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Master Precertification List 0f MASTER PRECERTIFICATION LIST For Health Care Providers Effective October 2021, Last updated September 24, 2021 Complete/PHS+ - The most comprehensive care management model that includes all the components of our Preferred level, plus additional digital tools and the highest level of engagement and potential savings. Preferred - A comprehensive care management model that includes all the components of our existing care management model, including comprehensive outpatient precertification, plus higher intensity of care coordination and more customer engagement opportunities. Basic Standard - A lower touch care management model that includes many of the components of our existing care management model, such as higher intensity of care coordination and more customer engagement opportunities. Basic Standard has a limited number of outpatient precertification categories (radiation therapy, medical oncology, medical injectables, home infusion therapy and private duty nursing), fewer than our Preferred and Complete solutions. *Removal from precertification is not a guarantee of payment. Codes may be subject to code editing, benefit plan exclusions and post-service review for coverage. Complete /PHS+/ Basic Code Code Description Addition/Removal Preferred Standard Precertification delegated to eviCore Revenue Radiology-Therapeutic and/or Chemotherapy Administration- healthcare National Code 0333 Radiation Therapy Radiation Therapy X X Program; Added 02/27/2016 Revenue Cell/Gene Therapy - General Classification Added 04/01/2019 Code 0870 X X Revenue Cell/Gene Therapy - Cell Collection Added 04/01/2019 Code 0871 X X Revenue Cell/Gene Therapy - Specialized Biologic Processing And Added 04/01/2019 Code 0872 Storage - Prior To Transport X X All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2020 Cigna. Some content provided under license. 1 Complete /PHS+/ Basic Code Code Description Addition/Removal Preferred Standard Revenue Cell/Gene Therapy - Storage And Processing After Receipt Of Added 04/01/2019 Code 0873 Cells From Manufacturer X X Revenue Cell/Gene Therapy - Infusion Of Modified Cells Added 04/01/2019 Code 0874 X X Revenue Cell/Gene Therapy - Injection Of Modified Cells Added 04/01/2019 Code 0875 X X Revenue Pharmacy - Extension Of 025X And 063X - Reserved (Use 0250 Added 04/01/2019 Code 0890 For General Classification) X X Revenue Pharmacy - Extension Of 025X And 063X - Special Processed Added 04/01/2019 Code 0891 Drugs – FDA Approved Cell Therapy X X Revenue Special Processed Drugs - FDA Approved Gene Therapy Added 04/01/2020 Code 0892 X X Revenue Intensive outpatient services-psychiatric Added 08/27/2015 Code 0905 X Revenue Intensive outpatient services-chemical dependency Added 08/27/2015 Code 0906 X Revenue Community behavioral health program (day treatment) Added 08/27/2015 Code 0907 X Revenue Partial hospitalization-less intensive Added 08/27/2015 Code 0912 X Revenue Partial hospitalization- intensive Added 08/27/2015 Code 0913 X Oncology (gastrointestinal neuroendocrine tumors), real-time 0007M PCR expression analysis of 51 genes, utilizing whole peripheral Added 07/01/2014 X blood, algorithm reported as a nomogram of tumor disease index Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of 0014M metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing Added 04/01/2020 X serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T- 0018M Added 10/01/2021 cytotoxic memory cells, utilizing whole peripheral blood, algorithm X X reported as a rejection risk score Added 07/01/2011 0058T* Cryopreservation; reproductive tissue, ovarian Removed 11/07/2020 X X All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2020 Cigna. Some content provided under license. 2 Complete /PHS+/ Basic Code Code Description Addition/Removal Preferred Standard Focused ultrasound ablation of uterine leiomyomata, including 0071T MR guidance; total leiomyomata volume less than 200 cc of X X tissue Focused ultrasound ablation of uterine leiomyomata, including 0072T MR guidance; total leiomyomata volume greater or equal to 200 X X cc of tissue Transcatheter placement of extracranial vertebral or intrathoracic 0075T carotid artery stent(s), including radiologic supervision and Added 10/25/2019 X interpretation, percutaneous; initial vessel Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and 0076T Added 10/25/2019 interpretation, percutaneous; each additional vessel (List X separately in addition to code for primary procedure) 0085T* Breath test for heart transplant rejection Removed 11/07/2020 X X Revision of total disc arthroplasty, anterior approach; each 0098T additional interspace (List separately in addition to code for X primary procedure) Extracorporeal shock wave involving musculoskeletal system, not 0101T* Removed 11/07/2020 otherwise specified, high energy X X Extracorporeal shock wave, high energy, performed by a 0102T* physician, requiring anesthesia other than local, involving lateral Removed 11/07/2020 X X humeral epicondyle Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) 0111T* Removed 11/07/2020 membranes X Total disc arthroplasty (artificial disc), anterior approach, including 0163T discectomy to prepare interspace (other than for decompression), X X lumbar, each additional interspace Revision of total disc arthroplasty, anterior approach, lumbar, 0165T* Removed 11/07/2020 each additional interspace X X All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2020 Cigna. Some content provided under license. 3 Complete /PHS+/ Basic Code Code Description Addition/Removal Preferred Standard Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician 0174T* review for interpretation and report, with or without digitization of Removed 11/07/2020 X X film radiographic images, chest radiograph(s), performed concurrent with primary interpretation Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician 0175T* review for interpretation and report, with or without digitization of Removed 11/07/2020 X X film radiographic images, chest radiograph(s), performed remote from primary interpretation 0191T Insertion aqueous drainage device internal approach X Measurement of ocular blood flow by repetitive intraocular 0198T* Removed 11/07/2020 pressure sampling, with interpretation and report X X Percutaneous sacral augmentation (sacroplasty) unilateral 0200T injection(s), inc the use of a balloon or mechanical device (if X X utilized), one or more needles Percutaneous sacral augmentation (sacroplasty) unilateral 0201T injection(s), inc the use of a balloon or mechanical device (if X X utilized), two or more needles Posterior vertebral joint(s) arthroplasty (e.g. facet joint(s) replacement) inc facetectomy, laminectomy, foraminotomy and 0202T* Removed 11/07/2020 vertebral column fixation, with or without injection of bone X X cement, inc fluoroscopy, single level, lumbar spine Evacuation of meibomian glands, automated, using heat and 0207T* Removed 11/07/2020 intermittent pressure, unilateral X X 0208T* Pure tone audiometry (threshold), automated; air only Removed 11/07/2020 X X 0209T* Pure tone audiometry (threshold), automated; air and bone Removed 11/07/2020 X X 0210T* Speech audiometry threshold, automated Removed 11/07/2020 X X All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Express Scripts, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2020 Cigna. Some content provided under license. 4 Complete /PHS+/ Basic Code Code Description Addition/Removal Preferred Standard Speech audiometry threshold, automated; with speech 0211T* Removed 11/07/2020 recognition X X Comprehensive audiometry threshold evaluation and speech 0212T* Removed 11/07/2020 recognition (0209T, 0211T combined), automated X X All markets are effective Injection(s), diagnostic or therapeutic agent, paravertebral facet with eviCore healthcare 0213T (zygapophyseal) joint (or nerves innervating that joint) with except for Hawaii, X ultrasound guidance, cervical or thoracic; single level Puerto Rico and Guam All markets are effective Injection(s), diagnostic or therapeutic agent, paravertebral facet with eviCore healthcare (zygapophyseal) joint (or nerves innervating that joint) with 0214T except for Hawaii, X ultrasound guidance, cervical or thoracic; second
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