AORTIC DYSFUNCTION/DILATION AIM Guidelines _
Genetic Lab 81411 AORTIC DYSFUNCTION/DILATION AIM Guidelines _
Genetic Lab 81412 ASHKENAZI JEWISH ASSOC DIS AIM Guidelines _
Genetic Lab 81413 CAR ION CHNNLPATH INC 10 GNS AIM Guidelines _
Genetic Lab 81414 CAR ION CHNNLPATH INC 2 GNS AIM Guidelines _
Genetic Lab 81415 EXOME SEQUENCE ANALYSIS AIM Guidelines _
Genetic Lab 81416 EXOME SEQUENCE ANALYSIS AIM Guidelines _
Genetic Lab 81417 EXOME RE-EVALUATION AIM Guidelines _
Genetic Lab 81422 FETAL CHRMOML MICRODELTJ AIM Guidelines _
Genetic Lab 81425 GENOME SEQUENCE ANALYSIS AIM Guidelines _
Genetic Lab 81426 GENOME SEQUENCE ANALYSIS AIM Guidelines _
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Genetic Lab 81427 GENOME RE-EVALUATION AIM Guidelines _
Genetic Lab 81430 HEARING LOSS SEQUENCE ANALYS AIM Guidelines _
Genetic Lab 81431 HEARING LOSS DUP/DEL ANALYS AIM Guidelines _
Genetic Lab 81432 HRDTRY BRST CA-RLATD DSORDRS AIM Guidelines _
Genetic Lab 81433 HRDTRY BRST CA-RLATD DSORDRS AIM Guidelines _
Genetic Lab 81434 HEREDITARY RETINAL DISORDERS AIM Guidelines _
Genetic Lab 81435 HEREDITARY COLON CA DSORDRS AIM Guidelines _
Genetic Lab 81436 HEREDITARY COLON CA DSORDRS AIM Guidelines _
Genetic Lab 81437 HEREDTRY NURONDCRN TUM DSRDR AIM Guidelines _
Genetic Lab 81438 HEREDTRY NURONDCRN TUM DSRDR AIM Guidelines _
Genetic Lab 81439 HRDTRY CARDMYPY GENE PANEL AIM Guidelines _
Genetic Lab 81440 MITOCHONDRIAL GENE AIM Guidelines _
Genetic Lab 81442 NOONAN SPECTRUM DISORDERS AIM Guidelines _
Genetic Lab 81443 GENETIC TSTG SEVERE INH COND AIM Guidelines _
Genetic Lab 81445 TARGETED GENOMIC SEQ ANALYS AIM Guidelines _
Genetic Lab 81448 HRDTRY PERPH NEURPHY PANEL AIM Guidelines _
Genetic Lab 81450 TARGETED GENOMIC SEQ ANALYS AIM Guidelines _
Genetic Lab 81455 TARGETED GENOMIC SEQ ANALYS AIM Guidelines _
Genetic Lab 81460 WHOLE MITOCHONDRIAL GENOME AIM Guidelines _
Genetic Lab 81465 WHOLE MITOCHONDRIAL GENOME AIM Guidelines _
Genetic Lab 81470 X-LINKED INTELLECTUAL DBLT AIM Guidelines _
Genetic Lab 81471 X-LINKED INTELLECTUAL DBLT AIM Guidelines _
Genetic Lab 81479 UNLISTED MOLECULAR PATHOLOGY AIM Guidelines _
Genetic Lab 81490 AUTOIMMUNE RHEUMATOID ARTHR AIM Guidelines _
Genetic Lab 81493 COR ARTERY DISEASE MRNA AIM Guidelines _
Genetic Lab 81500 ONCO (OVAR) TWO PROTEINS AIM Guidelines _
Genetic Lab 81503 ONCO (OVAR) FIVE PROTEINS AIM Guidelines _
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Genetic Lab 81504 ONCOLOGY TISSUE OF ORIGIN AIM Guidelines _
Genetic Lab 81518 ONC BRST MRNA 11 GENES AIM Guidelines _
Genetic Lab 81519 ONCOLOGY BREAST MRNA AIM Guidelines _
Genetic Lab 81520 ONC BREAST MRNA 58 GENES AIM Guidelines _
Genetic Lab 81521 ONC BREAST MRNA 70 GENES AIM Guidelines _
Genetic Lab 81522 ONC BREAST MRNA 12 GENES AIM Guidelines _
Genetic Lab 81525 ONCOLOGY COLON MRNA AIM Guidelines _
Genetic Lab 81535 ONCOLOGY GYNECOLOGIC AIM Guidelines _
Genetic Lab 81536 ONCOLOGY GYNECOLOGIC AIM Guidelines _
Genetic Lab 81538 ONCOLOGY LUNG AIM Guidelines _
Genetic Lab 81539 ONCOLOGY PROSTATE PROB SCORE AIM Guidelines _
Genetic Lab 81540 ONCOLOGY TUM UNKNOWN ORIGIN AIM Guidelines _
Genetic Lab 81541 ONC PROSTATE MRNA 46 GENES AIM Guidelines _
Genetic Lab 81542 ONC PROSTATE MRNA 22 CNT GEN AIM Guidelines _
Genetic Lab 81545 ONCOLOGY THYROID AIM Guidelines _
Genetic Lab 81551 ONC PROSTATE 3 GENES AIM Guidelines _
Genetic Lab 81552 ONC UVEAL MLNMA MRNA 15 GENE AIM Guidelines _
Genetic Lab 81595 CARDIOLOGY HRT TRNSPL MRNA AIM Guidelines _
Genetic Lab 81596 NFCT DS CHRNC HCV 6 ASSAYS AIM Guidelines _
Genetic Lab 81599 UNLISTED MAAA AIM Guidelines _
Genetic Lab 84999 CLINICAL CHEMISTRY TEST AIM Guidelines _
Meniscal Allografts and Other Joint & Spine Surgery 29868 ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT SUR705.034 Added 01/01/2021 Meniscal Implants
Sleep Medicine 95782 POLYSOM <6 YRS 4/> PARAMTRS AIM Guidelines _
Sleep Medicine 95783 POLYSOM <6 YRS CPAP/BILVL AIM Guidelines _
Sleep Medicine 95800 SLP STDY UNATTENDED AIM Guidelines _
Sleep Medicine 95801 SLP STDY UNATND W/ANAL AIM Guidelines _
Sleep Medicine 95805 MULTIPLE SLEEP LATENCY TEST AIM Guidelines _
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Sleep Medicine 95806 SLEEP STUDY UNATT&RESP EFFT AIM Guidelines _
Guidelines Sleep Medicine 95807 SLEEP STUDY ATTENDED AIM Diagnosis and Medical _ MED204.005 Management of Obstructive MED201.049 Diagnosis and Medical Sleep Medicine 95808 POLYSOM ANY AGE 1-3> PARAM Management of Obstructive _ Sleep Apnea Syndrome Diagnosis and Medical MED201.049 Sleep Medicine 95810 POLYSOM 6/> YRS 4/> PARAM Management of Obstructive _ MED204.005 Sleep Apnea Syndrome Diagnosis and Medical MED201.049 Sleep Medicine 95811 POLYSOM 6/>YRS CPAP 4/> PARM Management of Obstructive _ MED204.005 Sleep Apnea Syndrome Gastric Electrical Stimulation Gastroenterology 95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG SUR709.031 _ (GES)
Hyperbaric Oxygen (HBO2) Wound Care 99183 PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION THE801.003 _ Therapy
Genetic Lab 0001U RBC DNA HEA 35 AG 11 BLD GRP AIM Guidelines _
Genetic Lab 0002M Liver dis 10 assays w/ash AIM Guidelines _
Genetic Lab 0003M Liver dis 10 assays w/nash AIM Guidelines _
Genetic Lab 0004M Scoliosis dna alys AIM Guidelines _
Genetic Lab 0005U ONCO PRST8 3 GENE UR ALG AIM Guidelines _
Genetic Lab 0006M Onc hep gene risk classifier AIM Guidelines _
Genetic Lab 0007M Onc gastro 51 gene nomogram AIM Guidelines _
Genetic Lab 0011M ONC PRST8 CA MRNA 12 GEN ALG AIM Guidelines _
Genetic Lab 0012M ONC MRNA 5 GEN RSK URTHL CA AIM Guidelines _
Genetic Lab 0012U GERMLN DO GENE REARGMT DETCJ AIM Guidelines _
Genetic Lab 0013M ONC MRNA 5 GEN RECR URTHL CA AIM Guidelines _
Genetic Lab 0013U ONC SLD ORG NEO GENE REARGMT AIM Guidelines _
Genetic Lab 0014U HEM HMTLMF NEO GENE REARGMT AIM Guidelines _
Genetic Lab 0018U ONC THYR 10 MICRORNA SEQ ALG AIM Guidelines _
Genetic Lab 0019U ONC RNA TISS PREDICT ALG AIM Guidelines _
Genetic Lab 0022U TRGT GEN SEQ DNA&RNA 23 GENE AIM Guidelines _
Genetic Lab 0026U ONC THYR DNA&MRNA 112 GENES AIM Guidelines _
Genetic Lab 0029U RX METAB ADVRS TRGT SEQ ALYS AIM Guidelines _
Genetic Lab 0030U RX METAB WARF TRGT SEQ ALYS AIM Guidelines _
Genetic Lab 0031U CYP1A2 GENE AIM Guidelines _
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Genetic Lab 0032U COMT GENE AIM Guidelines _
Genetic Lab 0033U HTR2A HTR2C GENES AIM Guidelines _
Genetic Lab 0034U TPMT NUDT15 GENES AIM Guidelines _
Genetic Lab 0036U XOME TUM & NML SPEC SEQ ALYS AIM Guidelines _
Genetic Lab 0037U TRGT GEN SEQ DNA 324 GENES AIM Guidelines _
Advanced Imaging 0042T CT PERFUSION W/CONTRAST CBF AIM Guidelines _
Genetic Lab 0045U ONC BRST DUX CARC IS 12 GENE AIM Guidelines _
Genetic Lab 0047U ONC PRST8 MRNA 17 GENE ALG AIM Guidelines _
Genetic Lab 0048U ONC SLD ORG NEO DNA 468 GENE AIM Guidelines _
Genetic Lab 0050U TRGT GEN SEQ DNA 194 GENES AIM Guidelines _
Genetic Lab 0053U ONC PRST8 CA FISH ALYS 4 GEN AIM Guidelines _
Genetic Lab 0055U CARD HRT TRNSPL 96 DNA SEQ AIM Guidelines _
Genetic Lab 0056U HEM AML DNA GENE REARGMT AIM Guidelines _
Genetic Lab 0060U TWN ZYG GEN SEQ ALYS CHRMS2 AIM Guidelines _
Genetic Lab 0067U ONC BRST IMHCHEM PRFL 4 BMRK AIM Guidelines _
Genetic Lab 0069U ONC CLRCT MICRORNA MIR-31-3P AIM Guidelines _
Genetic Lab 0070U CYP2D6 GEN COM&SLCT RAR VRNT AIM Guidelines _
Genetic Lab 0071U CYP2D6 FULL GENE SEQUENCE AIM Guidelines _
Genetic Lab 0072U CYP2D6 GEN CYP2D6-2D7 HYBRID AIM Guidelines _
Genetic Lab 0073U CYP2D6 GEN CYP2D7-2D6 HYBRID AIM Guidelines _
Genetic Lab 0074U CYP2D6 NONDUPLICATED GENE AIM Guidelines _
Genetic Lab 0075U CYP2D6 5' GENE DUP/MLT AIM Guidelines _
Genetic Lab 0076U CYP2D6 3' GENE DUP/MLT AIM Guidelines _
Genetic Lab 0078U PAIN MGT OPI USE GNOTYP PNL AIM Guidelines _
Genetic Lab 0079U CMPRTV DNA ALYS MLT SNPS AIM Guidelines _
Genetic Lab 0084U RBC DNA GNOTYP 10 BLD GROUPS AIM Guidelines _
Genetic Lab 0087U CRD HRT TRNSPL MRNA 1283 GEN AIM Guidelines _
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Genetic Lab 0088U TRNSPLJ KDN ALGRFT REJ 1494 AIM Guidelines _
Genetic Lab 0089U ONC MLNMA PRAME & LINC00518 AIM Guidelines _
Genetic Lab 0090U ONC CUTAN MLNMA MRNA 23 GENE AIM Guidelines _
Genetic Lab 0094U GENOME RAPID SEQUENCE ALYS AIM Guidelines _
Joint & Spine Surgery 0095T RMVL ARTIFIC DISC ADDL CRVCL AIM Guidelines _
Joint & Spine Surgery 0098T REV ARTIFIC DISC ADDL AIM Guidelines _
Genetic Lab 0101U HERED COLON CA DO 15 GENES AIM Guidelines _
Genetic Lab 0102U HERED BRST CA RLTD DO 17 GEN AIM Guidelines _
Genetic Lab 0103U HERED OVA CA PNL 24 GENES AIM Guidelines _
Genetic Lab 0111U ONC COLON CA KRAS&NRAS ALYS AIM Guidelines _
Genetic Lab 0113U ONC PRST8 PCA3&TMPRSS2-ERG AIM Guidelines _
Genetic Lab 0114U GI BARRETTS ESOPH VIM&CCNA1 AIM Guidelines _
Genetic Lab 0118U TRNSPLJ DON-DRV CLL-FR DNA AIM Guidelines _
Genetic Lab 0120U ONC B CLL LYMPHM MRNA 58 GEN AIM Guidelines _
Genetic Lab 0129U HERED BRST CA RLTD DO PANEL AIM Guidelines _
Genetic Lab 0130U HERED COLON CA DO MRNA PNL AIM Guidelines _
Genetic Lab 0131U HERED BRST CA RLTD DO PNL 13 AIM Guidelines _
Genetic Lab 0132U HERED OVA CA RLTD DO PNL 17 AIM Guidelines _
Genetic Lab 0133U HERED PRST8 CA RLTD DO 11 AIM Guidelines _
Genetic Lab 0134U HERED PAN CA MRNA PNL 18 GEN AIM Guidelines _
Genetic Lab 0135U HERED GYN CA MRNA PNL 12 GEN AIM Guidelines _
Genetic Lab 0136U ATM MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0137U PALB2 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0138U BRCA1 BRCA2 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0153U ONC BREAST MRNA 101 GENES AIM Guidelines _
Genetic Lab 0156U COPY NUMBER SEQUENCE ALYS AIM Guidelines _
Genetic Lab 0157U APC MRNA SEQ ALYS AIM Guidelines _
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Genetic Lab 0158U MLH1 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0159U MSH2 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0160U MSH6 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0161U PMS2 MRNA SEQ ALYS AIM Guidelines _
Genetic Lab 0162U HERED COLON CA TRGT MRNA PNL AIM Guidelines _
Joint & Spine Surgery 0163T LUMB ARTIF DISKECTOMY ADDL AIM Guidelines _
Joint & Spine Surgery 0164T REMOVE LUMB ARTIF DISC ADDL AIM Guidelines _
Joint & Spine Surgery 0165T REVISE LUMB ARTIF DISC ADDL AIM Guidelines _
Genetic Lab 0169U NUDT15&TPMT GENE COM VRNT AIM Guidelines _
Genetic Lab 0170U NEURO ASD RNA NEXT GEN SEQ AIM Guidelines _
Genetic Lab 0171U TRGT GEN SEQ ALYS PNL DNA 23 AIM Guidelines _
Genetic Lab 0172U ONC SLD TUM ALYS BRCA1 BRCA2 AIM Guidelines _
Genetic Lab 0173U PEANUT ALLG SPEC ASMT 64 EPI AIM Guidelines _
Genetic Lab 0175U PSYC GEN ALYS PANEL 15 GENES AIM Guidelines _
Genetic Lab 0179U ONC NONSM CLL LNG CA ALYS 23 AIM Guidelines _
Surgical Treatment of Joint & Spine Surgery 29914 ARTHROSCOPY HIP W/FEMOROPLASTY SUR705.029 Femoroacetabular Impingement Added 01/01/2021 (FAI) Surgical Treatment of Joint & Spine Surgery 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY SUR705.029 Femoroacetabular Impingement Added 01/01/2021 (FAI) Surgical Treatment of Joint & Spine Surgery 29916 ARTHROSCOPY HIP W/LABRAL REPAIR SUR705.029 Femoroacetabular Impingement Added 01/01/2021 (FAI)
Neurology 61885 INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR SUR712.025 Deep Brain Stimulation Added 01/01/2021
Neurology 61886 INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS SUR712.025 Deep Brain Stimulation Added 01/01/2021
Temporomandibular Joint (TMJ) Neurology 64553 PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE SUR705.010 Disorders (TMJD) Added 01/01/2021 SUR712.021 Vagus Nerve Stimulation (VNS) Temporomandibular Joint (TMJ) SUR705.010 Neurology 64555 IMPLANT NEUROELECTRODES Disorders (TMJD) Added 01/01/2021 SUR712.021 Vagus Nerve Stimulation (VNS)
Pain Management 0213T NJX PARAVERT W/US CER/THOR AIM Guidelines _
Sleep Related Breathing Neurology 64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER SUR706.009 Added 01/01/2021 Disorders: Surgical Management
Pain Management 0214T NJX PARAVERT W/US CER/THOR AIM Guidelines _
Percutaneous and Implanted Neurology 64575 IMPLANT NEUROELECTRODES MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation
Pain Management 0215T NJX PARAVERT W/US CER/THOR AIM Guidelines _
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Category Procedure Code Description Medical Policy Number Medical Policy Title Updates Percutaneous and Implanted Neurology 64580 IMPLANT NEUROELECTRODES MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation
Pain Management 0216T NJX PARAVERT W/US LUMB/SAC AIM Guidelines _
Percutaneous and Implanted Neurology 64590 INSRT/REDO PN/GASTR STIMUL MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation
Pain Management 0217T NJX PARAVERT W/US LUMB/SAC AIM Guidelines _
Ear, Nose & Throat 92633 AUD REHAB POSTLING HEAR LOSS SUR714.004 Cochlear Implant Added 01/01/2021
Pain Management 0218T NJX PARAVERT W/US LUMB/SAC AIM Guidelines _
Pain Management 0228T NJX TFRML EPRL W/US CER/THOR AIM Guidelines _
Pain Management 0229T NJX TFRML EPRL W/US CER/THOR AIM Guidelines _
Pain Management 0230T NJX TFRML EPRL W/US LUMB/SAC AIM Guidelines _
Pain Management 0231T NJX TFRML EPRL W/US LUMB/SAC AIM Guidelines _
Pain Management 0274T PERQ LAMOT/LAM CRV/THRC AIM Guidelines _
Pain Management 0275T PERQ LAMOT/LAM LUMBAR AIM Guidelines _
Vagus Nerve Blocking Therapy Obesity Surgery 0312T LAPS IMPLTJ NSTIM ELTRD ARRAY&PLS GEN VAGUS NRV SUR701.039 _ for Treatment of Obesity
Vagus Nerve Blocking Therapy Obesity Surgery 0313T LAPS REVJ/REPLCMT NSTIM ELTRD ARRAY VAGUS NRV SUR701.039 _ for Treatment of Obesity
Vagus Nerve Blocking Therapy Obesity Surgery 0314T LAPS RMVL NSTIM ELTRD ARRAY & PLS GEN VAGUS NRV SUR701.039 _ for Treatment of Obesity
Vagus Nerve Blocking Therapy Obesity Surgery 0315T REMOVAL PULSE GENERATOR VAGUS NERVE SUR701.039 _ for Treatment of Obesity
Vagus Nerve Blocking Therapy Obesity Surgery 0316T REPLACEMENT PULSE GENERATOR VAGUS NERVE SUR701.039 _ for Treatment of Obesity
Vagus Nerve Blocking Therapy Obesity Surgery 0317T ELEC ALYS NSTIM PLS GEN VAGUS NRV W/REPRGRMG SUR701.039 _ for Treatment of Obesity
Radiation Oncology 0394T HDR ELCTRNC SKN SURF BRCHYTX AIM Guidelines _
Radiation Oncology 0395T HDR ELCTR NTRST/NTRCV BRCHTX AIM Guidelines _
Ambulance service, conventional air services, transport, one way Ambulance and Medical Air Ambulance Fixed Wing A0430 ADM1001.005 _ (fixed wing) Transport Services
Ambulance and Medical Air Ambulance Fixed Wing A0435 Fixed wing air mileage per statue mile ADM1001.005 _ Transport Services
Sacral Nerve Neurology A4290 Sacral nerve stimulation test lead each SUR710.018 Added 01/01/2021 Neuromodulation/Stimulation
Hyperbaric Oxygen (HBO2) Wound Care A4575 Topical hyperbaric oxygen chamber disposable THE801.003 _ Therapy
Sleep Medicine A4604 Tubing with heating element AIM Guidelines _
Sleep Medicine A7027 Combination oral/nasal mask AIM Guidelines _
Sleep Medicine A7028 Repl oral cushion combo mask AIM Guidelines _
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Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Sleep Medicine A7029 Repl nasal pillow comb mask AIM Guidelines _
Sleep Medicine A7030 CPAP full face mask AIM Guidelines _
Sleep Medicine A7031 Replacement facemask interfa AIM Guidelines _
Sleep Medicine A7032 Replacement nasal cushion AIM Guidelines _
Sleep Medicine A7033 Replacement nasal pillows AIM Guidelines _
Sleep Medicine A7034 Nasal application device AIM Guidelines _
Sleep Medicine A7035 Pos airway press headgear AIM Guidelines _
Sleep Medicine A7036 Pos airway press chinstrap AIM Guidelines _
Sleep Medicine A7037 Pos airway pressure tubing AIM Guidelines _
Sleep Medicine A7038 Pos airway pressure filter AIM Guidelines _
Sleep Medicine A7039 Filter non disposable w pap AIM Guidelines _
Sleep Medicine A7044 PAP oral interface AIM Guidelines _
Sleep Medicine A7045 Repl exhalation port for PAP AIM Guidelines _
Sleep Medicine A7046 Repl water chamber PAP dev AIM Guidelines _
Radiation Oncology A9513 Lutetium lu 177 dotatat ther AIM Guidelines _
Radiation Oncology A9543 Y90 ibritumomab rx AIM Guidelines _
Radiation Oncology A9590 Iodine i-131 iobenguane 1mci AIM Guidelines _
Radiation Oncology A9606 Radium ra223 dichloride ther AIM Guidelines _
Spinal Cord Stimulation (SCS) Neurology C1822 Gen neuro hf rechg bat SUR712.009 and Dorsal Root Ganglion Added 01/01/2021 (DRG) Stimulation
Advanced Imaging C8900 MRA w/cont abd AIM Guidelines _
Advanced Imaging C8901 MRA w/o cont abd AIM Guidelines _
Advanced Imaging C8902 MRA w/o fol w/cont abd AIM Guidelines _
Advanced Imaging C8903 MRI w/cont breast uni AIM Guidelines _
Advanced Imaging C8905 MRI w/o fol w/cont brst un AIM Guidelines _
Advanced Imaging C8906 MRI w/cont breast bi AIM Guidelines _
Advanced Imaging C8908 MRI w/o fol w/cont breast AIM Guidelines _
Advanced Imaging C8909 MRA w/cont chest AIM Guidelines _
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Advanced Imaging C8910 MRA w/o cont chest AIM Guidelines _
Advanced Imaging C8911 MRA w/o fol w/cont chest AIM Guidelines _
Advanced Imaging C8912 MRA w/cont lwr ext AIM Guidelines _
Advanced Imaging C8913 MRA w/o cont lwr ext AIM Guidelines _
Advanced Imaging C8914 MRA w/o fol w/cont lwr ext AIM Guidelines _
Advanced Imaging C8918 MRA w/cont pelvis AIM Guidelines _
Advanced Imaging C8919 MRA w/o cont pelvis AIM Guidelines _
Advanced Imaging C8920 MRA w/o fol w/cont pelvis AIM Guidelines _
Advanced Imaging C8931 MRA w/dye spinal canal AIM Guidelines _
Advanced Imaging C8932 MRA w/o dye spinal canal AIM Guidelines _
Advanced Imaging C8933 MRA w/o&w/dye spinal canal AIM Guidelines _
Advanced Imaging C8934 MRA w/dye upper extremity AIM Guidelines _
Advanced Imaging C8935 MRA w/o dye upper extr AIM Guidelines _
Advanced Imaging C8936 MRA w/o&w/dye upper extr AIM Guidelines _
Joint & Spine Surgery C9757 Spine/lumbar disk surgery AIM Guidelines _
Sleep Medicine E0470 RAD w/o backup non-inv intfc AIM Guidelines _
Sleep Medicine E0471 RAD w/backup non inv intrfc AIM Guidelines _
Sleep Medicine E0485 Oral device/appliance prefab AIM Guidelines _
Sleep Medicine E0486 Oral device/appliance cusfab AIM Guidelines _
Sleep Medicine E0561 Humidifier nonheated w PAP AIM Guidelines _
Sleep Medicine E0562 Humidifier heated used w PAP AIM Guidelines _
Sleep Medicine E0601 Cont airway pressure device AIM Guidelines _
Sacral Nerve Neurology E0745 Neuromuscular stimulator electronic shock unit SUR710.018 _ Neuromodulation/Stimulation
Joint & Spine Surgery E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications AIM Guidelines _
Joint & Spine Surgery E0749 Osteogenesis stimulator, electrical, surgically implanted AIM Guidelines _
OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON- Functional Neuromuscular Orthopedic Musculoskeletal E0760 MED201.033 _ INVASIVE Electrical Stimulation (FNMES)
Fda approved nerve stimulator with replaceable batteries for Gastric Electrical Stimulation Gastroenterology E0765 SUR709.031 _ treatment of nausea and vomiting (GES)
10/23/2020 33/40 2021 Medical Surgical Procedures Requiring Prior Authorization for ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Functional Neuromuscular Orthopedic Musculoskeletal E0770 FUNCTIONAL ELECTRIC STIM NOS MED201.033 _ Electrical Stimulation (FNMES)
Advanced Imaging G0219 PET img wholbod melano nonco AIM Guidelines _
Advanced Imaging G0235 Pet imaging any site not otherwise specified AIM Guidelines _
Advanced Imaging G0252 PET imaging initial dx AIM Guidelines _
Hyperbaric oxygen under pressure full body chamber per 30 minute Hyperbaric Oxygen (HBO2) Wound Care G0277 THE801.003 _ interval Therapy
Advanced Imaging G0297 Ldct for lung ca screen AIM Guidelines _
Radiation Oncology G0339 Robot lin-radsurg com first AIM Guidelines _
Radiation Oncology G0340 Robt lin-radsurg fractx 2-5 AIM Guidelines _
Sleep Medicine G0398 Home sleep test/type 2 Porta AIM Guidelines _
Sleep Medicine G0399 Home sleep test/type 3 Porta AIM Guidelines _
Sleep Medicine G0400 Home sleep test/type 4 Porta AIM Guidelines _
Collagen Meniscus Implant procedure for filling meniscal defects (e.g. Meniscal Allografts and Other Joint & Spine Surgery G0428 SUR705.034 Added 01/01/2021 CMI collagen scaffold Menaflex) Meniscal Implants
Radiation Oncology G6001 Echo guidance radiotherapy AIM Guidelines _
Radiation Oncology G6002 Stereoscopic x-ray guidance AIM Guidelines _
Radiation Oncology G6003 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6004 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6005 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6006 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6007 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6008 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6009 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6010 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6011 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6012 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6013 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6014 Radiation treatment delivery AIM Guidelines _
Radiation Oncology G6015 Radiation tx delivery imrt AIM Guidelines _
10/23/2020 34/40 2021 Medical Surgical Procedures Requiring Prior Authorization for ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Radiation Oncology G6016 Delivery comp imrt AIM Guidelines _
Radiation Oncology G6017 Intrafraction track motion AIM Guidelines _
Genetic Lab G9143 Warfarin respon genetic test AIM Guidelines _
Autologous Chondrocyte Joint & Spine Surgery J7330 Autologous cultured chondrocytes implant SUR705.035 Implantation (ACI) for Focal Added 01/01/2021 Articular Cartilage Lesions
Breast Surgery L8600 Implantable breast prosthesis, silicone or equal SUR716.010 Mastopexy _
COCHLEAR DEVICE INCLUDES ALL INTERNAL AND EXTERNAL Ear, Nose & Throat L8614 SUR714.004 Cochlear Implant _ COMPONENTS
HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE Ear, Nose & Throat L8615 SUR714.004 Cochlear Implant _ REPLACEMENT
MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE Ear, Nose & Throat L8616 SUR714.004 Cochlear Implant _ REPLACEMENT
TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE Ear, Nose & Throat L8617 SUR714.004 Cochlear Implant _ REPLACEMENT
Transmitter cable for use with cochlear implant device or auditory Ear, Nose & Throat L8618 SUR714.004 Cochlear Implant _ osseointegrated device replacement
COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR AND Ear, Nose & Throat L8619 SUR714.004 Cochlear Implant _ CONTROLLER INTEGRATED SYSTEM REPLACEMENT
Zinc air battery for use with cochlear implant device and auditory Ear, Nose & Throat L8621 SUR714.004 Cochlear Implant _ osseointegrated sound processors replacement each
ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE ANY Ear, Nose & Throat L8622 SUR714.004 Cochlear Implant _ SIZE REPLACEMENT EACH
LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE Ear, Nose & Throat L8623 SUR714.004 Cochlear Implant _ SPEECH PROCESSOR OTHER THAN EAR LEVEL REPLACEMENT EACH Lithium ion battery for use with cochlear implant or auditory Ear, Nose & Throat L8624 osseointegrated device speech processor ear level replacement SUR714.004 Cochlear Implant _ each COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR COMPONENT Ear, Nose & Throat L8627 SUR714.004 Cochlear Implant _ REPLACEMENT
COCHLEAR IMPLANT EXTERNAL CONTROLLER COMPONENT Ear, Nose & Throat L8628 SUR714.004 Cochlear Implant _ REPLACEMENT
TRANSMITTING COIL AND CABLE INTEGRATED FOR USE WITH Ear, Nose & Throat L8629 SUR714.004 Cochlear Implant _ COCHLEAR IMPLANT DEVICE REPLACEMENT Percutaneous and Implanted Ear, Nose & Throat L8679 Imp neurosti pls gn any type MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8680 Implt neurostim elctr each MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8681 Pt prgrm for implt neurostim MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8682 Implt neurostim radiofq rec MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8683 Radiofq trsmtr for implt neu MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8685 Implt nrostm pls gen sng rec MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8686 Implt nrostm pls gen sng non MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8687 Implt nrostm pls gen dua rec MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation Percutaneous and Implanted Ear, Nose & Throat L8688 Implt nrostm pls gen dua non MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation
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Category Procedure Code Description Medical Policy Number Medical Policy Title Updates Percutaneous and Implanted Ear, Nose & Throat L8689 External recharg sys intern MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation AUDITORY OSSEOINTEGRATED DEVICE INCLUDES ALL INTERNAL AND Ear, Nose & Throat L8690 SUR714.003 Bone Conduction Hearing Aids _ EXTERNAL COMPONENTS
Auditory osseointegrated device external sound processor excludes Ear, Nose & Throat L8691 SUR714.003 Bone Conduction Hearing Aids _ transducer/actuator replacement only each
AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT ANY LENGTH Ear, Nose & Throat L8693 SUR714.003 Bone Conduction Hearing Aids _ REPLACEMENT ONLY Percutaneous and Implanted Ear, Nose & Throat L8695 External recharg sys extern MED205.032 Nerve Stimulation and Added 01/01/2021 Neuromodulation
Pain Management M0076 Prolotherapy AIM Guidelines _
Autologous Chondrocyte Arthroscopy knee surgical for harvesting of cartilage (chondrocyte Joint & Spine Surgery S2112 SUR705.035 Implantation (ACI) for Focal Added 01/01/2021 cells) Articular Cartilage Lesions
Joint & Spine Surgery S2118 Total hip resurfacing AIM Guidelines _
Low density lipoprotein (ldl) apheresis using heparin-induced Cardiology S2120 THE802.003 Lipid Apheresis _ extracorporeal ldl precipitation
Genetic Lab S3800 Genetic testing ALS AIM Guidelines _
Genetic Lab S3840 DNA analysis RET-oncogene AIM Guidelines _
Genetic Lab S3841 Gene test retinoblastoma AIM Guidelines _
Genetic Lab S3842 Gene test Hippel-Lindau AIM Guidelines _
Genetic Lab S3844 DNA analysis deafness AIM Guidelines _
Genetic Lab S3845 Gene test alpha-thalassemia AIM Guidelines _
Genetic Lab S3846 Gene test beta-thalassemia AIM Guidelines _
Genetic Lab S3850 Gene test sickle cell AIM Guidelines _
Genetic Lab S3852 DNA analysis APOE alzheimer AIM Guidelines _
Genetic Lab S3854 Gene profile panel breast AIM Guidelines _
Genetic Lab S3861 Genetic test brugada AIM Guidelines _
Genetic Lab S3865 Comp genet test hyp cardiomy AIM Guidelines _
Genetic Lab S3866 Spec gene test hyp cardiomy AIM Guidelines _
Genetic Lab S3870 Cgh test developmental delay AIM Guidelines _
Advanced Imaging S8037 mrcp AIM Guidelines _
Advanced Imaging S8042 MRI low field AIM Guidelines _
Advanced Imaging S8085 Fluorine-18 fluorodeoxygluco AIM Guidelines _
Advanced Imaging S8092 Electron beam computed tomog AIM Guidelines _
10/23/2020 36/40 2021 Medical Drugs Requiring Prior Authorization For ASO Plans
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Category Procedure Code Drug Name Brand Name Effective Date Updates
Medical Infusion / Specialty Drug J3241 teprotumumab-trbw Tepezza 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug J3032 eptinezumab-jjmr Vyepti 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug J0223 givosiran Givlaari 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug J0791 crizanlizumab-tmca Adakveo 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug J1303 ravulizumab-cwvz Ultomiris 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug J1558 immune globulin subcutaneous, human-klhw Xembify 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug Q5121 infliximab-axxq Avsola 1/1/2021 Added 01/01/2021
Medical Infusion / Specialty Drug 90283 immune globulin intravenous IVIG 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug 90284 immune globulin subcutaneous SCIG 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J0222 patisiran Onpattro 1/1/2020 Added 01/01/2021
Medical Infusion / Specialty Drug J0585 onabotulinumtoxinA Botox 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J0586 abobotulinumtoxinA Dysport 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J0587 rimabotulinumtoxinB Myobloc 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J0588 incobotulinumtoxinA Xeomin 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J1325 epoprostenol Flolan, Veletri 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J1562 immune globulin subcutaneous Vivaglobin 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J1599 immune globulin intravenous IVIG 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J1675 histrelin acetate histrelin acetate 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J1726 hydroxyprogesterone caproate Makena 1/1/2019 Added 01/01/2021
Lupron Depot, Lupron Depot- Medical Infusion / Specialty Drug J1950 leuprolide acetate, for depot suspension, per 3.75 mg 1/1/2019 Added 01/01/2021 Ped
Medical Infusion / Specialty Drug J2502 pasireotide Signifor LAR 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J2941 somatropin Humatrope, Saizen 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J3121 testosterone enanthate testosterone enanthate 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J3145 testosterone undecanoate Aveed 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J3315 triptorelin pamoate Trelstar 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J3399 onasemnogene abeparvovec-xioi Zolgensma 9/10/2020 Added 01/01/2021
Medical Infusion / Specialty Drug J9155 degarelix Firmagon 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J9202 goserelin acetate implant Zoladex 1/1/2019 Added 01/01/2021
Eligard, Lupron Depot, Lupron Medical Infusion / Specialty Drug J9217 leuprolide acetate, for depot suspension, 7.5 mg 1/1/2019 Added 01/01/2021 Depot-Ped
Medical Infusion / Specialty Drug J9218 leuprolide acetate, non depot leuprolide acetate, non depot 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J9219 leuprolide acetate implant Viadur 1/1/2019 Added 01/01/2021
10/23/2020 37/40 2021 Medical Drugs Requiring Prior Authorization for ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Medical Infusion / Specialty Drug J9225 histrelin implant Vantas 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug J9226 histrelin implant Supprelin LA 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug S0157 becaplermin gel Regranex 1/1/2019 Added 01/01/2021
Medical Infusion / Specialty Drug S0189 testosterone pellets Testopel 1/1/2019 Added 01/01/2021
2021 Behavioral Health Services Requiring Prior Authorization For ASO PLans Service Service Description
A short-term acute care facility which: 1. Is duly licensed as a Hospital by the state in which it is located and meets the standards established for such licensing, and is either accredited by the Joint Commission on Accreditation of Healthcare Organizations or is certified as a Hospital provider under Medicare; 2. Is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians or Elective or Emergency Inpatient Behavioral Health Practitioner for compensation from its patients; 3. Has organized departments of medicine and major surgery, either on its premises or in facilities available to the Hospital on a contractual prearranged basis, and maintains clinical records on all patients; 4. Provides 24-hour nursing services by or under the supervision of a Registered Nurse; and 5. Has in effect a Hospital Utilization Review Plan.
A Claim Administrator approved planned program of a Hospital or Substance Use Disorder Treatment Facility for the treatment of Mental Illness or Substance Use Disorder Treatment in which patients spend days s. This behavioral healthcare is typically 5 to 8 hours per day, 5 days per week (not less than 20 hours of treatment services per week). The program is staffed similarly to the day shift of an inpatient unit, i.e. medically supervised by a Physician and nurse. The program shall ensure a psychiatrist sees the patient face to face at least once a week and it otherwise Partial Hospitalization Treatment available, in person or by telephone, to provide assistance and direction to the program as needed. Participants at this level of care do not require 24 hour supervision and are not considered a Program resident at the program. Requirements: the Claim Administrator requires that any Mental Illness and/or Substance Use Disorder Partial Hospitalization Treatment Program must be licensed in the state where it is located, or accredited by a national organization that is recognized by the Claim Administrator as set forth in its current credentialing policy, and otherwise meets all other credentialing requirements set forth in such policy.
A facility setting (including a Residential Treatment Center for Children and Adolescents) offering a defined course of therapeutic intervention and special programming in a controlled environment which also offers a degree of security, supervision, structure and is licensed by the appropriate state and local authority to provide such service. It does not include half-way houses, Residential Treatment Center (RTC) wilderness programs, supervised living, group homes, boarding houses or other facilities that provide primarily a supportive environment and address long-term social needs, even if counseling is Admissions provided in such facilities. Patients are medically monitored with 24 hour medical availability and 24 hour onsite nursing service for Mental Health Care and/or for treatment of Chemical Dependency. BCBSTX requires that any facility providing Mental Health Care and/or a Chemical Dependency Treatment Center must be licensed in the state where it is located, or accredited by a national organization that is recognized by BCBSTX as set forth in its current credentialing policy, and otherwise meets all other credentialing requirements set forth in such policy.
Applied behavior analysis is a method of therapy utilized to improve or change specific behaviors of members who have a diagnosis within the Pervasive and specific developmental disorders Applied Behavior Analysis (ABA) category of ICD-10.
A freestanding or Hospital-based program that provides services for at least three hours per day, two or more days per week, to treat mental illness, drug addiction, substance abuse or alcoholism, or specializes in the treatment of co-occurring mental illness with drug addiction, substance abuse or alcoholism. Programs that specialize in the treatment of severe or complex co- Intensive Outpatient Programs (IOP) occurring conditions offer integrated and aligned assessment, treatment and discharge planning services for mental illness and for drug addiction, substance abuse or alcoholism. It is more likely that Participants with co-occurring conditions will benefit from programs addressing both mental illness and drug addiction, substance abuse or alcoholism than programs that focus solely on mental illness conditions.
A treatment that involves brief electrical stimulation of the brain while a member is under anesthesia to treat severe psychiatric disorders and billed by a facility/clinic. It is typically administered Outpatient Electroconvulsive Therapy anywhere from 2-3 times per week if a member is simultaneously admitted to an inpatient Care Level. However, once the member steps down to an outpatient Care Level, frequency may change (ECT) to once every 3-4 weeks.
Psychological/Neuropsychological Psychological testing consists of the administration of psychological tests which measure a sample of a member’s behavior. Testing
A form of brain stimulation therapy used to treat psychiatric conditions in a facility/clinic setting. A treatment course is usually 1 daily session, 5 times per week for up to 6 weeks, followed by a 3- Repetitive Transcranial Magnetic week taper of 3 rTMS session in week one, 2 rTMS sessions the next week, and one rTMS session in the last week (total of 36 sessions). The treatment course may be repeated after a 6-month Stimulation (rTMS) cessation period if needed. The therapy cannot be administered on the same day as a PHP, IOP, ECT, or ABA Care Level service.
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Category Procedure Code Code Description Medical Policy Number Medical Policy Title Updates
Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97151 BHV ID ASSMT BY PHYS/QHP PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97152 BHV ID SUPRT ASSMT BY 1 TECH PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97153 ADAPTIVE BEHAVIOR TX BY TECH PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97154 GRP ADAPT BHV TX BY TECH PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97155 ADAPT BEHAVIOR TX PHYS/QHP PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis
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Category Procedure Code Description Medical Policy Number Medical Policy Title Updates Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97156 FAM ADAPT BHV TX GDN PHY/QHP PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97157 MULT FAM ADAPT BHV TX GDN PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 97158 GRP ADAPT BHV TX BY PHY/QHP PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 0362T BHV ID SUPRT ASSMT EA 15 MIN PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Applied Behavior Analysis (ABA) Applied Behavior Analysis (ABA) 0373T ADAPT BHV TX EA 15 MIN PSY301.021 for Autism Spectrum Disorder _ (ASD) Diagnosis Electroconvulsive Therapy 90870 Electroconvulsive therapy (includes necessary monitoring) PSY301.013 Electroconvulsive Therapy _
Electroconvulsive Therapy 00104 Anesthesia for electroconvulsive therapy PSY301.013 Electroconvulsive Therapy _
Psychological and Neuropsychological Psychological and 96101 Psychological Testing , per hour with psychologist or physician PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96102 Psychological Testing, per hour with technician PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96103 Psychological Testing administered by computer PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96105 Assessment of Aphasia, per hour PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96110 Developmental screening, per instrument PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96111 Developmental testing with interpretation and report PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96116 Neurobehavioral Status Exam, per hour PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96118 Neuropsychological testing, per hour with psychologist or physician PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96119 Neuropsychological testing, per hour with technician PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96120 Neuropsychological testing, by computer PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Each additional hour for Neurobehavioral status exam- must be used Psychological and 96121 PSY301.020 _ Testing with 96116 (not a stand alone code) Neuropsychological Testing Psychological and Neuropsychological Psychological and 96125 Standardized Cognitive testing, per hour PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological and 96127 Brief emotional/behavior assessment PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Psychological interpretation and reporting following testing, by Psychological and 96130 PSY301.020 _ Testing Qualified health care professional, first hour Neuropsychological Testing Psychological and Neuropsychological Psychological and 96131 Each additional hour of 96130 (not a stand alone code) PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Neuropsychological interpretation and reporting following testing, by Psychological and 96132 PSY301.020 _ Testing Qualified health care professional, first hour Neuropsychological Testing Psychological and Neuropsychological Psychological and 96133 Each additional hour of 96132 (not a stand alone code) PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Administration of Psychological or Neuropsychological testing by Psychological and 96136 PSY301.020 _ Testing physician or psychologist, first 30 minutes Neuropsychological Testing Psychological and Neuropsychological Psychological and 96137 Each additional 30 minutes of 96136 (not a stand alone code) PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological Administration of Psychological or Neuropsychological testing by a Psychological and 96138 PSY301.020 _ Testing technician, first 30 minutes Neuropsychological Testing Psychological and Neuropsychological Psychological and 96139 Each additional 30 minutes of 96138 (not a stand alone code) PSY301.020 _ Testing Neuropsychological Testing Psychological and Neuropsychological A single psychological or neuropsychological test administration by Psychological and 96146 PSY301.020 _ Testing computer Neuropsychological Testing Repetitive Transcranial Magnetic Repetitive Transcranial Magnetic 90867 TCRANIAL MAGN STIM TX PLAN PSY301.015 _ Stimulation (rTMS) Stimulation (rTMS) Repetitive Transcranial Magnetic Repetitive Transcranial Magnetic 90868 Subsequent delivery and management, per session PSY301.015 _ Stimulation (rTMS) Stimulation (rTMS) Repetitive Transcranial Magnetic Repetitive Transcranial Magnetic 90869 Sunsequent motor threshold re-determination PSY301.015 _ Stimulation (rTMS) Stimulation (rTMS)
10/23/2020 39/40 2021 Medical Surgical Procedures Requiring Prior Authorization For ASO Plans PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Category Procedure Code Description Medical Policy Number Medical Policy Title Updates
Psychological and Psychological and 96137 Each additional 30 minutes of 96136 (not a stand alone code) PSY301.020 _ Neuropsychological Testing Neuropsychological Testing Psychological and Administration of Psychological or Neuropsychological testing by a Psychological and 96138 PSY301.020 _ Neuropsychological Testing technician, first 30 minutes Neuropsychological Testing Psychological and Psychological and 96139 Each additional 30 minutes of 96138 (not a stand alone code) PSY301.020 _ Neuropsychological Testing Neuropsychological Testing Psychological and A single psychological or neuropsychological test administration by Psychological and 96146 PSY301.020 _ Neuropsychological Testing computer Neuropsychological Testing Repetitive Transcranial Magnetic Repetitive Transcranial 90867 TCRANIAL MAGN STIM TX PLAN PSY301.015 _ Stimulation (rTMS) Magnetic Stimulation (rTMS) Repetitive Transcranial Magnetic Repetitive Transcranial 90868 Subsequent delivery and management, per session PSY301.015 _ Stimulation (rTMS) Magnetic Stimulation (rTMS) Repetitive Transcranial Magnetic Repetitive Transcranial 90869 Subsequent motor threshold re-determination PSY301.015 _ Stimulation (rTMS) Magnetic Stimulation (rTMS)
CPT Copyright 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
AIM® is an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas.
As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if benefit prior authorization is required for a member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSTX’s provider website.
Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card
Update Date Description 1/1/2020 Original Posting 6/1/2020 Update Posting 1/1/2021 Update Posting
10/23/2020 40/40