Look-Up Tool: Prior Authorization HCPCS Code

bmchp.org | 888-566-0008 BMCHP Prior Authorization HCPCS Code Look-up Tool

TO FIND A CODE OR WORD - While holding The Plan requires prior authorization for ALL inpatient services. down the CTRL key, press Many outpatient Medical Services require prior authorization. the F key, type in Code, then press ENTER key ALL services rendered by Out of Network providers require prior authorization with limited exceptions.

For Pharmacy inquiries please see the Pharmacy section on BMCHP.org For Behavioral Health, DME, Radiology and Transportation providers, please see our Prior Authorization/Notification Requirements Matrix for authorization details and how to work with our vendors. Please refer to the Provider Manual Section 8: Utilization Management and Prior Authorization for information regarding authorizations.

This is not a comprehensive list of every code available. Code updates occur periodically and may be implemented at different intervals than the updates to this code tool. This code tool is only provided as a guide for authorization status and addition or omission of a code does not guarantee payment: 1. This tool cannot confirm member eligibility. 2. This tool cannot confirm member benefits/coverage. Please refer to the Member’s Benefit Documents. 3. This tool cannot confirm payment rules, edits, fee schedules and restrictions that may affect code/claim payment even if authorization is obtained. The plan applies standard industry billing and coding rules to claims. Please refer to the Plan Payment Policies. 4. This code tool cannot confirm provider contract terms. Please reach out to your provider representative.

Prior authorization or Plan notification is required for services listed in the Prior Authorization/Notification Requirements Matrix even if a specific code is not listed in the code look-up tool.

Please contact the BMCHP Prior Authorization Team at 888-566-0008 and Press 3 for questions related to authorization requirements for codes that may or may not be listed in this tool.

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 1 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

PA REQUIRED for any HCPCS code used w/TMJ DX Codes M26.60-69 UPDATED 9/17/2021 Please review carefully for changes Please review all disclaimers and information on the first page of this code look-up tool before and/or after your code search

A0021 AMB SRVC OTSD STATE-MILE TRANSPORT MH QHP SCO Yes No No Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0080 NONEMERG TRNSPRT VOLUN NOT VESTED MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0100 NONEMERGENCY TRANSPORTATION; TAXI MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0110 NONEMERG TRNSPRT&BUS INTERSTATE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0120 NONEMERG TRNSPRT: MINI-BUS MTN/OTH MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0130 NONEMERG TRNSPRT: WHEELCHAIR VAN MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0140 NONEMERG TRNSPRT & AIR TRAVEL MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0160 NONEMERGENCY TRANSPORTATIONI MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 2 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A0170 TRNSPRT ANCILLRY: PARK FEE TOLL OTH MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0180 NONEMERGENCY TRANSPORTATION MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0190 NONEMERGENCY TRANSPORTATION MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0200 NONEMERG TRNSPRT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0210 NONEMERG TRNSPRT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0380 BLS MILEAGE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0382 BLS ROUTINE DISPOSABLE SUPPLIES MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0384 BLS SPCLIZED SRVC DISPBL SPL; DEFIB MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0420 AMB WAITING TIME 1/2 HR INCREMENTS MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix.

A0422 AMB OXYGEN&O2 SPL LIFE SUSTAINING MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix.

A0425 GROUND MILEAGE PER STATUTE MILE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix.

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 3 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A0426 AMB SRVC ALS NONEMERG TRNSPRT LVL 1 MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0428 AMB SERVICE BLS NONEMERG TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0433 ADVANCED LIFE SUPPORT LEVEL 2 MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0434 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0435 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0436 SPECIALTY CARE TRANSPORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

A0998 AMBULANCE RSPN&TREATMENT NO MH QHP SCO TRNSPRT Yes Yes No Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

A0999 UNLISTED AMBULANCE SERVICE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 4 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4206 SYRINGE W/NEEDLE STERIL 1 CC/< EACH MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4207 SYRINGE W/NEEDLE STERILE 2 CC EACH MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4208 SYRINGE W/NEEDLE STERILE 3 CC EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4209 SYRINGE W/NEEDLE STERILE 5 CC/> EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4210 NEEDLE-FREE INJECTION DEVICE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4211 SUPPLIES SELF-ADMINED INJECTIONS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4212 NONCORING NEEDLE/STYLET W/WO CATH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 5 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4213 SYRINGE STERILE 20 CC/GREATER EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4215 NEEDLE STERILE ANY SIZE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4216 STERL H2O SALINE & OR DXT DIL 10 ML MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4217 STERILE WATER/SALINE 500 ML MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4218 STERL SALINE/WATR METRD DOSE 10 ML MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4220 REFILL KIT IMPLANTABLE INFUS PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4221 SUPPLIES FOR MAINT NON-INS RX INFUS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CATH PER WK No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 6 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4222 INFUS SPL EXT RX INFUS PUMP CAS/BAG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4223 INFUS SPL NO EXT INFUS PUMP CAS/BAG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4224 SPL MAINT INSULIN INFUS CATH PER WK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4225 SPL EXT INS INF PMP SYR T CART ST E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4230 INFUS SET EXT INSULIN PUMP NONNDLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4231 INFUS SET EXT INSULIN PUMP NEEDLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4232 SYRINGE NDLE EXT INSULIN PUMP STERL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 7 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4233 REPL BATT ALK NOT J CELL HOM BG MON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4234 REPL BATT ALK J CELL HOM BG MON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4235 REPL BATT LITHIUM HOM BG MON OWN PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4236 REPL BATT SILVER OXIDE HOM BG MON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4244 ALCOHOL OR PEROXIDE PER PINT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4245 ALCOHOL WIPES PER BOX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4246 BETADINE/PHISOHEX SOLUTION PER PINT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 8 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4247 BETADINE/IODINE SWABS/WIPES PER BOX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4248 CHLORHEXIDINE CONTAINING ANTISEPTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4250 URINE TEST/REAGENT STRIPS/TABLETS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4252 BLOOD KETONE TEST/REAGENT STRIP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4253 BLD GLU TST/REAGT STRIPS HOM MON-50 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4255 PLATFORMS HOM BLD GLU MON 50-BOX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4256 NORMAL LOW&HI CALIBRATOR SOL/CHIPS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 9 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4257 REPL LENS SHIELD CARTRIDGE LASR SKN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4258 SPRING-POWERED DEVICE LANCET EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4259 LANCETS PER BOX OF 100 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4265 PARAFFIN PER POUND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4280 ADHES SKN SUPP ATTCH BRST PROSTH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4281 TUBING FOR BREAST PUMP REPLACEMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4282 ADAPTER FOR BREAST PUMP REPLACEMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 10 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4283 CAP BREAST PUMP BOTTLE REPLACEMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4284 BRST SHIELD&SPLSH PROTCTR PUMP REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4285 POLYCARBATE BOTTLE BREAST PUMP REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4286 LOCKING RING BREAST PUMP REPLACMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4290 SACRAL NERVE STIM TEST LEAD EACH MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

A4310 INSRTION TRAY W/O DRN BAG&W/O CATH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4311 INSRTION TRAY W/O BAG 2-WAY LATEX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 11 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4312 INSRTION TRAY W/O BAG 2-WAY SILCON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4313 INSRT TRAY W/O BAG 3-WAY CNT IRRIG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4314 INSRTION TRAY W/BAG 2-WAY LATEX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4315 INSRTION TRAY W/BAG 2-WAY SILCON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4316 INSRTION TRAY W/BAG 3-WAY CONT IRRG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4320 IRRIG TRAY W/BULB/PISTON SYRINGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4321 THERAPEUTIC AGT URIN CATH IRRIG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 12 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4322 IRRIGATION SYRINGE BULB/PISTON EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4326 MALE EXT CATH CLCT CHAMB ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4327 FE EXT URIN CLCT DEVC; METL CUP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4328 FE EXT URIN CLCT DEVICE; POUCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4330 PERIAN FECAL CLCT POUCH W/ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4331 EXT DRN TUBING W/CNCTOR/ADAPTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4332 LUBRICNT INDIVIDUAL STERL PACKET EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 13 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4333 URIN CATH ANCHR DEVC ADHES ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4334 URIN CATH ANCHR DEVICE LEG STRAP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4335 INCONTINENCE SUPPLY; MISCELLANEOUS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4336 INCONT SUPPLY URETHRAL INSERT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4338 INDWLL CATH; 2-WAY LATEX W/COAT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4340 INDWELL CATHETER; SPECIALTY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4344 INDWLL CATH FOLEY 2-WAY SILCON EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 14 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4346 INDWLL CATH; FOLY 3-WAY CONT IRRIG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4349 MALE EXT CATH W/WO ADHES DISPBL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4351 INTERMIT URIN CATH; STRAIT TIP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4352 INTERMIT URIN CATH; COUDE TIP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4353 INTERMIT URIN CATH W/INSERTION SPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4354 INSRTION TRAY W/DRN BAG W/O CATH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4355 IRRIG TUBING CONT 3-WAY CATH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 15 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4356 EXT URETHRAL CLAMP/COMPRS DEVICE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4357 BEDSID DRN BAG DAY/NGT W/WO TUBE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4358 URINARY LEG BAG; VINYL W/WO TUBE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4360 DISP EXT URETHRAL CLAMP/COMP DEV EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4361 OSTOMY FACEPLATE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4362 SKN BARRIER; SOLID 4X4/EQUVALNT; EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4363 OSTOMY CLAMP ANY TYPE REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 16 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4364 ADHES LIQUID/EQUAL ANY TYPE-OUNCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4366 OSTOMY VENT ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4367 OSTOMY BELT EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4368 OSTOMY FILTER ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4369 OSTOMY SKIN BARRIER LIQUID PER OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4371 OSTOMY SKIN BARRIER POWDER PER OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4372 OST SKIN BARR SOL 4X4/EQUV STD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 17 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4373 OST SKN BARR W/FLNGE BUILT-IN CONVX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4375 OST POUCH DRNABLE W/FCEPLAT PLST EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4376 OST POUCH DRNABLE W/FCEPLAT RUBR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4377 OST POUCH DRNABLE FCEPLAT PLSTC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4378 OST POUCH DRAINABLE FCEPLAT RUBR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4379 OST POUCH URIN W/FCEPLAT PLSTC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4380 OST POUCH URIN W/FCEPLAT RUBR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 18 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4381 OST POUCH URIN USE FCEPLAT PLSTC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4382 OST POUCH URIN FCEPLAT HVY PLSTC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4383 OST POUCH URIN USE FCEPLAT RUBR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4384 OST FCEPLAT EQUVALNT SILCON RING EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4385 OST SKN BARRIER 4X4 EXT W/O CONVXTY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4387 OST POUCH CLOS BARR BUILT-IN CONVX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4388 OST POUCH DRNABL W/EXT WEAR BARR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 19 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4389 OST POUCH DRNBL BARR BUILT-IN CONVX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4390 OST POUCH DRNABLE EXT W/CONVXITY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4391 OST POUCH URIN W/EXT WEAR BARR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4392 OST POUCH URIN STD W/CONVXITY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4393 OST POUCH URIN EXT W/CONVXITY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4394 OSTOMY DEODORANT W/WO LUB PER FL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. OZ No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4395 OST DEODORANT OST POUCH SOLID-TAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 20 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4396 OSTOMY BELT W/PERISTOMAL HERN SUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4397 IRRIGATION SUPPLY; SLEEVE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4398 OSTOMY IRRIGATION SUPPLY; BAG EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4399 OST IRRIG SPL; CONE/CATH W/WO BRUSH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4400 OSTOMY IRRIGATION SET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4402 LUBRICANT PER OUNCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4404 OSTOMY RING EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 21 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4405 OST SKN BARRIER NONPECTIN PASTE-OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4406 OST SKN BARRIER PECTIN PASTE-OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4407 OST SKN BARRIER W/CONVXITY 4X4 IN/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4408 OST SKN BARRIER W/CONVXITY > 4X4 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4409 OST SKN BARR EXT W/O CONVX 4X4 IN/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4410 OST SKN BARR EXT W/O CONVX >4X4 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4411 OST SKN BARR SOLID 4X4/EQ W/CONVXTY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 22 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4412 OST POUCH DRNBL BARR FLNGE W/O FLTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4413 OST POUCH DRNABL BARRIER FLNGE/FLTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4414 OST SKN BARRIER W/O CONVX 4X4 IN/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4415 OST SKN BARRIER W/O CONVX >4X4 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4416 OST POUCH CLO BARR ATTCH W/FILTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4417 OST POUCH CLO BARR W/BLT-IN CONVXIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4418 OST POUCH CLOS; W/O BARR W/FILTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 23 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4419 OST POUCH CLOS; BARRIER W/NON-LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4420 OST POUCH CLO;USE BARR LOCK FLNG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4421 OSTOMY SUPPLY; MISCELLANEOUS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4422 OST ABSORB MATL THICKN LQD STOML OP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4423 OST POUCH CLOS; BARR W/LOCK FLNG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4424 OST POUCH DRNBL BARR ATTCH FILTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4425 OST POUCH DRNBL; BARR NON-LOCK FLNG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 24 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4426 OST POUCH DRNBL;BARR W/LOCK FLNG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4427 OST POUCH DRN;BARR LOCK FLNG FLTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4428 OST POUCH URIN W/FAUCET TAP W/VALVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4429 OST POUCH URIN W/BLT-IN CONVX VALVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4430 OST POUCH URN BLT-IN CNVX FAUCT VLV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4431 OST POUCH URIN;BARR FAUCT TAP VLV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4432 OST POUCH URN;NO-LCK FLNG FAUCT VLV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 25 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4433 OST POUCH URIN; BARR W/LOCK FLNG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4434 OST POUCH URN;LOCK FLNG FAUCT VLV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4435 OST POUCH DRN HI OP EXT WR BARR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4450 TAPE NON-WATERPROOF 18 SQUARE IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4452 TAPE WATERPROOF PER 18 SQUARE IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4455 ADHESIVE REMOVER/SOLVENT PER OUNCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4456 ADHESIVE REMOVER WIPES ANY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 26 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4458 ENEMA BAG WITH TUBING REUSABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4459 MAN PUMP-OP ENEMA SYS REUSE ANY TYP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4461 SURG DRESSING HOLDR NON-REUSABLE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4463 SURG DRESSING HOLDER REUSABLE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4465 NONELASTIC BINDER FOR EXTREMITY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4466 GARMENT BELT SLEEVE OTH ELASTIC EA MH QHP SCO

Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4467 BELT STRAP SLV GARMENT/COV ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 27 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4470 GRAVLEE JET WASHER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4480 VABRA ASPIRATOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4481 TRACHEOSTOMA FLTR TYPE SZ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4483 MOISTR EXCHGR DISPBL W/INVASV VENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4490 SURG STOCKING ABOVE KNEE LENGTH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4495 SURGICAL STOCKING THIGH LENGTH EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4500 SURG STOCKING BELOW KNEE LENGTH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 28 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4510 SURGICAL STOCKING FULL-LENGTH EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4520 INCONTINENCE GARMENT ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4550 SURGICAL TRAYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4553 NON-DISPOSABLE UNDERPADS ALL SIZES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4554 DISPOSABLE UNDERPADS ALL SIZES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4555 E/TRANSDUCR E-STIM U CA TX RPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4556 ELECTRODES PER PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 29 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4557 LEAD WIRES PER PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4558 CONDUCTVE GEL/PASTE USE W/ELEC DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4559 COUPLING GEL/PASTE W/US DEVC PER OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4561 PESSARY RUBBER ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4562 PESSARY NON RUBBER ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4565 SLINGS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4566 SHOULDR SLING/VEST ABD RSTRN PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 30 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4570 SPLINTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4575 TOPICAL HYPRBR OXYGEN CHAMB DISPBL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Eff 12/1/20)

A4580 CAST SUPPLIES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4590 SPECIAL CASTING MATERIAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4595 ELEC STIM SUPPLIES 2 LEAD PER MONTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4600 SLEEVE INTERMITT LIMB COMP REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 31 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4601 LIB RECHARG NONPROSTHETIC USE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4602 REPL BA EXT IP OWND PT LI 1.5 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4604 TUBING W/INTGR HEAT ELEM W/PAP DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4605 TRACHEAL SUCTION CATH CLOS SYS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4606 O2 PROBE W/OXIMETER DEVICE REPLCMT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4608 TRANSTRACHEAL OXYGEN CATHETER EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4611 BATTRY HEVY DUTY; REPL PT-OWND VENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 32 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4612 BATTRY CABLES; REPL PT-OWNED VENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4613 BATTRY CHARGER; REPL PT-OWNED VENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4614 PEAK EXPIRATORY FLW METER HAND HELD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4615 CANNULA NASAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4616 TUBING PER FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4617 MOUTHPIECE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4618 BREATHING CIRCUITS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 33 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4619 FACE TENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4620 VARIABLE CONCENTRATION MASK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4623 TRACHEOSTOMY INNER CANNULA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4624 TRACHEAL SUCTN CATH NOT CLOS SYS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4625 TRACHEOST CARE KIT NEW TRACHEOST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4626 TRACHEOSTOMY CLEANING BRUSH EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4627 SPACR BAG/RESRVOR METRD DOSE INHAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 34 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4628 OROPHARYNGEAL SUCTION CATHETER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EACH No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4629 TRACHEOST CARE KIT EST TRACHEOST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4630 REPL BATTRY TRNSQ ELEC STIM OWND PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4633 REPLCMT BULB/LAMP UV LGHT TX SYS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4634 REPLCMT BULB TX LGHT BOX TABOP MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4635 UNDERARM PAD CRUTCH REPLACEMENT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4636 REPL HANDGRIP CANE CRTCH/WALKER EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 35 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4637 REPL TIP CANE CRUTCH WALKER EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4638 REPL BATT PT-OWND EAR PULSE GEN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4639 REPL PAD INFRARD HEATING PAD SYS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4640 REPL PAD W/ALTRNAT PRSS PAD OWND PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4641 RADIOPHARMACEUTICAL DIAGNOSTIC NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4642 IN-111 SATUMOMB PENDETID DX TO 6MCI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4648 TISSUE MARKER IMPLANTBL ANY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 36 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4649 SURGICAL SUPPLY; MISCELLANEOUS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4650 IMPLANTABLE RADIATION DOSIMETER EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4657 SYRINGE WITH OR WITHOUT NEEDLE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4660 SPHYGMOMANOMETER/BP W/CUFF&STETH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4663 BLOOD PRESSURE CUFF ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4670 AUTOMATIC BLOOD PRESSURE MONITOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4927 GLOVES NON-STERILE PER 100 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 37 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A4928 SURGICAL MASK PER 20 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4930 GLOVES STERILE PER PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4931 ORL THERMOMETER REUSBL ANY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A4932 RECTAL THERMOMETER REUSBL TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5051 OST POUCH CLOS; W/BARRIER ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5052 OST POUCH CLOS; W/O BARR ATTACH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5053 OSTOMY POUCH CLOS; USE FACEPLATE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 38 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5054 OST POUCH CLOS; BARRIER W/FLNGE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5055 STOMA CAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5056 OST POUCH DRAIN EXT BARRIER FLTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5057 OST POUCH DRAIN BARR CONVX FLTR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5061 OST POUCH DRNABLE; W/BARR ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5062 OST POUCH DRNABL; W/O BARR ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5063 OST POUCH DRNABLE; BARR W/FLNGE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 39 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5071 OST POUCH URIN; W/BARRIER ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5072 OST POUCH URIN; W/O BARR ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5073 OST POUCH URIN; BARRIER W/FLNGE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5081 STOMA PLUG OR SEAL ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5082 CONTINENT DEVC;CATH CONTINENT STOMA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5083 CONT DEVICE STOMA ABSORPTIVE COVER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5093 OSTOMY ACCESSORY; CONVEX INSERT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 40 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5102 BEDSIDE DRN BOTTLE W/WO TUBING EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5105 URIN SUSPENSRY LEG BAG W/WO TUBE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5112 URINARY DRAIN BAG LEG/ABD LATEX EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5113 LEG STRAP; LATEX REPLCMT ONLY-SET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5114 LEG STRAP; FOAM/FABRIC REPL-SET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5120 SKIN BARRIER WIPES OR SWABS EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5121 SKN BARRIER; SOLID 6X6/EQUVALNT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 41 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5122 SKN BARRIER; SOLID 8X8/EQUVALNT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5126 ADHES/NON-ADHES; DISK/FOAM PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5131 APPLINC CLNR INCONT&OST APPLN-16 OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5200 PERQ CATH/TUBE ANCHR DEVC ADHES SKN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5500 DM ONLY CSTM PREP SHOE MX DNS INSRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5501 DM ONLY CSTM PREP SHOE MOLD PTS FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5503 DM ONLY MOD SHOE/CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. ROLLER/ROCKER No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 42 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5504 DM ONLY MOD SHOE/CSTM W/WEDGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SHOE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5505 DM ONLY MOD SHOE/CSTM W/MT BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SHOE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5506 DM ONLY MOD SHOE/CSTM OFF SET HEEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5507 DM ONLY NOS MOD SHOE/CSTM MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SHOE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5508 DM ONLY DELUX FEATUR SHOE/CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. MOLD No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5510 DIAB ONLY DIR FORM COMPRS MOLD FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A5512 FOR DIAB ONLY MX DNSITY INSRT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 43 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A5513 FOR DIAB ONLY MX DNSITY INSRT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6000 NON-CNTC WND WARMING COVR W/DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6010 COLLEGEN WOUND FILLR DRY FORM PER G MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6011 COLLEGEN WOUND FIL GEL/PASTE PER G MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6021 COLL DRESS PAD SIZE 16 SQ/LESS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6022 COLL DRSG STRL>16 BUT

A6023 COLL DRSG STERILE SZ >48 SQ IN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 44 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6024 COLL DRESS WND FIL STERL PER 6 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6025 GEL SHEET DERMAL/EPIDRMAL APPLIC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6154 WOUND POUCH EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6196 ALGINAT/OTH FIBR GELL PAD 16 SQ/

A6197 ALGINAT/OTH FIBR GELL >16<=48 SQEA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6198 ALGINAT/OTH FIBR GELL PAD >48 SQ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6199 ALGINAT/OTH FIBR GELL DRESS FIL-6IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 45 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6203 COMPOS DRESS 16 SQ/< W/ADHES BORDR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6204 COMPOS DRESS >16 <=48 SQ W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6205 COMPOS DRESS >48SQ W/ADHES BORDR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6206 CNTCT LAYR STERL 16 SQ IN/

A6207 CNTC LAYER > 16 SQ BUT <= 48 SQ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6208 CONTACT LAYER > 48 SQ EACH DRESSING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6209 FOAM DRESS STERL 16 SQ/< NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 46 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6210 FOAM DRESS >16 <=48SQ W/O ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6211 FOAM DRESS STERL > 48 SQ NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6212 FOAM DRESS 16 SQ/< W/ADHES BORDR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6213 FOAM DRESS >16 <= 48 SQ W/ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6214 FOAM DRESS > 48 SQ W/ADHES BORDR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6215 FOAM DRESSING WOUND FIL STERL PER G MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6216 GAUZE NON-IMPREG NONSTERL 16 SQ/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 47 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6217 GAUZE NON-IMPREG NONSTRL >16<=48SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6218 GAUZE NON-IMPREG NONSTERL > 48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6219 GAUZE NON-IMPREG STERL 16 SQ/

A6220 GAUZE NON-IMPREG >16 <=48 SQ ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6221 GAUZE NON-IMPREG > 48 SQ W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6222 GAUZ IMPREG NOT H2O/HYDRGEL 16 SQ/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6223 GAUZ IMPREG NOT H2O/HYDRGL >16<=48 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 48 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6224 GAUZ IMPREG NOT H2O/HYDROGEL >48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6228 GAUZ IMPREG WATR/NL SALINE > 16 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6229 GAUZ IMPREG WATR/SALINE >16<=48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6230 GAUZ IMPREG H2O/SALINE STERL >48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6231 GAUZ IMPREG HYDRGEL DIR WND 16 SQ/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6232 GAUZ IMPREG HYDRGEL DIR >16 <= 48 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6233 GAUZ IMPREG HYDRGEL DIR WND > 48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 49 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6234 HYDRCOLLOID DRESS 16 SQ/< W/O ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6235 HYDRCOLLOID DRESS >16<=48 NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6236 HYDROCOLLOID DRESS >48 SQ W/O ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6237 HYDROCOLLOID DRESS 16 SQ/< W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6238 HYDRCOLLOID DRESS >16<= 48 W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6239 HYDROCOLLOID DRESS > 48 SQ W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6240 HYDROCOLLOID DRESS FIL PASTE-FL OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 50 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6241 HYDROCOLLOID DRESS DRY FORM PER G MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6242 HYDROGEL DRESS 16 SQ/< W/O ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6243 HYDROGEL DRESS >16 <=48SQ NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6244 HYDROGEL DRESS > 48 SQ W/O ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6245 HYDROGEL DRESS 16 SQ/< W/ADHES EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6246 HYDROGEL DRESS >16 <=48 SQ W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6247 HYDROGEL DRESS STERL >48 SQ ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 51 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6248 HYDROGEL DRESS WOUND FIL GEL FL OZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6250 SKN SEALNT PROTCT MOISTURZR OINTMNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6251 SPCLTY ABSORB DRESS 16SQ/< NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6252 SPCL ABSORB DRESS >16<=48 NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6253 SPCLTY ABSORB DRESS >48 SQ NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6254 SPCLTY ABSORB DRESS 16 SQ/< W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6255 SPCL ABSORB DRESS >16<= 48 W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 52 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6256 SPCLTY ABSORB DRESS > 48 SQ W/ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6257 TRNSPRT FILM STERL 16 SQ/< EA DRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6258 TRNSPRT FILM >16 SQ BUT <=48 SQ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6259 TRNSPRT FILM STERL > 48 SQ EA DRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6260 WOUND CLEANSERS ANY TYPE ANY SIZE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6261 WOUND FILLR GEL/PASTE PER FL OZ NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6262 WOUND FILLER DRY FORM PER G NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 53 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6266 GAUZ IMPRG NOT H2O SAL/ZINC LINR YD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6402 GAUZ NON-IMPREG STERL 16 SQ/< NO AD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6403 GAUZ NON-IMPREG STERL >16 <= 48 SQ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6404 GAUZ NON-IMPREG STRL >48SQ NO ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6407 PACK STRIPS NON-IMPREGNTD UP 2 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6410 EYE PAD STERILE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6411 EYE PAD NON-STERILE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 54 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6412 EYE PATCH OCCLUSIVE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6413 ADHESIVE BANDAGE FIRST-AID TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6441 PADD BANDGE NON-ELAST NON- MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. WOVEN/NON No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6442 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6443 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6444 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6445 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 55 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6446 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6447 CONFORMING BANDGE NON-ELAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNITTED No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6448 LT COMPRS BANDGE ELAST WDTH < 3 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6449 LT COMPRS BANDGE WDTH >/= 3 & <5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6450 LT COMPRS BANDGE WDTH >/= 5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6451 MOD COMPRS BANDGE WD >/= 3 & <5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6452 HI COMPRS BANDGE WD >/= 3 & <5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 56 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6453 SELF-ADHERENT BANDGE WDTH

A6454 SLF ADHERNT BANDGE WD >/= 3 & <5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6455 SELF-ADHERENT BANDGE WDTH >/= 5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6456 ZINC PAST BANDGE WD >/= 3 & <5 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6457 TUBULR DRSG W/WO ELAST WDTH LINR YD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6501 COMPRS BURN GARMNT BDYSUIT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FAB No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6502 COMPRS BRN GARMNT CHIN STRAP CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 57 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6503 COMPRS BRN GARMNT FCE HOOD CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FAB No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6504 COMPRS BRN GARMNT GLOV WRST CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6505 COMPRS BRN GARMNT GLOV ELB CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6506 COMPRS BURN GARMNT GLOV AX CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FAB No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6507 COMPRS BRN GARMNT FT KNEE LEN CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6508 COMPRS BRN GARMNT FT THI LEN CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6509 COMPRS BRN GARMNT TRNK WAIST CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 58 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6510 COMPRS BRN GARMNT TRNK ARM LEG OPN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6511 COMPRS BRN GARMNT LW TRNK LEG OPN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6512 COMPRESSION BURN GARMENT NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6513 COMPRS BRN MASK FCE&/NCK PLSTC/EQUL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6530 GRADIENT COMPRS STK BK 18-30 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6531 GRADIENT COMPRS STK BK 30-40 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6532 GRADIENT COMPRS STK BK 40-50 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 59 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6533 GRADENT COMPRS STK THIGH 18-30 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6534 GRADENT COMPRS STK THIGH 30-40 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6535 GRADENT COMPRS STK THIGH 40-50 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6536 GRADENT COMPRS STK FULL 18-30 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6537 GRADENT COMPRS STK FULL 30-40 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6538 GRADENT COMPRS STK FULL 40-50 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6539 GRADENT COMPRS STK WAIST 18-30 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 60 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A6540 GRADENT COMPRS STK WAIST 30-40 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6541 GRADENT COMPRS STK WAIST 40-50 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6544 GRADENT COMPRESSION STK GARTER BELT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6545 GRD CMPRS WRP NONELST BK 30-50 MMHG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6549 GRADIENT COMP STOCKING/SLEEVE NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A6550 WND CARE SET NEG PRSS WND TX PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7000 CANISTER DISPBL USED W/SUCTN PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 61 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7001 CANISTR NONDISPBL USED W/SUCTN PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7002 TUBING USED WITH SUCTION PUMP EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7003 ADMN SET SM VOL NONFILTR NEB DISPBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7004 SM VOL NONFILTR PNEUMAT NEB DISPBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7005 ADMN SET SM VOL NONFLTR NEB NONDISP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7006 ADMN SET W/SM VOL FILTR NEBULIZR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7007 LG VOL NEBULIZR DISPBL UNFIL COMPRS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 62 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7008 LG VOL NEBULIZR DISPBL PRFIL COMPRS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7009 RESRVOR BOTTLE LG VOL US NEBULIZR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7010 CORUG TUBE DISPBL LG VOL NEB 100 FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7012 WATER COLLEC DEV USE W/LG VOL NEB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7013 FILTER DISP W/AREO COMPRESS/US GEN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7014 FLTR NON-DISPBL AROSL COMPRS/US GEN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7015 AREO MASK USED W/ DME NEB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 63 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7016 DOME&MOUTHPECE W/SM VOL US MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. NEBULIZR No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7017 NEB GLASS/AUTOCLAV NOT USE W/O2 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7018 H2O DIST USE W/LG VOL NEB 1000 ML MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7020 INTERFACE COUGH STIM DEVC REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7025 HI FREQ CHST WALL OSCILAT VEST REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7026 HI FREQ CHST WALL OSCILAT HOSE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7027 COMB ORAL/NASAL MASK W/CPAP EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 64 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7028 ORAL CUSH ORAL/NASAL MASK REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7029 NASL PILLOW ORL/NASL MASK REPL PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7030 FULL FCE MASK POS ARWAY PRSS DEV EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7031 FCE MASK INTERFCE REPL FULL MASK EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7032 CUSHN NASAL MASK INTF REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7033 PILLW NASL CANNULA TYPE INTF REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7034 NASL INTERFCE POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 65 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7035 HEADGEAR USED W/POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7036 CHINSTRAP USE W/POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7037 TUBING USED W/POS ARWAY PRESS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7038 FLTR DISPBL W/POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7039 FLTR NON DISPBL POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7040 ONE WAY CHEST DRAIN VALVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7041 WATER SEAL DRNAGE CONTAINER&TUBING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 66 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7044 ORL INTERFCE W/POS ARWAY PRSS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7045 EXHALATION PORT REPLACEMENT ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7046 WATR CHAMB HUMDIFIR USED W/POS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. ARWA No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7501 TRACHEOSTOMA VALV INCL DIAPHRAGM EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7502 REPL DIAPH/FCEPLAT TRACHESTOMA VALV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7503 FLTR HOLDER/CAP REUSBL TRACHEOSTOMA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7504 FLTR USE TRACHEOSTOMA EXCHG SYS EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 67 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7505 HOUS REUSABL W/O ADHES EXCHG SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7506 ADHES DISC EXCHG SYS&/ W/TRACH VALV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7507 FLTR HLDR&INTGR FLTR TRACHEOSTOMA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7508 HOUS&INTGR ADHES EXCHG SYS &/ VALV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7509 FLTR HLDR&INTGR FLTR HOUS&ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7520 TRACHEOST/LARYNGECT TUBE NON-CUFFED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7521 TRACHEOST/LARYNGECT TUBE CUFF PVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 68 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A7522 TRACHEOST/LARYNGECT TUBE STNLESS ST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7523 TRACHEOSTOMY SHOWER PROTECTOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EACH No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7524 TRACHEOSTOMA STENT/STUD/BUTTON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EACH No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7525 TRACHEOSTOMY MASK EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7526 TRACHEOSTOMY TUBE COLLAR/HOLDER EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A7527 TRACHEOST/LRYNGCT TUBE PLUG/STOP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A8000 HELMET PROTECTIVE SOFT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 69 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A8001 HELMET PROTECTIVE HARD PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A8002 HELMET PROTECTIVE SOFT CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A8003 HELMET PROTECTIVE HARD CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A8004 SOFT INTERFACE FOR HELMET REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9270 NONCOVERED ITEM OR SERVICE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9272 WND SCTN DISPBL DRSG ACC ANY TYP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9273 HOT WATER BOTTLE ICE CAP/COLLAR ANY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 70 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A9274 EXT AMB INSULIN DEL SYS DISPOSBL EA MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

A9275 HOME GLU DISPBL MON W/TEST STRIPS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9276 SENSOR; INVSV INTRSTL GLU MON SYS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

A9277 TRANSMTR; EXT INTRSTL CONT GLU MON MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

A9278 RECEIVER MON; EXT INTRSTL GLU MON MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

A9279 MON FEATURE/DEVC ALONE/INTEGRAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. NOC No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 71 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A9280 ALERT OR ALARM DEVICE NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9281 REACH/GRABBING DEVC ANY TYPE/LEN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9282 WIG ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9283 FOOT PRESSURE OFF LOAD/SUPP DEV EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9284 SPIROMETER NONELECTRONC INCL ACCESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9285 INVERSION/EVERSION CORRECTION DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9286 HYG I/DVC DISPBL/NON-DISPBL ANY T E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 72 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A9300 EXERCISE EQUIPMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9515 CHOLINE C-11 DX STUDY DOS TO 20 MCI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9529 I-131 SODIM IODIDE SOL DX PER MCI MH QHP SCO No No

A9587 GALLIUM GA-68 DOTATATE DX 0.1 MCI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9588 FLUCICLOVINE F-18 DIAGNOSTIC 1 MCI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9597 PET RADIOPHARMA DX TUMOR ID NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9598 PET RADIOPHARM DX NON-TUMOR ID NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9900 DME SUP/ACCESS/SRV-COMPON/OTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. HCPCS No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 73 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

A9901 DME DEL SET&/DSPNS SRVC ANOTH HCPCS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

A9999 MISCELLANEOUS DME SUPPLY/ACCESS NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4081 NASOGASTRIC TUBING WITH STYLET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4082 NASOGASTRIC TUBING WITHOUT STYLET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4083 STOMACH TUBE - LEVINE TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4087 GASTROSTOMY/J-TUBE STANDARD EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4088 GASTROSTOMY/J-TUBE LOW-PROFILE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 74 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B4100 FOOD THICKENER ADMINED ORALLY-OUNCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B4102 ENTRAL F ADLT REPL FL&LYTES 500 ML MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4103 ENTRAL F PED REPL FL&LYTES 500 ML MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4104 ADDITIVE FOR ENTERAL FORMULA MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 75 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B4105 IN-LINE CART CTG DIG ENZYME EF EACH MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4149 ENTRAL F MANF BLNDRIZD NAT FOODS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4150 ENTRAL F NUTRITIONALLY COMPLETE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4152 ENTRAL F NUTRITION CMPL CAL DENSE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 76 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B4153 ENTRL F NUTRTN CMPL HYDROLYZD PROTS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4154 ENTRAL F CMPL NO INHERITED DZ METAB MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4155 ENTRAL F NUTRITN INCMPL/MOD NUTRNTS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4157 ENTRAL F CMPL INHERITED DZ METAB MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 77 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B4158 ENTRAL F PED NUTRITION COMPLETE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4159 ENTRAL F PED NUTRITN CMPL SOY BASD MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4160 ENTRAL F PED NUTRITN CMPL CAL DENSE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B4161 ENTRAL F PED HYDROLYZED/AA PROTEINS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 78 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B4162 ENTRAL F PED INHERITED DZ METAB MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 10/1/20) Retired 10/31/21 Enteral Nutrition (Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges (Eff 11/1/21)

B9000 ENTERAL NUT INFUS PUMP - W/O ALARM MH QHP SCO

Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B9002 ENTERAL NUTR INFUSION PUMP ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B9004 PARNTRAL NUTRIT INFUS PUMP PRTBLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B9006 PARNTRAL NUTRIT INFUS PUMP STATION MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

B9998 NOC FOR ENTERAL SUPPLIES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 79 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

B9999 NOC FOR PARENTERAL SUPPLIES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

C1062 Intravertebral fx aug impl MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No No Yes rationale for request (e.g., notes, lab values, X-rays, etc.). Policy: InterQual® criteria is available

C1821 INTER PROC DIST DEV IMP MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Minimally Invasive Procedures and Associated Devices used to Treat Back Pain Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Eff 6/1/21) Retired 8/31/21 Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Eff 9/1/21)

C1825 Gen, neuro, carot sinus baro MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C1849 SKIN SUBSTITUTE SYNTHETIC RESORBABLE MH QHP SCO Please review the BMCHP policy for authorization/criteria details PER SQ CM No No Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

C9076 Lisocabtagene maraleucal MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Car T-Cell Therapy to Treat Hematological Malignancies Car T-Cell Therapy to Treat Hematological Malignancies (Eff 5/1/21) Retired 10/31/21 Car T-Cell Therapy to Treat Hematological Malignancies (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 80 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

C9761 Cystourethroscopy, with ureteroscopy MH QHP SCO Please review the BMCHP policy for authorization/criteria details and/or pyeloscopy, with lithotripsy (ureteral No No Yes catheterization i Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C9769 Cystourethroscopy, with insertion of MH QHP SCO Please review the BMCHP policy for authorization/criteria details temporary prostatic implant/stent with No No Yes fixation/anchor and inci Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C9770 Vitrec/mech pars, subret inj MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab No No Yes values, X-rays, etc.) Policy: InterQual® criteria is available

C9771 Nsl/sins cryo post nasal tis MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C9772 Revasc lithotrip tibi/perone MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C9773 Revasc lithotr-stent tib/per MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 81 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

C9774 Revasc lithotr-ather tib/per MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

C9775 Revasc lith-sten-ath tib/per MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

E0100 CANE ALL MATL ADJUSTBLE/FIXED W/TIP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0105 CANE QUAD/3-PRONG ALL MATL W/TIPS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0110 CRTCHES FORARM VARIOUS MATL PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0111 CRTCH FORARM VARIOUS MATL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0112 CRTCHS UNDARM WOOD PAIR ADJSTBL/FIX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 82 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0113 CRTCH UNDARM WOOD EA ADJUSTBL/FIX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0114 CRTCHES UNDARM OTH THAN WOOD PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0116 CRTCH UNDARM OTH THAN WOOD ADJ/FIX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0117 CRTCH UNDERARM ARTIC SPRNG ASSTD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0118 CRUTCH SUBSTITUTE LW LEG PLATFORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0130 WALKER RIGID ADJUSTBLE/FIXED HEIGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0135 WALKER FOLDING ADJUSTBLE/FIX HEIGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 83 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0140 WALK W/TRNK SUPP ADJUSTBL/FIX HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0141 WALKER RIGID WHEELD ADJUSTBL/FIX HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0143 WALKER FOLD WHEELED ADJUSTBL/FIX HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0144 WALKER ENCLOS 4 SIDE WHL POST SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0147 WALKR HEVY DUTY MX BRAKE VARIBL WHL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0148 WALK HEVY DUTY NO WHLS RIGD/FOLD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0149 WALKER HEVY DUTY WHEELD ANY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 84 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0153 PLATFORM ATTCH FOREARM CRUTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0154 PLATFORM ATTACHMENT WALKER EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0155 WHL ATTCH PCK-UP WLK- PER PAIR SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0156 SEAT ATTACHMENT WALKER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0157 CRUTCH ATTACHMENT WALKER EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0158 LEG EXTENSIONS WALKER PER SET FOUR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0159 BRAKE ATTCH WHEELED WALK REPLCMT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 85 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0160 SITZ BATH/EQP PRTBLE W/WO COMMODE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0161 SITZ BATH/EQP PRTBLE USED W/FAUCET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0162 SITZ BATH CHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0163 COMMODE CHAIR WITH FIXED ARMS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0165 COMMODE CHAIR WITH DETACHABLE ARMS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0167 PAIL/PAN USE W/COMMODE CHAIR REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0168 COMMODE CHAIR XTRA WIDE&/HEVY DUTY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 86 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0170 COMMODE CHAIR SEAT LIFT MECH ELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0171 COMMODE CHAIR SEAT LIFT MCH NONELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0172 SEAT LIFT MECH PLACE OVR/TOP TOILET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0175 FOOT REST USE W/COMMODE CHAIR EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0181 PWR PRESS RED MATTRESS PAD W/PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0182 PUMP ALTERNATING PRESSURE PAD REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0184 DRY PRESSURE MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 87 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0185 GEL/GEL-LIKE PRSS PAD MATTRSS STD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0186 AIR PRESSURE MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0187 WATER PRESSURE MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0188 SYNTHETIC SHEEPSKIN PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0189 LAMBSWOOL SHEEPSKIN PAD ANY SIZE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0190 PSTN CUSH/PILLOW/EDGE ALL COMPONENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0191 HEEL OR ELBOW PROTECTOR EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 88 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0193 POWERED AIR FLOTATION BED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0194 AIR FLUIDIZED BED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0196 GEL PRESSURE MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0197 AIR PRSS PAD MATTRSS STD LEN&WDTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0198 WATR PRSS PAD MATTRSS STD LEN&WDTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0199 DRY PRSS PAD MATTRSS STD LEN&WDTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0200 HEAT LAMP W/O STAND W/INFRARD ELEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 89 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0202 PHOTOTHERAPY LIGHT WITH PHOTOMETER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0203 TX LTBOX MINI 10000 LUX TABLE TOP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0205 HEAT LAMP W/STAND W/INFRARD ELEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0210 ELECTRIC HEAT PAD STANDARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0215 ELECTRIC HEAT PAD MOIST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0217 WATER CIRCULATING HEAT PAD W/PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0218 WATER CIRCULATING COLD PAD W/PUMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 90 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0221 INFRARED HEATING PAD SYSTEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0225 HYDROCOLLATOR UNIT INCLUDES PADS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0231 NON-CNTC WND WARM DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. W/CARD&COVR No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0232 WOUND WARMING WOUND COVER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0235 PARAFFIN BATH UNIT PORTABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0236 PUMP FOR WATER CIRCULATING PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0239 HYDROCOLLATOR UNIT PORTABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 91 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0240 BATH/SHOWER CHAIR W/WO WHLS ANY SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0241 BATHTUB WALL RAIL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0242 BATHTUB RAIL FLOOR BASE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0243 TOILET RAIL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0244 RAISED TOILET SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0245 TUB STOOL OR BENCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0246 TRANSFER TUB RAIL ATTACHMENT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 92 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0247 TRNSF BENCH TUB/TOILET W/WO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. COMMODE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0248 TRNSF BENCH HEVY DUTY TUB/TOILET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0249 PAD H2O CIRC HEAT UNIT REPLCMT ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0250 HOS BED FIX HT W/RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0251 HOS BED FIX HT W/RAIL W/O MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0255 HOS BED VARIBL HT W/RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0256 HOS BED VARIBL HT W/RAIL NO MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 93 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0260 HOS BED SEMI-ELEC W/RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0261 HOS BED SEMI-ELEC W/RAIL NO MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0265 HOS BED TOT ELEC W/RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0266 HOS BED TOT ELEC W/RAIL W/O MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0270 HOSP BED INST TYPE: W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0271 MATTRESS INNER SPRING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0272 MATTRESS FOAM RUBBER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 94 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0273 BED BOARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0274 OVER-BED TABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0275 BED PAN STANDARD METAL OR PLASTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0276 BED PAN FRACTURE METAL OR PLASTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0277 POWER PRESSURE-REDUCING AIR MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0280 BED CRADLE ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0290 HOS BED FIX HT W/O RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 95 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0291 HOS BED FIX HT W/O RAIL W/O MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0292 HOS BED VARIBL HT NO RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0293 HOS BED VARIBL HT W/O RAIL/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0294 HOS BED SEMI-ELEC NO RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0295 HOS BED SEMI-ELEC W/O RAIL/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0296 HOS BED TOT ELEC W/O RAIL W/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0297 HOS BED TOT ELEC W/O RAIL/MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 96 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0300 PED CRIB HOS GRADE ENC W/WO TOP ENC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0301 HOS BED HEVY DUTY W/WT CAP >350 PDS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0302 HOS BED WT CAP>600 W/O MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0303 HOS BED HEVY DUTY WT CAP >350<=600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0304 HOS BED XTRA HD WT CAP>600 MTTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0305 BEDSIDE RAILS HALF-LENGTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0310 BEDSIDE RAILS FULL-LENGTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 97 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0315 BED ACCESS: BOARD/TABL/SUPPRT DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0316 SFTY ENCLOS FRME/CANOPY W/HOSP BED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0325 URINAL; MALE JUG-TYPE ANY MATERIAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0326 URINAL; FE JUG-TYPE ANY MATERIAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0328 HOSP BED PED MANUAL INCL MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0329 HOSP BED PED ELECTRIC INCL MATTRESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0350 CNTRL U ELEC BOWEL IRRIG/EVAC SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 98 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0352 DISPBL PACK W/ELEC BOWEL IRRIG/EVAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0370 AIR PRESSURE ELEVATOR FOR HEEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0371 NONPWR PRSS RDUC OVRLAY MATTRSS STD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0372 PWR AIR OVRLAY MATTRSS STD LEN&WDTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0373 NONPWR ADVD PRESS REDUCING MATTRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0424 STATION COMPRS GASOUS O2 SYS RENT; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0425 STATION COMPRS GAS SYS PURCHASE; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 99 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0430 PRTBLE GASEOUS O2 SYS PURCHASE; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0431 PRTBLE GASEOUS O2 SYS RENTAL; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0433 PORTBL LIQ O2 SYS RENT; HOME LIQUIF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0434 PRTBLE LIQUID O2 SYS RENTAL; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0435 PRTBLE LIQUID O2 SYS PURCHASE; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0439 STATION LIQUID O2 SYS RENTAL; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0440 STATION LIQUID O2 SYS PURCHASE; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 100 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0441 STATIONARY O2 CONT GAS 1 MO SPL=1 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0442 STATIONARY 02 CONT LQD 1 MO SPL=1 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0443 PORTBL O2 CONTENT GAS 1 MO SPL= 1 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0444 PORTBL O2 CONTENT LIQ 1 MO SPL=1 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0445 OXIMETER MSR BLD O2 LEVL NON-INVASV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0446 TOPICAL OXYGEN DELIVERY SYSTEM NOS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Eff 12/1/20)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 101 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0455 O2 TENT EXCLD CROUP/PEDIATRIC TENTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0457 CHEST SHELL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0459 CHEST WRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0462 ROCKING BED W/WO SIDE RAILS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0470 RESP ASST DEVC BI-LEVL PRSS CAPABIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0471 RESP ASST DEVC BI-LEVL PRSS CAPABIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0472 RESP ASST DEVC BI-LEVL PRSS CAPABIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 102 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0480 PERCUSSOR ELEC/PNEUMAT HOME MODEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0481 INTRAPULM PERCUSS VENT SYS&REL ACSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0482 COUGH STIM DEVC ALTRNAT POS&NEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0483 HI FREQ CHST WALL AIR-PULSE GEN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0484 OSCILLAT POS EXPIRTORY PRSS NO-ELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0485 ORL DEVC/APPL RDUC UA COLLAPS PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0486 ORL DEVC/APPL RDUC UA COLLAPS CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 103 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0487 SPIROMETER ELECTRONIC INCL ACCESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0500 IPPB MACH BUILT-IN NEBULZ;VALVS;PWR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0550 HUMDIFR EXT SUPLMNTL DUR IPPB TX/O2 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0555 HUMDIFR GLASS/AUTOCLVBL PLSTC BOTTL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0560 HUMDIFIR SUPLMNTL DUR IPPB TX/O2 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0561 HUMDIFIR NON-HEAT USED W/POS AIRWAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0562 HUMDIFIR HEAT USED W/POS ARWAY PRSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 104 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0565 COMPRS AIR PWR EQP NOT SLF-CONTAIND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0570 NEBULIZER WITH COMPRESSOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0572 AROSL COMPRS ADJSTBL PRSS INTERMIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0574 US/ELEC AROSL GEN W/SM VOLUME NEB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0575 NEBULIZER ULTRASONIC LARGE VOLUME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0580 NEBULIZR GLASS/AUTOCLVBL PLST BOTTL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0585 NEBULIZER W/COMPRESSOR AND HEATER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 105 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0600 RESP SUCTN PUMP HOME MODEL ELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0601 CONTINUOUS POS AIRWAY PRESSURE DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0602 BREAST PUMP MANUAL ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0603 BREAST PUMP ELECTRIC ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0604 BREAST PUMP HEVY DUTY HOSP GRADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0605 VAPORIZER ROOM TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0606 POSTURAL DRAINAGE BOARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 106 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0607 HOME BLOOD GLUCOSE MONITOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0610 PACEMKR MON CHCK BATTRY AUDBL&VISBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0615 PACEMKR MON CHCK BATTRY DIGTL/VISBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0616 IMPL CARD EVNT REC MEM MH QHP SCO Please review the BMCHP policy for authorization/criteria details ACTVTR&PRGMR Yes Yes Yes Policy: Ambulatory Cardiac Monitors (Excluding Holter Monitors) Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Eff 3/1/21)

E0617 EXT DEFIB W/INTEGRATED ECG ANALY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0618 APNEA MONITOR W/O RECORDING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FEATURE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0619 APNEA MONITOR W/RECORDING FEATURE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 107 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0620 SKN PIERC DEVC CLCT CAPLRY BLD LASR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0621 SLING/SEAT PT LIFT CANVAS/NYLON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0625 PATIENT LIFT BATHROOM OR TOILET NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0627 SEAT LIFT MECH COMB LIFT-CHAIR MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0628 SEP SEAT LIFT MECH PT OWN FURN-ELEC MH QHP SCO

Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0629 SEAT LIFT MECH NON-ELECTRIC ANY TYP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0630 PATIENT LIFT HYRAULIC/MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 108 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0635 PATIENT LIFT ELECTRIC W/SEAT/SLING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0636 MX PSTN PT SUPP SYS LIFT PT CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0637 COMB SIT STAND FRAME/TABLE SEATLIFT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0638 STAND FRAME/TABLE SYS 1 POS ANY SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0639 PT LIFT MOVEABLE DISASSMBL&REASSMBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0640 PT LIFT FIX SYS ALL CMPNTS/ACCESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0641 STAND FRAME/TABLE SYS MX-POS ANY SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 109 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0642 STAND FRAME/TABLE SYS MOBILE ANY SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0650 PNEUMAT COMPRS NONSEG HOME MODEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0651 PNEUMAT COMPRS NO CALBRT GRDNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. PRSS No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0652 PNEUMAT COMPRS W/CALBRT GRADNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. PRSS No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0655 NONSEG PNEUMAT APPLINC HALF ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0656 SEG PNEUMAT APPLINC W/COMPRS TRUNK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0657 SEG PNEUMAT APPLINC W/COMPRS CHEST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 110 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0660 NONSEG PNEUMAT APPLINC FULL LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0665 NONSEG PNEUMAT APPLINC FULL ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0666 NONSEG PNEUMAT APPLINC HALF LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0667 SEG PNEUMAT APPLINC COMPRS FULL LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0668 SEG PNEUMAT APPLINC COMPRS FULL ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0669 SEG PNEUMAT APPLINC COMPRS HALF LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0670 SEG PNEU APPL P C INT 2 F LEG TRNK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 111 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0671 SEG GRAD PRSS PNUMAT APPLNC FUL LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0672 SEG GRAD PRSS PNUMAT APPLNC FUL ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0673 SEG GRAD PRSS PNUMAT APPLNC HLF LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0675 PNEUMAT COMPRS DEVC HI PRESS RAPID MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0676 INTERMITT LIMB COMPRESSION DEVC NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0691 UV LIGHT TX BULB/LAMP; TX 2 SQ FT/< MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0692 UV LT TX SYS PANL W/LAMP 4 FT PANEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 112 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0693 UV LT TX SYS PANL W/LAMP 6 FT PANEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0694 UV MX DIR LT TX SYS 6 FT CABINET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0700 SAFETY EQP DEVICE/ACCESSRY ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0705 TRANSFER DEVICE ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0710 RESTRAINT ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0720 TENS DEVICE 2 LEAD LOCALIZED STIM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0730 TENS DEVICE 4/> LEADS MX NERVE STIM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 113 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0731 FORM FIT CONDUCT GARM TENS/NMES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0740 N-IMPL PELV FLR ELEC STIM CMPL SYS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Eff 6/1/21)

E0744 NEUROMUSCULAR STIMULATOR SCOLIOSIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0745 NEUROMUSC STIM ELEC SHOCK UNIT MH QHP SCO Please review the BMCHP policies for more details. Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

E0746 ELECTROMYOGRAPHY BIOFEEDBACK DEVICE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation (Eff 10/1/20)

E0747 OSTOGNS STIM NONINVASV NOT SP APPLC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0748 OSTOGNS STIM NONINVASV SP APPLIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 114 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0749 OSTOGNS STIM ELEC SURGICALLY IMPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0755 ELEC SALIVARY REFLEX STIMULATOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0760 OSTOGNS STIM LW INTENS US NONINVASV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0761 NON-THRML PULS RADIOWAVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. ELECMAGNET No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0762 TRANSCUT ELEC JOINT STIM DEVC SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0764 FUNC NEUROMUSC STIM CMPT SC INJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0765 FDA APPRVD NRV STIM TX NAUSA&VOMIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 115 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0766 ELEC STM DVC CA TX ALL ACC ANY TYPE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Electric Tumor Treatment Fields (TTF) Electric Tumor Treatment Fields (Eff 3/1/21)

E0769 ESTIM/ELECMAGNET WOUND TX DEVC NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0770 FES TRANSQ STIM NERV&/MUSC CMPL NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0776 IV POLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0779 AMB INFUS PUMP MECH INFUS 8 HR/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0780 AMB INFUS PUMP MECH INFUS < 8 HR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0781 AMB INFUS PUMP 1/MX CHANNL W/ADMIN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 116 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0782 INFUS PUMP IMPL NON-PROGMMABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0783 INFUS PUMP SYSTEM IMPL PROGMMABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0784 EXTERNAL AMB INFUSION PUMP INSULIN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0785 IMPLANT INTRASPINL CATH PUMP-REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0786 IMPLNT PROGRAM INFUSION PUMP-REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0791 PAR INFUS PUMP STAT SINGLE/MXCHANEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0830 AMB TRACTION DEVICE ALL TYPES EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 117 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0840 TRACTION FRAME HEADBOARD CERV TRACT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0849 TRAC EQP CERV FREESTND FRME PNEUMAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0850 TRACT STAND FREESTAND CERV TRACT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0855 CERV TRACT EQUIP NOT RQR ADD STAND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0856 CERVICAL TRAC DEVC INFL AIR BLADDER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0860 TRACTION EQUIPMENT OVERDOOR CERV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0870 TRACT FRAME FOOTBOARD EXTREM TRACT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 118 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0880 TRACT STAND FREESTAND EXTREM TRACT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0890 TRAC FRAME ATTCH FOOTBRD PELV TRAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0900 TRACT STAND FREESTAND PELV TRACT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0910 TRAPEZ BAR PT HLPR ATTCH BED W/GRAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0911 TRAPEZ BAR PT WT >250 LBS BED GRAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0912 TRAPEZ BAR PT WT >250 LBS FREE STND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0920 FX FRAME ATTCH BED INCL WEIGHTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 119 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0930 FX FRAME FREESTANDING INCL WEIGHTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0935 CONT PSV MOT EXER DEVC KNEE ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0936 CONT PASS MOTION EXER DEVC NOT KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0940 TRAPEZ BAR FREESTND CMPL W/GRAB BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0941 GRAVITY ASSTD TRAC DEVICE ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0942 CERVICAL HEAD HARNESS/HALTER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0944 PELVIC BELT/HARNESS/BOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 120 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0945 EXTREMITY BELT/HARNESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0946 FX FRAM DUAL CROSS BARS ATTACH BED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0947 FX FRAME ATTCH CMPLX PELV TRAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0948 FX FRAME ATTCH CMPLX CERV TRAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0950 WHEELCHAIR ACCESSORY TRAY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0951 HEEL LOOP/HOLDER ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0952 TOE LOOP/HOLDER ANY TYPE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 121 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0955 WC ACSS HEADREST CUSHND HARDWARE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EA No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0956 WC ACSS LAT TRNK/HIP HARDWARE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0957 WC ACSS MED THI SUPP HARDWARE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0958 MNL WC ACCESS 1-ARM DRIVE ATTCH EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0959 MNL WC ACCSS ADAPTER FOR AMPUTEE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0960 WC ACSS SHLDR HRNSS/STRAPS/CHST STR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0961 MNL WC ACCESS WHL LOCK BRAKE EXT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 122 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0966 MNL WC ACCESS HEADREST EXTENSION EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0967 MNL WC AC HND RIM PROJ REPL ONL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0968 COMMODE SEAT WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0969 NARROWING DEVICE WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0970 NO 2 FOOTPLATES EXCEPT ELEV LEGREST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0971 MNL WC ACSS ANTI-TIPPING DEVC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0973 WC ACCSS ADJ HT DTACH ARMRST EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 123 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0974 MNL WC ACCESS ANTI-ROLLBACK DEVC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0978 WC ACSS PSTN/SFTY BELT/PELV STRP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0980 SAFETY VEST WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0981 WC ACSS SEAT UPHLSTER REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0982 WC ACSS BACK UPHLSTER REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0983 MNL WC ACSS PWR ADD-ON CNVRT MNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. WC No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0984 MNL WC ACSS PWR ADD-ON CNVRT MNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. WC No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 124 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E0985 WHEELCHAIR ACCESS SEAT LIFT MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0986 MNL WC ACSS PSH-RM ACT PWR ASST SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0988 MNL WC ACSS LEVR-ACT WHL DRIVE PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0990 WC ACCSS ELEV LEG REST CMPL ASSMBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0992 MNL WHLCHAIR ACCSS SOLID SEAT INSRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0994 ARMREST EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E0995 WC AC CALF REST/PAD REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 125 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1002 WC ACSS PWR SEATING SYS TILT ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1003 WC ACSS RECLINE ONLY NO SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1004 WC ACSS RECLINE W/MECH SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1005 WC ACSS RECLINE W/PWR SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1006 WC ACSS TILT&RECLINE NO SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1007 WC ACSS TILT&RECLIN MECH SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1008 WC ACSS TILT&RECLINE PWR SHEAR RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 126 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1009 WC ACCSS MECH LINKD LEG ELEV EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1010 WC ACCSS PWR LEG ELEV SYS PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1011 MOD PED SIZE WC WIDTH ADJ PACKAGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1014 RECLIN BACK ADD PED SIZE WHLCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1015 SHOCK ABSORBER MANUAL WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EA No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1016 SHOCK ABSORBER POWER WHEELCHAIR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1017 HEAVY DUTY SHOCK ABSORBR MNL WC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 127 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1018 HEAVY DUTY SHOCK ABSORBR PWR WC EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1020 RES LIMB SUP SYS WHEELCHAIR ANY TYP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1028 WC ACCSS MANL SWINGAWAY OTH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1029 WHEELCHAIR ACCESS VENT TRAY FIX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1030 WHLCHAIR ACCESS VENT TRAY GIMBALED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1031 ROLLABOUT CHAIR W/CASTRS 5 IN/GT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1035 MX-PSTN PT TRNSF SYS PT

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 128 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1036 MX-PSTN PT TRNSF SYS PT > 300 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1037 TRANSPORT CHAIR PEDIATRIC SIZE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1038 TRNSPRT CHAIR PT WT CAP TO&= 300 LB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1039 TRNSPRT CHAIR ADLT PT WT CAP>300 LB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1050 FULL RECLINE WC FIX ARM DETACH LEGS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1060 FULL RECLN WHLCHAR;DTACH ARM LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1070 FULL RECLN WHLCHR;DTACH ARM FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 129 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1083 HEMI-W/C; FIXED ARM DETACH LEGREST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1084 HEMI-WHLCHAIR; DTACHBLE ARMS LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1085 HEMI-WHLCHAIR;FIX ARM DTACH FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1086 HEMI-WHLCHAIR; DTACHBL ARMS FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1087 HI-STRGTH WHLCHAIR; FIX ARMS LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1088 HI-STRGTH WHLCHAIR;DTACH ARM LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1089 HI-STRGTH WHLCHAIR; FIX ARM FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 130 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1090 HI-STRGTH WHLCHAR;DTACH ARM FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1092 WIDE HEVY-DUT WHLCHR; DTACH ARM LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1093 WIDE HEVY-DUT WHLCHR;DTACH ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FOOT No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1100 SEMI-RECLN WHLCHR;FIX ARM DTACH LEG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1110 SEMI-RECLN WHLCHR; DTACH ARM LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1130 STD WHLCHAIR; FIX ARM DTACH FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1140 WHLCHAIR; DTACHBLE ARMS FOOTRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 131 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1150 WHLCHAIR; DTACHBLE ARMS LEGRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1160 WHLCHAIR; FIX ARMS DTACHBL LEGRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1161 MANUAL ADLT SZ WC INCL TILT SPACE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1170 AMP WHLCHAIR; FIX ARM DTACH LEGREST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1171 AMP WHLCHAIR;FIX ARM NO FOOT/LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1172 AMP WHLCHR;DTACH ARM NO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FOOT/LEGRST No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1180 AMP WHLCHAIR; DTACHBL ARMS FOOTRSTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 132 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1190 AMP WHLCHAIR; DTACHBL ARMS LEGRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1195 HVY DUT WHLCHR;FIX ARM DTACH LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1200 AMP WHLCHAIR; FIX ARM DTACH FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1220 WHEELCHAIR; SPCL SIZED/CONSTRUCTED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1221 WHEELCHAIR WITH FIXED ARM FOOTRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1222 WHEELCHAIR W/FIX ARM ELEV LEGRESTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1223 WHLCHAIR W/DETACHBLE ARMS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FOOTRESTS No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 133 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1224 WHLCHAIR W/DTACHBL ARMS ELEV LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1225 WC ACCESS MNL SEMIRECLINING BACK EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1226 WC ACCESS MNL FULL RECLIN BACK EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1229 WHEELCHAIR PEDIATRIC SIZE NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1230 PWR OP VEH SPEC BRAND&MODEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. NUMBER No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 134 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1231 WC PED SZ TILT-IN-SPACE RIGD W/SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1232 WC PED SZ TILT-IN-SPACE FOLD W/SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1233 WC PED SZ TILT-IN-SPCE RIGD NO SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1234 WC PED SZ TILT-IN-SPCE FOLD NO SEAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1235 WC PED SZ RIGD ADJUSTBL W/SEAT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1236 WC PED SZ FOLD ADJUSTBL W/SEAT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1237 WC PED SZ RIGD ADJUSTBL NO SEAT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 135 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1238 WC PED SZ FOLD ADJUSTBL NO SEAT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1239 POWER WHEELCHAIR PEDIATRIC SIZE NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1240 LGHTWT WHLCHAIR; DTACH ARMS LEGRSTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1250 LGHTWT WHLCHR;FIX ARM DTACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FOOTRST No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1260 LGHTWT WHLCHAIR; DTACH ARMS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. FOOTRST No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1270 LGHTWT WHLCHR; FIX ARM DTACH LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1280 HEVY-DUTY WHLCHR; DTACH ARMS LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 136 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1285 HEVY-DUTY WHLCHR;FIX ARM DTACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1290 HEVY-DUTY WHLCHR; DTACH ARM FOOTRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1295 HEVY-DUTY WHLCHAIR; FIX ARMS LEGRST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1296 SPECIAL WHEELCHAIR SEAT HT FROM FLR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1297 SPECIAL WHLCHAIR SEAT DEPTH UPHLSTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1298 SPCL WHLCHAIR SEAT DPTH&/WDTH CNSTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1300 WHIRLPOOL PORTABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 137 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1310 WHIRLPOOL NONPORTABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1353 REGULATOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1354 O2 ACCESS CART PRTBLE CYL/CONC REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1355 STAND/RACK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1356 O2 ACCESS BTTRY PACK/CRTRDGE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1357 O2 ACCESS BATTRY CHARGER REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1358 O2 ACCESS DC POWER ADAPTER REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 138 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1372 IMMERSION EXTERNAL HEATER NEBULIZER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1390 O2 CONC 85%/>02 CONC PRSC FLW RATE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1391 02 CONC 2 DEL 85%/>02 CONC FLW RATE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1392 PORTABLE OXYGEN CONCENTRATOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. RENTAL No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1399 DME MISCELLANEOUS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1405 O2&WATR VAPR ENRICH SYS W/HEAT DEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1406 O2&WATR VAPR ENRCH SYS NO HEAT DEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 139 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1639 SCALE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1700 JAW MOTION REHABILITATION SYSTEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1701 REPL CUSHNS JAW MOT REHAB SYS PKG 6 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1702 REPL MSR SCLS JAW MOT REHAB SYS 200 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1800 DYN ADJUSTABLE ELB EXT/FLX DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1801 STATIC PROGRESSV STRETCH ELBOW DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1802 DYN ADJUSTBL FORARM PRON/SUPIN DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 140 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1805 DYN ADJUSTABLE WRIST EXT/FLX DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1806 STATIC PROGRESSV STRETCH WRIST DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1810 DYN ADJUSTABLE KNEE EXT/FLX DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1811 STATIC PROGRESSV STRETCH KNEE DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1812 DYN KNEE EXT/FLEX DEVC RESIST CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1815 DYN ADJ ANK EXT/FLX DVC W/INTF MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1816 STATIC PROGRESSV STRETCH ANKLE DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 141 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1818 STATIC PROGRSV STRETCH FOREARM DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1820 REPL SFT INTERFCE MATL DYN EXT/FLX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1821 REPL SFT INTERFCE MATL/CUFF BI-DIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1825 DYN ADJUSTABLE FINGER EXT/FLX DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1830 DYN ADJUSTABLE TOE EXT/FLX DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1831 STATIC PROGRESSIVE STRETCH TOE DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1840 DYN ADJUST SHLDR FLX/ABDUCT/ROT DVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 142 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E1841 STATIC PROGRS STRETCH SHOULDER DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E1902 CMNCT BD NON-ELEC AUG/ALTERNTV DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2000 GASTR SUCTN PUMP HOME MODEL ELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2100 BLD GLU MON INTEGRT VOICE SYNTHESZR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2101 BLD GLU MON INTGRT LANCING/BLD SAMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2120 PULSE GEN SYS TYMPANIC TX INNR EAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2201 MNL WC ACSS SEAT WDTH >/=20 IN &<24 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 143 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2202 MNL WC ACSS SEAT WIDTH 24-27 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2203 MNL WC ACSS SEAT DEPTH 20 < 11 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2204 MNL WC ACSS SEAT DEPTH 22-25 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2205 MNL WC HANDRIM W/O PROJ REPL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2206 MANL WC AC WL ASM CMPL REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2207 WHLCHAIR ACCESS CRUTCH&CANE HLDR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2208 WHEELCHAIR ACCESS CYL TANK CARR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 144 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2209 ARM TROUGH W/WO HAND SUPPORT EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2210 WC ACESS BEARINGS ANY TYPE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2211 MNL WC ACESS PNEUMAT PROPULSN TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2212 MNL WC TUBE PNEUMAT PROPULSION TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2213 MNL WC INSRT PNEUMAT PROPULSN TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2214 MNL WC ACCESS PNEUMAT CASTER TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2215 MNL WC ACSS TUBE PNEUMAT CASTR TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 145 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2216 MNL WC ACSS FOAM FILL PROPULSN TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2217 MNL WC ACCSS FOAM FILL CASTER TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2218 MNL WC ACCSS FOAM PROPULSION TIRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2219 MNL WC ACSS FOAM CASTER TIRE ANY SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2220 MNL WC AC SLD PROP T SZ RPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2221 MNL WC AC SLD C TIR SZ REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2222 MNL WC AC SLD C TIRE I WHL SZ RPL E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 146 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2224 MNL WC AC P WHL EXCL T SZ RPL ONL E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2225 MNL WC CASTR WHL EXCLD TIRE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2226 MNL WC ACSS CASTR FORK REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2227 MNL WC GEAR RED DRIVE WHEEL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2228 MNL WC WHL BRAKE SYS&LOCK COMPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2230 MNL WHEELCHAIR ACCESS MNL STAND SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2231 MNL WC ACCESS SOLID SEAT SUPP BASE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 147 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2291 BACK PLANR PED WC FIX ATTCH HARDWRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2292 SEAT PLANR PED WC FIX ATTCH HARDWRE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2293 BACK CONTRD PED WC ATTCH HARDWARE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2294 SEAT CONTRD PED WC ATTCH HARDWARE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2295 MNL WC ACCESS PED SIZE WC SEAT FRME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2300 WC ACC PWR SEAT ELEV SYS ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2301 WHEELCHAIR ACC PWR STND SYS ANY TYP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 148 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2310 PWR WC ACSS ELEC CNCT BETWN WC CNTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2311 PWR WC ACSS ELEC CNCT BETWN WC CNTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2312 POWER WC HAND/CHIN CONTRL INTERFACE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2313 POWER AC HARNESS UPGRD EXP CONTRLLR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2321 PWR WC ACSS HND CNTRL NO PRPRTNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2322 PWR WC ACSS MX MECH SWTCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. NOPRPRTNL No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2323 PWR WC ACSS SPCLTY JOYSTCK HND PRFB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 149 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2324 PWR WC ACSS CHIN CUP CHIN CNTRL INT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2325 PWR WC ACSS SIP&PUFF NONPRPRTNAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2326 PWR WC ACSS BREATH TUBE KIT SIP&PUF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2327 PWR WC ACSS HEAD CNTRL MECH PRPRTNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2328 PWR WC ACSS HEAD/EXT ELEC PRPRTNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2329 PWR WC ACSS CNTC SWTCH NOPRPRTNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2330 PWR WC ACCSS PROX SWTCH NOPROPRTNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 150 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2331 PWR WC ACSS ATDANT CNTRL PROPRTNAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2340 POWER WC NONSTAND SEAT WD 20-23 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2341 PWR WC ACSS NONSTD SEAT W 24-27 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2342 PWR WC NONSTD SEAT DEPTH 20/21 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2343 PWR WC NONSTD SEAT DEPTH 22-25 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2351 PWR WC ACSS ELEC OP SPCH GEN DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2358 PWR WC GRP 34 NONSEALED LA BATT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 151 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2359 PWR WC GRP 34 SEALED LA BATT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2360 PWR WC ACSS 22 NF NON-SEALED BATTRY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2361 PWR WC ACSS 22NF SEALED LEAD BATTRY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2362 PWR WC ACSS GRP 24 NON-SEALED BATT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2363 PWR WC ACSS GRP 24 SEALED BATTRY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2364 PWR WC ACSS U-1 NON-SEALED BATTRY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2365 PWR WC ACSS U-1 SEALED BATTRY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 152 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2366 PWR WC ACSS BATTRY CHARGER 1 MODE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2367 PWR WC ACSS BATTRY CHARGER DUL MODE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2368 PWR WC CMPNT DR WHEEL MTR REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. ONLY No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2369 PWR WC CMPNNT DR WHL GR BX RPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2370 P WC CMP INT DR WHL MTR&GB CMB RPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2371 PWR WC GRP 27 SEALED LEAD ACID BATT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2372 PWR WC GRP 27 NONSEAL LED ACID BATT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 153 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2373 PWR WC MINI COMPACT REMOTE JOYSTICK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2374 PWR WC STANDRD REMOTE JOYSTICK REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2375 PWR WC NONEXPANDBLE CONTROLLER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. REPL No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2376 PWR WC EXPANDABLE CONTROLLER REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2377 PWR WC EXPANDBL CONTROLLER UPGRADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2378 POWER WC CMPNT ACTUATOR REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2381 PWR WC PNEUMATIC WHEEL TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 154 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2382 PWR WC TUBE WHEEL TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2383 PWR WC INSERT WHEEL TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2384 PWR WC PNEUMATIC CASTR TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2385 PWR WC TUBE CASTER TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2386 PWR WC FOAM FILL WHEEL TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2387 PWR WC FOAM FILL CASTR TIRE REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2388 PWR WC FOAM WHEEL TIRE REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 155 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2389 PWR WC FORM CASTER TIRE REPL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2390 PWR WC SOLID WHEEL TIRE REPL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2391 PWR WC SOLID CASTER TIRE REPL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2392 PWR WC S CASTR TIRE INTEGRT REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2394 PWR WC DRIVE WHEEL EXCL TIRE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2395 PWR WC CASTER WHEEL EXCL TIRE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2396 PWR WC CASTER FORK REPL ONLY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 156 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2397 POWER WC LITHIUM BASED BATTERY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2402 NEG PRSS WND TX PUMP STATN/PRTBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2500 SPEECH GEN DEV DIGTIZD

E2502 SPCH GEN DEVC DGTZD>8<= 20 MINS REC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2504 SPCH GEN DEVC DGTZD>20

E2506 SPCH GEN DEVC DIGTIZD>40 MINS REC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2508 SPCH GEN DEVC SYNTHSIZD REQ MESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 157 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2510 SPCH GEN DVC SYNTHSIZD MX METH MESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2511 SPEECH GENERATING SOFTWARE PROGRAM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2512 ACSS SPCH GEN DEVICE MOUNTING SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2599 ACCESS SPEECH GENERATING DEVICE NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2601 GEN WC SEAT CUSHN WIDTH < 22 DEPTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2602 GEN WC SEAT CSHN WDTH 22 IN/GT DPTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2603 SKN PROTCT WC SEAT WDTH<22IN DPTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 158 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2604 SKN PROTECT WC SEAT WDTH 22 IN/GT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2605 PSTN WC SEAT CUSHN WIDTH < 22 DEPTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2606 PSTN WC SEAT CSHN WDTH 22IN/GT DPTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2607 SKN PROTCT&PSTN WC SEAT WDTH <22IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2608 SKN PROTCT&PSTN WC SEAT WDTH 22IN/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2609 CUSTOM FAB WHLCHAIR SEAT CUSHN SIZE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2610 WHEELCHAIR SEAT CUSHION POWERED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 159 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2611 GEN WC BACK CUSHN WIDTH < 22 IN HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2612 GEN WC BACK CUSHN WIDTH 22 IN/GT HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2613 PSTN WC BACK CUSHN POST WDTH <22 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2614 PSTN WC BACK CUSHN POST WD 22 IN/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2615 PSTN WC BACK CUSHN POSTLAT WD<22 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2616 PSTN WC BACK CUSH POSTLAT WD 22IN/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2617 CSTM FAB WC BACK CUSHION ANY SIZE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 160 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2619 REPL COVER WC SEAT/BACK CUSHN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2620 PSTN WC BACK CUSHN PLANAR WD <22 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2621 PSTN WC BACK CUSHN PLANAR WD 22IN/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2622 SKIN PROTECT WC CUSH WIDTH <22 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2623 SKIN PROTECT WC CUSH WIDTH 22 IN/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2624 SKIN PROTCT&POSITION WC CUSH WD <22 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2625 SKIN PROTCT&POSITION WC CUSH W 22/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 161 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2626 WC SHLDR ELB MOBL ARM SUPP ADJUSTBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2627 WC SHLDR ELB M SUPP ADJUSTBL RANCHO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2628 WC SHLDR ELB MOBIL SUPP RECLINING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2629 WC SHLDR ELB M SUPP FRICTN ARM SUPP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2630 WC SHLDR ELB M SUP MONOSUSP ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. HND No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2631 WC ADD MOBIL ARM SUPP ELEV PROX ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E2632 WC ADD MOBL SUP OFFSET/LAT RCKR ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 162 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

E2633 WC ACSS ADD MOBIL ARM SUPP SUPINATR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E8000 GAIT TRAINER PED SZ POST SUPP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E8001 GAIT TRAINER PED SZ UPRIGHT SUPP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

E8002 GAIT TRAINER PED SZ ANT SUPP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

G0128 DIR SKLED SERV RN OP REHAB EA 10MIN MH QHP SCO No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 163 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0151 SRVC PT HOM HLTH/HOSPICE EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP-IInterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care for Maintenance Services Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care Services for an Acute Episode of Care Policy: InterQual® criteria is available

G0152 SRVC OT HOM HLTH/HOSPICE EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP:InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care for Maintenance Services Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care Services for an Acute Episode of Care Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 164 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0153 SRVC SPCH&LANG PATH HH/HOSPIC EA 15 MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP;InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care for Maintenance Services Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care Services for an Acute Episode of Care Policy: InterQual® criteria is available

G0155 SRVC CLINICAL SW HH/HOSPICE EA 15 MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP:InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0156 SRVC HH/HOSPICE AIDE EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP:InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care for Maintenance Services Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care Services for an Acute Episode of Care Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 165 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0157 SRVC PT ASSIST HH/HOSPICE EA 15 MIN MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0158 SRVC OT ASSIST HH/HOSPICE EA 15 MIN MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0159 SRVC PT HH EST/DEL PT MP EA 15 MINS MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0160 SRVC OT HH EST/DEL OT MP EA 15 MIN MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0161 SRVC SLP HH EST/DEL SLP TX MP 15 MN MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting No Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 166 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0176 ACTV TX PTS DISABL MENTL HLTH-SESS MH QHP SCO Please review the BMCHP policies for more details. Yes Yes Policy: Complementary and Alternative Medicine, Including Acupuncture Complementary and Alternative Medicine, Including Acupuncture (Eff 1/1/21)

G0237 MUSCLES FACE FACE 1 ON 1 EA 15 MIN MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) Policy: InterQual® criteria is available

G0238 TX PROC IMPRV RESP NOT G0237 15 MIN MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) Policy: InterQual® criteria is available

G0239 TX PROC IMPRV RESP FUNCT 2/> IND MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) Policy: InterQual® criteria is available

G0246 F/U EVAL DIABETIC PT W/LOPS MH QHP SCO *PA may be req'd for Specialty Care - please review the Notification #125 and Prov Man Sec 8.8 for more No No details Policy: Provider Network Notification - 125 Provider Network Notification -125 Provider Manual Section 8

G0247 ROUTINE FT CARE PHYS DIAB PT W/LOPS MH QHP SCO *PA may be req'd for Specialty Care - please review the Notification #125 and Prov Man Sec 8.8 for more No No details Policy: Provider Network Notification - 125 Provider Network Notification -125 Provider Manual Section 8

G0248 DEMONSTRATION HOME INR MONITOR MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Home Prothrombin Time Monitoring Devices Home Prothrombin Time Monitoring Devices (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 167 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0249 PRVS TST MATL&EQUIP HM INR MON;Q WK MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Home Prothrombin Time Monitoring Devices Home Prothrombin Time Monitoring Devices (Eff 1/1/21)

G0250 PHYS REV INTEPR HOME INR MON; Q WK MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Home Prothrombin Time Monitoring Devices Home Prothrombin Time Monitoring Devices (Eff 1/1/21)

G0260 INJ SI JNT; ANES &/TX AGT &ARTHROG MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Sacroiliac Joint Injections Sacroiliac Joint Injections (Eff 3/1/21)

G0270 MED NUT TX; REASSESS W/PT EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medical Nutrition Therapy in the Outpatient Setting or Office Setting Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Eff 8/1/20) Retired 8/31/21 Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Eff 9/1/21)

G0271 MED NUT TX REASSESS GRP EA 30 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medical Nutrition Therapy in the Outpatient Setting or Office Setting Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Eff 8/1/20) Retired 8/31/21 Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Eff 9/1/21)

G0277 HPO UND PRSS FULL B CHMBR PER 30 MN MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes Yes rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Eff 12/1/20) Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 168 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0283 E-STIM 1/>NOT WND CARE PART TX PLAN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Eff 6/1/21) Policy: Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Eff 6/1/21)

G0297 LOW DOSE CT SCAN FOR LUNG CANCR SCR MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

G0299 DIR SNS RN HH/HOSPICE SET EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP-InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0300 Services of an LPN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP- InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 169 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0329 EM TX ULCERS NOT HEALING 30 DA CARE MH QHP SCO No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

G0341 PERQ ISLET CELL TPLNT PV CATH&INFUS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

G0342 LAP ISLET CELL TPLNT PV CATH&INFUS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

G0343 LAPROT ISLET CELL TPLNT PV CATH&INF MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

G0400 HST TYPE IV PRTBLE MON MIN 3 CH MH QHP SCO No No

G0422 INTENS CARD REHAB; W/WO ECG W/EXER MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting yes Yes Yes rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Cardiac Rehabilitation, Outpatient Cardiac Rehabilitation, Outpatient (Eff 12/1/20) Policy: InterQual® criteria is available

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 170 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0423 INTENS CARD REHAB; W/WO ECG W/O EX MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes Yes rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Cardiac Rehabilitation, Outpatient Cardiac Rehabilitation, Outpatient (Eff 12/1/20) Policy: InterQual® criteria is available

G0424 PULM REHAB EXER 1 HR SESS 2 PER DAY MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) Policy: InterQual® criteria is available

G0464 CC SCR; STL-BASED DNA & F OCCLT HGB MH QHP SCO Yes Yes

G0480 DR TST DEFIN DR ID M P D 1-7 DR CL MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 1/1/21) Retired 6/30/21 Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 7/1/21)

G0481 DR TST DEFIN DR ID M P D 8-14 DR CL MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 1/1/21) Retired 6/30/21 Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 7/1/21)

G0482 DR TST DEFN DR ID M P D 15-21 DR CL MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 1/1/21) Retired 6/30/21 Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 171 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G0483 DR TST DEFIN DR ID M P D 22/M DR CL MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 1/1/21) Retired 6/30/21 Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 7/1/21)

G0493 SKD SRVC RN OBV&ASMT PT C EA 15 MIN MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP; InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

G0659 DRUG TST DEFIN DR ID M ANY # DR CLS MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 1/1/21) Retired 6/30/21 Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Eff 7/1/21)

G2168 SERVICES PRFRM BY PT ASST HH SETTING MH QHP SCO Please review the BMCHP policy for authorization/criteria details EA 15 MIN No No Yes Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21)

G2169 SERVICES PRFRM BY OT ASST HH SETTING MH QHP SCO Please review the BMCHP policy for authorization/criteria details EA 15 MIN No No Yes Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 172 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

G6015 INTENS MOD TX DEL 1/MX FLDS TX SESS MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Intensity Modulated Radiation Therapy, Outpatient Intensity Modulated Radiation Therapy, Outpatient (Eff 7/1/20) Retired 8/31/21 Intensity Modulated Radiation Therapy, Outpatient (Eff 9/1/21)

G6016 CMP-B BM MD TX DEL I PLND TX P TX S MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No Yes Policy: Intensity Modulated Radiation Therapy, Outpatient Intensity Modulated Radiation Therapy, Outpatient (Eff 7/1/20) Retired 8/31/21 Intensity Modulated Radiation Therapy, Outpatient (Eff 9/1/21)

J3590 Unclassified biologics MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Car T-Cell Therapy to Treat Hematological Malignancies Car T-Cell Therapy to Treat Hematological Malignancies (Eff 5/1/21) Retired 10/31/21 Car T-Cell Therapy to Treat Hematological Malignancies (Eff 11/1/21)

J7330 AUTOL CULTURD CHONDROCYTES IMPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Eff 3/1/21)

K0001 STANDARD WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0002 STANDARD HEMI WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0003 LIGHTWEIGHT WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 173 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0004 HIGH STRENGTH LIGHTWEIGHT WHLCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0005 ULTRALIGHTWEIGHT WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0006 HEAVY-DUTY WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0007 EXTRA HEAVY-DUTY WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0009 OTHER MANUAL WHEELCHAIR/BASE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0010 STD-WT FRME MOTRIZED/PWR WHLCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0011 STD FRME MOTRIZD WHLCHAIR W/PROG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 174 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0012 LGHTWT PRTBLE MOTRIZED/PWR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. WHLCHAIR No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0014 OTH MOTORIZED/POWER WHEELCHAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. BASE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0015 DETACHBLE NONADJUSTBL HT ARMREST EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0017 DTACHBLE ADJUST HT ARMREST REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0018 DTACH ADJ HT ARMRST UP PRTN REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0019 ARM PAD REPLACEMENT ONLY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0020 FIXED ADJUSTBLE HEIGHT ARMREST PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 175 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0037 HIGH MNT FLP-UP FTREST REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0038 LEG STRAP EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0039 LEG STRAP H STYLE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0040 ADJUSTABLE ANGLE FOOTPLATE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0041 LARGE SIZE FOOTPLATE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0042 STANDARD SIZE FOOTPLTE REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0043 FOOTREST LWR EXT TUBE REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 176 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0044 FOOTREST UPR HGR BRKT REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0045 FOOTREST CMPL ASSEMBLY REPL ONLY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0046 ELEVAT LEGRST L EXT TUBE RPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0047 ELEVT LEGRST UP HGR BRKT RPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0050 RATCHET ASSEMBLY REPLACEMENT ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0051 CAM RLS ASSM FTRST/LGRST RPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0052 SPL EX N-INS RX INF PMP SYR CRT S E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 177 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0053 ELEVATING FOOTRESTS ARTICULATING EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0056 SEAT HT<17/=>21 IN LTWT/ULTRLT WC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0065 SPOKE PROTECTORS EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0069 RW ASM CMPL SOLID T SPKE/MLD RPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0070 RW ASM CMP PN T SPKS/MLD RPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0071 FRT C ASM COMPL PN TIRE REPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0072 FRT C ASM CMPL SEMIPN T RPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 178 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0073 CASTER PIN LOCK EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0077 FRT C ASM CMPL SLD TIRE REPL ONLY E MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0098 DRIVE BELT FOR POWER WC REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0105 IV HANGER EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0108 WC COMPONENT/ACCESSORY NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0195 ELEVATING LEGREST PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0455 INFUS PUMP UNINTRPT PARNTRAL MED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 179 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0462 TEMP REPL PT EQUIP REPR ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0552 SPL EXT INFUSION PUMP STERILE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0554 REC THER CONT GLU MON MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

K0601 REPL BATTERY SILVER OXIDE 1.5 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0602 REPL BATTERY SILVER OXIDE 3 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0603 REPL BATTERY PUMP ALKALINE 1.5 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0604 REPL BATTERY PUMP LITHIUM 3.6 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 180 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0605 REPL BATTERY PUMP LITHIUM 4.5 V EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0606 AED W/INTGR ECG ANALY GARMNT TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0607 REPL BATTERY AUTO EXT DEFIB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0608 REPL GARMNT W/AUTO EXT DEFIB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0609 REPL ELECTRODE W/AUTO EXT DEFIB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0669 WC ACCSS SEAT/BK CUSHN NO DME PDAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0672 ADD LOW EXT ORTHOSIS REPL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 181 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0730 CNTRL DOSE INHAL RX DEL ERY SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0733 PWR WC 12-24 AMP HR LEAD BATT EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0738 PORT GASEOUS O2 SYS RNTL;HOM COMPRS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0739 REPR/SRVC DME NOT O2 PER 15 MINS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0740 REPR/SRVC O2 EQP TECH PER 15 MINS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0743 SX PUMP HOME MDL PORT FOR WOUNDS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0744 ABSRB WD DR H MDL PAD 16 SQ IN/LESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 182 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0745 ABS WD DR PAD>16 SQ IN

K0746 ABSRB WD DR H MDL PAD SZ >48 SQ IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0800 PWR OP VEH GRP 1 STD PT TO 300 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0801 PWR OP VEH GRP 1 HVY PT 301-450 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0802 PWR OP VEH GRP 1 HVY PT 451-600 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0806 PWR OP VEH GRP 2 STD PT TO 300 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0807 PWR OP VEH GRP 2 HVY PT 301-450 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 183 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0808 PWR OP VEH GRP 2 PT 451-600 LBS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0812 POWER OPERATED VEHICLE NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0813 PWR WC GRP 1 SLING SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0814 PWR WC GRP 1 CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0815 PWR WC GRP 1 SLING PT UP TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0816 PWR WC GRP 1 CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0820 PWR WC GRP 2 SLING SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 184 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0821 PWR WC GRP 2 CAPT CHAIR TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0822 PWR WC GRP 2 SLING SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0823 PWR WC GRP 2 CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0824 PWR WC GRP 2 SLING SEAT PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0825 PWR WC GRP 2 CAPT CHAIR PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0826 PWR WC GRP 2 SLING SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0827 PWR WC GRP 2 CAPT CHAIR PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 185 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0828 PWR WC GRP 2 SLING SEAT PT 601/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0829 PWR WC GRP 2X HVY DUTY CHR PT 601/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0830 PWR WC 2 SEAT ELEV SLING PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0831 PWR WC 2 SEAT ELEV CAPT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0835 PWR WC GRP 2 1 PWR SLING PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0836 PWR WC 2 1 PWR CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0837 PWR WC GRP 2 1 PWR SLING PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 186 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0838 PWR WC 2 1 PWR CAPT CHR PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0839 PWR WC 2 1 PWR SLNG SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0840 PWR WC GRP 2 1 PWR SLING PT 601/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0841 PWR WC GRP 2 MX PWR SLING PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0842 PWR WC 2 MX PWR CAPT CHR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0843 PWR WC 2 MX PWR SLING PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0848 PWR WC GRP 3 SLING SEAT PT TO &=300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 187 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0849 PWR WC GRP 3 CAPT CHAIR PT TO &=300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0850 PWR WC GRP 3 SLING SEAT PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0851 PWR WC GRP 3 CAPT CHAIR PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0852 PWR WC GRP 3 SLING SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0853 PWR WC GRP 3 CAPT CHAIR PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0854 PWR WC GRP 3 SLING SEAT PT 601 LB/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0855 PWR WC GRP 3 CAPT CHAIR PT 601 LB/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 188 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0856 PWR WC 3 1 PWR SLING SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0857 PWR WC 3 1 PWR CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0858 PWR WC 3 1 PWR SLNG SEAT PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0859 PWR WC 3 1 CAP CHAIR PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0860 PWR WC 3 1 PWR SLNG SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0861 PWR WC 3 MX PWR SLNG SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0862 PWR WC 3 MX PWR SLING PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 189 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0863 PWR WC 3 MX PWR SLING PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0864 PWR WC 3 MX PWR SLNG SEAT PT 601/> MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0868 PWR WC GRP 4 SLING SEAT PT TO &=300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0869 PWR WC GRP 4 CAPT CHAIR PT TO &=300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0870 PWR WC GRP 4 SLING SEAT PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0871 PWR WC GRP 4 SLING SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0877 PWR WC 4 1 PWR SLING SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 190 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0878 PWR WC 4 1 PWR CAPT CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0879 PWR WC 4 1 PWR SLNG SEAT PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0880 PWR WC 4 1 PWR SLNG SEAT PT 451-600 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0884 PWR WC 4 MX PWR SLNG SEAT PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0885 PWR WC 4 MX PWR CAP CHAIR PT TO 300 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0886 PWR WC 4 MX PWR SLING PT 301-450 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0890 PWR WC 5 PED 1 PWR SLING PT TO 125 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 191 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K0891 PWR WC 5 PED MX PWR SLING PT TO 125 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0898 POWER WHEELCHAIR NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0899 PWR MOBILTY DEVC NOT CODED DME PDAC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0901 KO SNGL UPRIGHT THIGH & CALF PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K0902 KO DBLE UPRIGHT THIGH & CALF PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K1006 Suction pump, home model, portable or MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information stationary, electric, any type, for use with No No No external urine ma Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 192 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K1007 Bilateral hip, knee, ankle, foot device, MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information powered, includes pelvic component, single No No No or double uprigh Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K1009 Speech volume modulation system, any MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information type, including all components and No No No accessories Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K1010 Indwelling intraurethral drainage device MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information with valve, patient inserted, replacement No No No only, each Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

K1011 Activation device for intraurethral drainage MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information device with valve, replacement only, each No No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 193 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

K1012 Charger and base station for intraurethral MH QHP SCO DME and all providers, for auth details, please see plan's Auth Matrix for Northwood information activation device, replacement only No No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0112 CRANIL CERV ORTHOT CONGN TORTICOLLI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0113 CRANIL CERV ORTHOT TORTICOLLI PRFB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0120 CERVICAL FLEX NONADJUSTABLE PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0130 CERV FLXBL THRMOPLSTC COLLR MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0140 CERVICAL SEMI-RIGID ADJUSTABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 194 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0150 CERV SEMI-RIGD ADJUST MOLD CHIN CUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0160 CERV SEMI-RIGID OCCIP/MAND PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0170 CERV COLLAR MOLDED PATIENT MODEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0172 CERV COLLAR SEMI-RIGID FOAM PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0174 CERV COLLR SEMI-RGD THOR EXT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0180 CERV MX POST COLLR SUPPS ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0190 CERV MX POST COLLR ADJ CERV BARS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 195 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0200 CERV COLLR ADJ CERV BARS&THOR EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0220 THORACIC RIB BELT CUSTOM FABRICATED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0450 TLSO FLEX TRUNK SUPP UP THOR PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0452 TLSO FLEX TRUNK SUPP UP THOR CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0454 TLSO FLEX SC JUNC T-9 PRFAB CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0456 TLSO FLEX SC SCAP SPN PRFAB CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0458 TLSO TRIPLANR 2 SHELL ANT-XIPHOID MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 196 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0460 TLSO TRIPLANR 2 SHELL ANT-STERNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0462 TLSO TRIPLANR 3 SHELL ANT-STERNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0464 TLSO TRIPLANR 4 SHELL ANT-STERNL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0466 TLSO SAGITTAL CONTROL PREFAB CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0468 TLSO SAGITTAL-CORONAL PREFAB CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0470 TLSO TRIPLANAR FRME&APRON W/STRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0472 TLSO TRIPLANAR HYPREXT RIGD FRME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 197 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0480 TLSO TRIPLANR 1 PC NO INTERFCE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0482 TLSO TRIPLANAR 1 PC W/INTERFCE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0484 TLSO TRIPLANR 2 PC NO INTERFCE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0486 TLSO TRIPLANAR 2 PC W/INTERFCE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0488 TLSO TRIPLANR 1 PC W/INTERFCE PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0490 TLSO SAGIT-CORONAL REINFORCE PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0491 TLSO 2 RIGID PLASTIC SHELLS PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 198 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0492 TLSO 3 RIGID PLASTIC SHELLS PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0621 SACROILIAC ORTHOSIS FLEXIBLE PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0622 SACROILIAC ORTHOTIC FLEXIBLE CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0623 SACROILIAC ORTHOSIS RIGID PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0624 SACROILIAC ORTHOTIC RIGID CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0625 LUMBAR ORTHOSIS FLEXIBLE PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0626 LUMB ORTHOS RIGID POST PREFAB CUSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 199 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0627 LUMB ORTHOS RIGD A&P PNL PRFAB CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0628 LSO FLEXIBLE PREFAB OFF THE SHELF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0629 LSO FLEXIBLE CUSTOM FABRICATED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0630 LSO SAGIT CNTRL RIGID POST PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0631 LSO SAGIT CNTRL RIGID POST CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0632 LSO SAGIT CNTRL RIGID A&P CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0633 LSO SAG-COR CNTRL RIGID POST PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 200 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0634 LSO SAG-COR CNTRL RIGID POST CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0635 LSO SAG-COR CNTRL LUMB FLEX PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0636 LSO SAG-COR CNTRL LUMB FLEX CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0637 LSO SAG-COR CNTRL RIGID A&P PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0638 LSO SAG-COR CNTRL RIGID A&P CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0639 LSO SAG-COR CNTRL RIGD SHELL PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0640 LSO SAG-COR CNTRL RIGD SHELL CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 201 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0700 CTLSO ANT-POST-LAT CNTRL MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0710 CTLSO-MOLD PT-INTERFACE MATERIAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0810 HALO PROC CERV HALO IN JACKT VEST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0820 HALO PROC CERV HALO-PLAST BDY JACKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0830 HALO PROC CERV HALO-MLWAKEE ORTHOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0859 RINGS&PINS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0861 ADD HALO PROC REPLCMT LINER/INTERFC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 202 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0970 TLSO CORSET FRONT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0972 LSO CORSET FRONT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0974 TLSO FULL CORSET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0976 LSO FULL CORSET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0978 AXILLARY CRUTCH EXTENSION MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0980 PERONEAL STRAPS PREFAB PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0982 STOCKING SUPPORT GRIPS PREFAB SET 4 MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 203 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L0984 PROTECTIVE BODY SOCK PREFAB EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L0999 ADDITION TO SPINAL ORTHOTIC NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1000 CTLSO INCL FURNISH INIT ORTHOS-MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1001 CTLS IMMOBILIZER INFANT SZ PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1005 TENSION BASED SCOLIOSIS ORTHOTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1010 ADD CTLSO/SCOLIO ORTHOS AX SLING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1020 ADD CTLSO/SCOLIO ORTHOS KYPHOS PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 204 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1025 ADD CTLSO/SCOLIO ORTHOS KYPHOS PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1030 ADD CTLSO/SCOLIO ORTHOS LUMB PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1040 ADD CTLSO/SCOLIO ORTHO LUMB/RIB PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1050 ADD CTLSO/SCOLIOS ORTHOS STERNL PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1060 ADD CTLSO/SCOLIOS ORTHOS THOR PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1070 ADD CTLSO/SCOLIO ORTHO TRPEZUS SLNG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1080 ADD CTLSO/SCOLIOSIS ORTHOSIS OUTRIG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 205 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1085 ADD CTLSO/SCOLIO OUTRIG BIL-VRT EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1090 ADD CTLSO/SCOLIOS ORTHOS LUMB SLING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1100 ADD CTLSO/SCOLIOS RING PLSTC/LEATHR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1110 ADD CTLSO/SCOLIOS RING MOLD PT MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1120 ADD CTLSO SCOLIO ORTHO COVR UPRT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1200 TLSO INCL FURNISH INIT ORTHOTC ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1210 ADDITION TLSO LATERAL THORACIC EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 206 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1220 ADDITION TLSO ANT THORACIC EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1230 ADD TLSO MLWAKEE TYPE SUPERSTRCT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1240 ADDITION TLSO LUMBAR DEROTATION PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1250 ADDITION TO TLSO ANTERIOR ASIS PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1260 ADD TLSO ANT THOR DEROTATION PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1270 ADDITION TO TLSO ABDOMINAL PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1280 ADDITION TO TLSO RIB GUSSET EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 207 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1290 ADDITION TLSO LAT TROCHANTERIC PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1300 OTH SCOLIOS PROC BDY JACKT MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1310 OTH SCOLIOSIS PROC POSTOP BDY JACKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1499 SPINAL ORTHOTIC NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1600 HIP ORTHOS ABDUCT FLX FREJKA PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1610 HIP ORTHOS ABDUCT CNTRL FLEX PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1620 HIP ORTHOS ABDUCT FLEX PAVLIK PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 208 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1630 HIP ORTHOTIC ABDUCT CONTRL/SEMI-FLX MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1640 HIP ORTHOTIC-PELV BAND/SPRDR BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1650 HIP ORTHOTIC ABDUCT CNTRL-STATC ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1652 HIP ORTHOT BIL THI CUFF ADLT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1660 HIP ORTHOT ABDUCT CNTRL-STATC PLSTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1680 HIP ORTHOT DYN PELV CNTRL THI CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1685 HIP ORTHOS POSTOP HIP ABDCT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 209 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1686 HIP ORTHOT POSTOP HIP ABDCT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1690 COMB BIL LUMBO-SAC HIP FEM ORTHOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1700 LEGG PERTHES ORTHOTIC TORONTO CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1710 LEGG PERTHES ORTHOT NEWINGTON CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1720 LEGG PERTHES ORTHO TRILAT TACHDIJAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1730 LEGG PERTHES ORTHOTIC SCOTTISH RITE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1755 LEGG PERTHES ORTHOT PATTEN BOTTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 210 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1810 KNEE ORTHOSIS ELASTIC JOINTS PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1820 KO ELAST W/CONDYLR PADS&JNT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1830 KNEE ORTHOSIS IMMOBLIZER PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1831 KNEE ORTHT LOCK KNEE JNT PSTN ORTHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1832 KNEE ORTHOS IMMOBLZR ADJUST PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1834 KO W/O KNEE JOINT RIGID CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1836 KNEE ORTHOSIS RIGD W/O JOINT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 211 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1840 KO DEROTATION MED-LAT ACL CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1843 KNEE ORTHOS 1 UPRT THI&CALF PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1844 KNEE ORTHOS 1 UPRT THI&CALF CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1845 KNEE ORTHOS DBL UPRT THI&CALF PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1846 KNEE ORTHOS DBL UPRT THI&CALF CUSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1847 KNEE ORTHOS DBL UPRT ADJ JNT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1850 KNEE ORTHOS SWEDISH TYPE PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 212 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1860 KO MOD SUPRACNDYLR PROSTH SCKT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1900 AFO SPRNG WIRE DORSIFLX ASST CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1902 ANK ORTH ANK GAUNTLT/SIM PREFAB OTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1904 ANK ORTH ANK GAUNTLT/SIM CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1906 AFO MX-LIGAMENT ANK SUPT PREFB OTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1907 ANKLE ORTHOS SUPRAMALLEOLAR CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1910 AFO POST 1 BAR CLASP ATTCH SHOE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 213 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1920 AFO 1 UPRT W/STAT/ADJ STOP CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1930 AFO PLASTIC/OTH MATERIAL PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1932 AFO RIGD ANT TIBL CARB FIBR/= PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1940 ANK FT ORTHOT PLSTC/OTH MATL CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1945 AFO MOLD PLSTC RIGD ANT TIBL CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1950 AFO SPIRAL PLASTIC CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1951 ANK FT ORTHOT SPIRAL PLSTC/OTH MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 214 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L1960 AFO POST SOLID ANK PLSTC CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1970 AFO PLASTIC W/ANK JOINT CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1971 ANK FT ORTHOT PLSTC/OTH MATL PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1980 AFO 1 UPRT DORSIFLX SLID STIRUP FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L1990 AFO DBL UPRT DORSIFLX STIRUP CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2000 KAFO 1 UPRT SOLID STIRUP CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2005 KAFO ANY MATL AUTO RLS ANK JNT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 215 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2010 KAFO 1 UPRT STIRUP NO KNEE JNT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2020 KAFO DBL UPRT STIRUP THI&CALF CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2030 KAFO DBL UPRT STIRUP NO KNEE JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2034 KAFO PLSTC MED LAT ROTAT CNTRL CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2035 KAFO FULL PLSTC STAT PED SZ PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2036 KAFO FULL PLSTC DBL UPRT CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2037 KAFO FULL PLSTC 1 UPRIGHT CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 216 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2038 KAFO FULL PLSTC MX-AXIS ANKLE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2040 HKAFO TORSN CNTRL BIL ROTAT STRAPS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2050 HKAFO BIL TORSION CABLES CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2060 HKAFO BIL TORSION BALL BEAR CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2070 HKAFO UNI ROTAT STRAPS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2080 HKAFO UNI TORSION CABLE CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2090 HKAFO UNI TORSN CABL BALL BEAR CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 217 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2106 AFO TIB FX CAST THERMOPLSTC CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2108 AFO TIB FX CAST ORTHT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2112 AFO TIB FX ORTHOT SFT PRFAB FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2114 AFO TIBL FX ORTHOS SEMI-RIGD PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2116 AFO TIB FX ORTHOT RIGD PRFAB FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2126 KAFO FEM FX CAST THERMOPLSTC CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2128 KAFO FEM FX CAST ORTHOT CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 218 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2132 KAFO FEM FX CAST ORTHOT SFT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2134 KAFO FEM FX CAST SEMI-RIGD PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2136 KAFO FEM FX CAST ORTHOT RIGD PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2180 ADD LW EXTRM ORTH PLSTC SHOE INSRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2182 ADD LW EXT ORTH DROP LOCK KNEE JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2184 ADD LW EXTRM ORTH LTD MOT KNEE JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2186 ADD LW EXT ORTH ADJ MOT KNEE JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 219 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2188 ADD LW EXT FX ORTHOT QUADRILAT BRIM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2190 ADD LOW EXTREM FX ORTHOT WAIST BELT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2192 ADD LW EXT ORTH HIP JNT THI FLNGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2200 ADD LOW EXTRM LTD ANK MOTION EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2210 ADD LOW EXTREM DORSIFLX ASST EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2220 ADD LW EXT DRSFLX&PLNTR ASST EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2230 ADD LW EXT SPLIT FLAT CALIPR STIRUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 220 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2232 ADD LOW EXT ORTHOS ROCKR BOTTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CSTM No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2240 ADD LW EXT ROUND CALIPER&PLAT ATTCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2250 ADD LW EXT FT PLAT MOLD PT STIRUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2260 ADD LW EXT REINFORCED SOLID STIRUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2265 ADD LOW EXTREM LONG TONGUE STIRUP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2270 ADD LW EXT VARUS/VALGUS CORR STRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2275 ADD LW EXT VARUS/VULGUS CORR PLSTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 221 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2280 ADD LOW EXTREM MOLDED INNR BOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2300 ADD LW EXTRM ABDUCT BAR JNTED ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2310 ADD LOW EXTREM ABDUCT BAR STRAIGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2320 ADD LOW EXT NONMOLD LACER CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. ONLY No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2330 ADD LOW EXT LACER MOLD PT CSTM ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2335 ADDITION LOW EXTREM ANT SWING BAND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2340 ADD LW EXTRM PRETIBL SHELL MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 222 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2350 ADD LW EXT PROSTH TYPE SCKT MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2360 ADDITION LOW EXTREM EXT STEEL SHANK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2370 ADDITION LOWER EXTREM PATTEN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. BOTTOM No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2375 ADD LW EXT TORSION CNTRL ANK JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2380 ADD LW EXT TORSN CNTRL STRAIT KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2385 ADD LW EXTREM STRAIT KNEE JNT HD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2387 ADD LW EXT POLYCNTRC KNEE CSTM KAFO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 223 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2390 ADD LW EXTRM OFFSET KNEE JNT EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2395 ADD LW EXT OFFSET KNEE JNT HD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2397 ADD LOW EXTREM ORTHOTIC SUSP SLEEVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2405 ADDITION KNEE JOINT DROP LOCK EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2415 ADD KNEE LOCK-INTEGRATD RLSE EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2425 ADD KNEE JNT DISC/DIAL LOCK EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2430 ADD KNEE JNT RATCHT LOCK EXT EA JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 224 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2492 ADD KNEE LIFT LOOP DROP LOCK RING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2500 ADD LW EXTRM THIGH/WT BEAR RING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2510 ADD LW EXTRM THI/WT BEAR MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2520 ADD LW EXTRM THI/WT BEAR CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2525 ADD LW EXT ISCH M-L BRIM MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2526 ADD LW EXTRM ISCH M-L BRIM CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2530 ADD LW EXT THI/WT BEAR LACR NONMOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 225 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2540 ADD LW EXT THI/WT BEAR LACR MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2550 ADD LW EXT THI/WT BEAR HI ROLL CUFF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2570 ADD LW EXT PELV HIP JNT CLEVIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2580 ADD LOW EXTRM PELV CNTRL PELV SLING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2600 ADD LW EXT PELV THRUST BEAR FREE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2610 ADD LW EXT PELV THRUST BEAR LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2620 ADD LW EXT PLV HIP JNT HEVY-DUTY EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 226 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2622 ADD LW EXT PELV HIP JNT ADJ FLX EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2624 ADD LW EXTRM PELV HIP JNT FLX EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2627 ADD LW EXT PELV PLSTC MOLD PT-CABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2628 ADD LW EXT PELV METL FRME-CABLES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2630 ADD LW EXTRM PELV BAND&BELT UNI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2640 ADD LW EXTRM PELV BAND&BELT BIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2650 ADD LW EXTRM PELV&THOR GLUTL PAD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 227 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2660 ADD LOW EXTREM THOR CNTRL THOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. BAND No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2670 ADD LW EXTRM THOR CNTRL PARASP UPRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2680 ADD LW EXT THOR CNTRL LAT SUPP UPRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2750 ADD LW EXT ORTHOT PLAT CHROME/NICKL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2755 ADD LOW EXT ORTHOT PER SEG CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2760 ADD LOW EXTREM ORTHOTIC EXT-EXT-BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2768 ORTHOTIC SIDE BAR DISCNCT DEVC-BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 228 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2780 ADD LW EXT ORTH NONCORROSIVE BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2785 ADD LW EXT ORTHOT DROP LOCK RETN EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2795 ADD LW EXT ORTH KNEE CNTRL FULL CAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2800 ADD LOW EXT ORTHOT KNEE CAP CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2810 ADD LW EXT ORTH KNEE CNDYLR PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2820 ADD LW EXT SFT INTERFCE BELW KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2830 ADD LW EXT SFT INTERFCE ABVE KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 229 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L2840 ADD LW EXT ORTHOT TIB LEN SOCK FX/= MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2850 ADD LW EXT ORTHO FEM LEN SOCK FX/= MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2861 ADD LOW EXT JNT KNEE/ANK CSTM EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L2999 LOWER EXTREMITY ORTHOSES NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3000 FT INSRT MOLD UCB TYPE BERKLY SHELL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3001 FOOT INSRT REMV MOLD PT SPENCO EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3002 FT INSRT REMV MOLD PLASTAZOTE/= EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 230 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3003 FOOT INSRT REMV MOLD SILCON GEL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3010 FT INSRT MOLD LNGTUDNL ARCH SUPP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3020 FT INSRT REMV MOLD LNGTUDNL SUPP EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3030 FOOT INSERT REMV FORMED PT FT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3031 FOOT INSRT/PLAT REMV ADD LW EXT ORT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3040 FOOT ARCH SUPP PREMOLD LNGTUDNL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3050 FOOT ARCH SUPP REMV PREMOLD MT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 231 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3060 FT ARCH SUPP PREMOLD LNGTUDNL/MT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3070 FOOT ARCH SUPP NONREMV LNGTUDNL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3080 FT ARCH SUPP NONREMV ATTCH SHOE MT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3090 FT ARCH SUPP NONREMV LNGTUDNL/MT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EA No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3100 HALLUS-VALGUS NIGHT DYN SPLNT PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3140 FOOT ABDUCT ROTATION BAR INCL SHOES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3150 FOOT ABDUCT ROTATION BAR W/O SHOES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 232 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3160 FOOT ADJUSTBL SHOE-STYLD PSTN DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3170 FOOT PLASTC SIL HEEL STAB PREFAB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3201 ORTHOPED SHOE OXFRD SUPINATR INFNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3202 ORTHOPED SHOE OXFRD W/SUPINATR CHLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3203 ORTHOPED SHOE OXFRD W/SUPINATR JR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3204 ORTHOPED SHOE HITOP SUPINATR INFNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3206 ORTHOPED SHOE HITOP W/SUPINATR CHLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 233 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3207 ORTHOPED SHOE HITOP W/SUPINATR JR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3208 SURGICAL BOOT EACH INFANT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3209 SURGICAL BOOT EACH CHILD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3211 SURGICAL BOOT EACH JUNIOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3212 BENESCH BOOT PAIR INFANT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3213 BENESCH BOOT PAIR CHILD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3214 BENESCH BOOT PAIR JUNIOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 234 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3215 ORTHOPED FTWEAR LADIES OXFORD EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3216 ORTHO FTWEAR LADIES SHOE DPTH INLAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3217 ORTHOPED FTWEAR LADIES HITOP INLAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3219 ORTHOPED FTWEAR MENS SHOE OXFORD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. EA No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3221 ORTHOPD FTWEAR MENS SHOE DPTH INLAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3222 ORTHO FTWEAR MENS HITOP DPTH INLAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3224 ORTHO FTWEAR WOMAN OXFRD PART MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. BRACE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 235 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3225 ORTHO FTWEAR MAN OXFRD PART BRACE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3230 ORTHO FTWEAR CSTM SHOE DEPTH INLAY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3250 ORTHOPED FOOTWEAR CSTM MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. PROSTH No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3251 FOOT SHOE MOLD PT SILCON SHOE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3252 FOOT SHOE MOLD PT PLASTAZOTE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3253 FOOT MOLD SHOE PLASTAZOTE CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3254 NONSTANDARD SIZE OR WIDTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 236 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3255 NONSTANDARD SIZE OR LENGTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3257 ORTHOPED FOOTWEAR ADD CHRG SPLIT SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3260 SURGICAL BOOT/SHOE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3265 PLASTAZOTE SANDAL EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3300 LIFT ELEV HEEL TAPERED MTS PER INCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3310 LIFT ELEV HEEL&SOLE NEOPRENE-INCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3320 LIFT ELEV HEEL&SOLE CORK PER INCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 237 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3330 LIFT ELEVATION METAL EXTENSION MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3332 LIFT ELEV IN SHOE TAPERED TO 1/2 IN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3334 LIFT ELEVATION HEEL PER INCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3340 HEEL WEDGE SACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3350 HEEL WEDGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3360 SOLE WEDGE OUTSIDE SOLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3370 SOLE WEDGE BETWEEN SOLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 238 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3380 CLUBFOOT WEDGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3390 OUTFLARE WEDGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3400 METATARSAL BAR WEDGE ROCKER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3410 METATARSAL BAR WEDGE BETWEEN SOLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3420 FULL SOLE&HEEL WEDGE BETWEEN SOLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3430 HEEL COUNTER PLASTIC REINFORCED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3440 HEEL COUNTER LEATHER REINFORCED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 239 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3450 HEEL SACH CUSHION TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3455 HEEL NEW LEATHER STANDARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3460 HEEL NEW RUBBER STANDARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3465 HEEL THOMAS WITH WEDGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3470 HEEL THOMAS EXTENDED TO BALL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3480 HEEL PAD AND DEPRESSION FOR SPUR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3485 HEEL PAD REMOVABLE FOR SPUR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 240 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3500 ORTHOPED SHOE ADD INSOLE LEATHR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3510 ORTHOPED SHOE ADD INSOLE RUBBER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3520 ORTHO SHOE ADD INSOLE FELT W/LEATHR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3530 ORTHOPEDIC SHOE ADDITION SOLE HALF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3540 ORTHOPEDIC SHOE ADDITION SOLE FULL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3550 ORTHOPED SHOE ADD TOE TAP STANDARD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3560 ORTHOPED SHOE ADD TOE TAP HORSESHOE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 241 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3570 ORTHOPED SHOE ADD SPCL EXT INSTEP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3580 ORTHO SHOE ADD CNVRT INSTP-VELC CLO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3590 ORTHO SHOE ADD CONVERT FIRM TO SOFT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3595 ORTHOPEDIC SHOE ADDITION MARCH BAR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3600 TRNSF ORTH-ANOTHER CALIPR PLAT XST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3610 TRNSF ORTH-ANOTHER CALIPR PLAT NEW MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3620 TRNSF ORTH-ANOTH SOLID STIRUP XST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 242 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3630 TRNSF ORTH-ANOTH SOLID STIRUP NEW MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3640 TRNSF ORTH-ANOTH DENNS BRWN SPLNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3649 ORTHOPED SHOE MOD ADD/TRANSFER NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3650 SHOULDER ORTHOS FIG 8 ABDUCT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3660 SHOULDER ORTHOS FIG 8 CANVAS PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3670 SHOULDER ORTHOS ACROMIO/CLAV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. PREFAB No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3671 SO JOINT DESIGN W/O JOINTS CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 243 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3674 SHOULDER ORTHOTIC ABDUCT PSTN CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3675 SHLDR VEST ABDUCT RESTRAINR PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3677 SHLDR ORTHOS JNT DSGN PREFAB CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3702 EO W/O JOINTS CUSTOM FABRICATED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3710 ELB ORTHOS ELASTIC METL JNTS PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3720 EO DBL UPRT W/CUFF FREE MOT CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3730 EO DBL UPRT-CUFF EXT/FLX ASST CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 244 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3740 EO DBL UPRT W/CUFF ADJ LOCK CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3760 ELB ORTH W/ADJ LOCK JNT PRFAB W/FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3762 ELBOW ORTHOS RIGID W/O JOINT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3763 EWHO RIGID W/O JOINTS CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3764 EWHO 1/> NONTORSION JNTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3765 EWHFO RIGID W/O JOINTS CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3766 EWHFO 1/> NONTORSION JNTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 245 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3806 WHFO CUSTOM FAB INCL FIT & ADJUST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3807 WHF ORTHOS NO JNT PRFAB CUSTOM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3808 WHF ORTHOTIC RIGID NO JNT; CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3891 ADD UP EXT JNT WRIST/ELB CSTM EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3900 WHFO DYN FLX HNG WRST DRVN CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3901 WHFO DYN FLX HNG CABLE DRIVEN CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3904 WHFO EXTERNAL POWER ELEC CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 246 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3905 WHO 1/> NONTORSION JOINTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3906 WHO W/O JOINTS STRAPS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3908 WRST HND ORTHOS CNTRL COCK-UP PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3912 HAND FINGR ORTHOS FINGR CNTRL PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3913 HFO W/O JOINTS CUSTOM FABRICATED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3915 WH ORTHOS 1/>NONTRSN PRFAB CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3917 HAND ORTHOSIS MC FX PREFAB CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 247 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3919 HAND ORTHOTIC W/O JOINTS CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3921 HFO 1/> NONTORSION JOINTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3923 HF ORTHOSIS NO JOINT PRFAB CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3925 FINGER ORTHOS NONTORSION JNT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3927 FINGER ORTHOSIS W/O JOINT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3929 HF ORTHOS 1/>NONTRSN JNT PRFAB CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3931 WHFO PREFAB INCL FITTING & ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 248 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3933 FINGER ORTHOTIC W/O JOINTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3935 FO NONTORSION JOINT CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3956 ADD JNT UP EXTREM ORTHOT MATL; JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3960 SEWHO ABDUCT PSTN AIRPLANE DESIGN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3961 SEWHO SHLDR CAP DESN NO JNTS CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3962 SEWHO ABDUCT PSTN ERBS PALS DESIGN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3967 SEWHO ABDUCT PSTN W/O JNTS CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 249 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3971 SEWHO SHOULDER CAP DESIGN CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3973 SEWHO ABDUCTION POSITION CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3975 SEWHFO SHLDR CAP DESN NO JNTS CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3976 SEWHFO ABDUCT PSTN W/O JNTS CUS FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3977 SEWHFO SHOULD CAP DESIGN CUSTOM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3978 SEWHFO ABDUCTION P0SITION CSTM FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3980 UP EXT FX ORTHOT HUM PRFAB-FIT&ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 250 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L3982 UP EXTRM FX ORTH RADUS/ULNAR PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3984 UP EXTRM FX ORTHOTIC WRST PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3995 ADD UP EXTREM ORTHOT SOCK FX/= EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L3999 UPPER LIMB ORTHOSIS NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4002 REPL STRAP ANY ORTHOTIC ALL CMPNTS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4010 REPLACE TRILATERAL SOCKET BRIM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 251 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L4020 REPL QUADRILAT SOCKT BRIM MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4030 REPL QUADRILAT SOCKT BRIM CSTM FIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4040 REPL MOLDED THI LACER CSTM ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4045 REPL NONMOLD THI LACER CSTM ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4050 REPL MOLDED CALF LACER CSTM ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4055 REPL NONMOLD CALF LACER CSTM ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4060 REPLACE HIGH ROLL CUFF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 252 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L4070 REPLACE PROXIMAL&DIST UPRIGHT KAFO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4080 REPLACE METAL BANDS KAFO PROX THIGH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4090 REPL METL BANDS KAFO-AFO CALF/THI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4100 REPLACE LEATHR CUFF KAFO PROX THIGH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4110 REPL LEATHR CUFF KAFO-AFO CALF/THI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4130 REPLACE PRETIBIAL SHELL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4205 REPR ORTHOT DEVC LABR CMPNT 15 MIN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 253 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L4210 REP ORTHOT DEVC REP/REPL MINOR PART MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4350 ANKLE CONTROL ORTHOS STIRRUP PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4360 WALK BOOT PNEUMAT&/VAC PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CUSTM No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4370 PNEUMATIC FULL LEG SPLINT PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4386 WALK BOOT NON-PNEUMATIC PREFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CSTM No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4392 REPLCMT SFT INTERFCE MATL STAT AFO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4394 REPL SFT INTRFCE MATL FT DROP SPLNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 254 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L4396 STAT/DYN ANK FT ORTHOS PREFAB CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4398 FOOT DROP SPLINT RECUMBNT POS PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L4631 AFO WALK BOOT TYP ROCKR BOTTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CSTM No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5000 PART FT SHOE INSRT W/LNGTUDNL ARCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5010 PART FT MOLD SOCKT ANK HT W/TOE FIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5020 PART FT MOLD SOCKET TIB TUBERCLE HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5050 ANKLE SYMES MOLDED SOCKET SACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 255 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5060 ANK SYMS METL FRME MOLD LEATHR SCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5100 BELW KNEE MOLD SOCKT SHIN SACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5105 BK PLSTC SCKT JNT&THI LACER SACH FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5150 KNEE DISRTC MOLD SCKT EXT KNEE JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5160 KNEE DISARTIC MOLD SOCKT BENT KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5200 AK MOLD SOCKT 1 AXIS CONSTANT FRICT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5210 AK SHRT PROS NO KNEE JNT-ANK JNT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 256 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5220 AK SHRT PROSTH W/ARTIC ANK/FOOT DYN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5230 AK PROX FEM FOCAL DEFIC SACH FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5250 HIP DISRTC CANADIAN; MOLD SCKT HIP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5270 HIP DISRTC TLT TABL; MOLD SCKT LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5280 HEMIPELVECT CANADIAN; MOLD SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5301 BK MOLD SCKT SHIN SACH FT ENDO SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5312 KNEE DISART MOLD SOCKET 1 AXIS KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 257 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5321 AK OPEN END SACH FT ENDO SYS 1 AXIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5331 JOINT SINGLE AXIS KNEE SACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5341 SINGLE AXIS KNEE SACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5400 IMMED POSTSURG RIGD DRSG W/1 CHG BK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5410 IMMED POSTSURG RIGD DRS BK-EA CAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5420 IMMED POSTSURG RIGD DRSG 1 CHG AK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5430 IMMED POSTSURG RIGD DRSG AK EA CAST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 258 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5450 IMMED POSTSURG NONWT BEAR RIGD BK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5460 IMMED POSTSURG NONWT BEAR RIGD AK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5500 INIT BK PTB SCKT NON-ALIGN DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5505 INIT AK-DISRTC ISCH LEVL NON-ALIGN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5510 PREP BK PTB SCKT NON-ALIGN MOLD MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5520 PREP BK PTB THERMOPLSTC/=DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5530 PREP BK PTB THERMOPLSTC/=MOLD MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 259 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5535 PREP BK PTB PRFAB ADJ OPEN END SCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5540 PREP BK PTB LAMINATED SCKT MOLD MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5560 PREP AK-DISARTIC PLASTER MOLD MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5570 PREP AK-DISRTC THRMOPLSTC/=DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5580 PREP AK-DISARTIC THERMOPLSTC/=MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5585 PREP AK-DISARTIC PRFAB ADJ OPN END MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5590 PREP AK-DISARTC LAMINATD SCKT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 260 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5595 PREP HIP DISARTC THERMOPLSTC/=MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5600 PREP HIP DISARTC LAMINATD SCKT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5610 ADD LW EXTRM ENDO AK HYDRACADENCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5611 ADD LW EXT AK-DISARTC W/FRICT CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5613 ADD LW EXT AK-DSRTC W/HYDRAUL CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5614 ADD LW EXT AK-DSRTC W/PNEUMAT CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5616 ADD LW EXT AK UNIVRSL MXPLX FRICT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 261 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5617 ADD LW EXTREM QUICK CHANGE AK/BK EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5618 ADD LOW EXTREM TEST SOCKT SYMES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5620 ADD LOW EXTREM TEST SOCKT BELW KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5622 ADD LW EXTRM TST SOCKT KNEE DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5624 ADD LOW EXTREM TEST SOCKT ABVE KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5626 ADD LW EXTRM TST SOCKT HIP DISARTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5628 ADD LOW EXTRM TST SOCKT HEMIPELVECT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 262 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5629 ADD LW EXTRM BELW KNEE ACRYLC SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5630 ADD LW EXT SYMS TYPE XPND WALL SCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5631 ADD LW EXT ABVE KNEE/DISARTC ACRYLC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5632 ADD LW EXT SYMS PTB BRIM DESN SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5634 ADD LW EXT SYMS POST OPENING SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5636 ADD LW EXT SYMS MED OPENING SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5637 ADD LOW EXTREM BELW KNEE TOTAL CNTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 263 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5638 ADD LW EXTRM BELW KNEE LEATHR SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5639 ADD LOW EXTREM BELW KNEE WOOD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SOCKT No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5640 ADD LW EXT KNEE DISARTC LEATHR SCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5642 ADD LW EXTRM ABVE KNEE LEATHR SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5643 ADD LW EXT HIP DISRTC FLX EXT FRAME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5644 ADD LOW EXTREM ABVE KNEE WOOD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SOCKT No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5645 ADD LW EXTRM BK FLX INNR EXT FRME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 264 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5646 ADD LOW EXT BELOW KNEE CUSHN SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5647 ADD LOW EXTRM BELW KNEE SUCTN SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5648 ADD LOW EXT ABOVE KNEE CUSHN SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5649 ADD LW EXT ISCHIAL CONTAINMENT SCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5650 ADD LW EXTRM TOT CONTACT AK/DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5651 ADD LW EXTRM AK FLX INNR EXT FRME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5652 ADD LW EXTRM SUCTN SUSP AK/DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 265 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5653 ADD LW EXT KNEE DISRTC XPNDABL WALL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5654 ADD LOW EXTREM SOCKT INSERT SYMES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5655 ADD LOW EXTRM SOCKT INSRT BELW KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5656 ADD LW EXT SOCKT INSRT KNEE DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5658 ADD LOW EXTRM SOCKT INSRT ABVE KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5661 ADD LW EXT INSRT MXIDUROMETER SYMES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5665 ADD LW EXT INSRT MXDROMTR BELW KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 266 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5666 ADD LOW EXTREM BELOW KNEE CUFF SUSP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5668 ADD LW EXTRM BK MOLD DISTAL CUSHION MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5670 ADD LW EXTRM BK MOLD SUPRACOND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. SUSP No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5671 ADD LW EXTRM BK/AK SUSP LOCK MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5672 ADD LW EXTRM BK REMV MED BRIM SUSP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5673 ADD LW EXT BK/AK CSTM FAB XST MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5676 ADD LW EXT BK KNEE JNT 1 AXIS PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 267 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5677 ADD LW EXT BK KNEE JNT POLYCNTRC PR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5678 ADD LW EXT BELW KNEE JNT COVRS PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5679 ADD LW EXT BK/AK CSTM FAB XST MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5680 ADD LW EXTRM BK THI LACER NONMOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5681 ADD LW EXT INSRT CONGN/AMPUTEE INIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5682 ADD LW EXT BK THIGH LACER MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5683 ADD LW EXT INSRT NO CONGN/AMP INIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 268 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5684 ADD LOW EXTREM BELW KNEE FORK STRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5685 ADD LOW EXT PROS BELW KNEE SLEEVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5686 ADD LOW EXTREM BELW KNEE BACK CHECK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5688 ADD LW EXTRM BK WAIST BELT WEB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5690 ADD LW EXTRM BK WAIST BELT PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5692 ADD LW EXTRM AK PELVIC CONTROL BELT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5694 ADD LW EXTRM AK PELV CNTRL BELT PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 269 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5695 ADD LW EXT AK PELV CNTRL SLV NEOPRN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5696 ADD LW EXTRM AK/DISARTIC PELV JNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5697 ADD LW EXTRM AK/DISARTIC PELV BAND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5698 ADD LW EXTRM AK/KD SILESIAN BANDAGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5699 ALL LOW EXTREM PROSTH SHLDR HARNESS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5700 REPL SOCKET BELOW KNEE MOLD PT MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5701 REPL SCKT AK/DISARTIC W/ATTCH PLAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 270 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5702 REPL SCKT HIP DISRTC W/HIP JNT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5703 ANK SYMES MLD PT MDL SACH FT REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5704 CUSTOM SHAP PROTVE COVER BELOW MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. KNEE No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5705 CUSTOM SHAP PROTVE COVER ABOVE KNEE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5706 CUSTOM SHAPED COVER KNEE DISARTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5707 CUSTOM SHAPED COVER HIP DISARTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5710 ADD EXOSKL KNEE-SHIN 1 AXS MNL LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 271 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5711 ADD EXO KNEE-SHIN MNL LOCK ULTRA-LT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5712 ADD EXO KNEE-SHIN FRICT SWING CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5714 ADD EXO KNEE-SHIN VARBL FRICT SWING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5716 ADD EXO KNEE-SHIN MECH STANCE LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5718 ADD EXO KNEE-SHIN FRICT SWING CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5722 ADD EXO KNEE-SHIN PNUMAT SWNG FRICT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5724 ADD KNEE-SHIN 1 AXIS FL SWING PHASE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 272 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5726 ADD EXO KNEE-SHIN EXT JNT FL SWING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5728 ADD EXO KNEE-SHIN FL SWING&STANCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5780 ADD EXO KNEE-SHIN PNEUMAT/HYDRA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5781 ADD LW LIMB PROS LIMB MGMT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5782 ADD LW LIMB PROS LIMB MGMT HVY DUTY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5785 ADD EXOSKEL BELW KNEE ULTRA-LT MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5790 ADD EXOSKEL ABVE KNEE ULTRA-LT MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 273 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5795 ADD EXOSKEL HIP DISARTIC ULTRA-LGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5810 ADD ENDOSKEL KNEE-SHIN MANUAL LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5811 ADD ENDO KNEE-SHIN MNL LCK ULTRA-LT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5812 ADD ENDO KNEE-SHIN FRICT SWNG CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5814 ADD ENDO KNEE-SHN HYDRAUL MECH LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5816 ADD ENDO KNEE-SHIN MECH STANCE LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5818 ADD ENDO KNEE-SHIN FRICT SWNG&STANC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 274 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5822 ADD ENDO KNEE-SHIN PNEUMATIC FRICT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5824 ADD ENDO KNEE-SHIN FL SWING CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5826 ADD ENDO KNEE-SHIN MIN HI ACTV FRME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5828 ADD ENDO KNEE-SHIN FL SWING&STANCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5830 ADD ENDO KNEE-SHIN PNEUMAT/SWING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5840 ADD ENDO KNEE-SHIN 4-BAR LINK SWING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5845 ADD ENDOSKL KNEE-SHIN STANC FLX ADJ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 275 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5848 ADD ENDOSKEL KNEE-SHIN FLUID EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5850 ADD ENDO AK/HIP DSRTC KNEE EXT ASST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5855 ADD ENDO HIP DISARTIC MECH EXT ASST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5856 ADD LOW EXT PROS KN-SHN SWING&STNCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5857 ADD LOW EXT PROS KN-SHN SWING ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5858 ADD LW EXT PROS KNEE SHN SYS STANCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5859 ADD LW EXT PROS KN-SHN PROG FLX/EXT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 276 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5910 ADD ENDOSKEL BELW KNEE ALIGNBL SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5920 ADD ENDOSKEL AK/HIP DISRTC ALIGNBL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5925 ADD ENDO AK/HIP DISARTIC MNL LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5930 ADD ENDO HI ACTV KNEE CNTRL FRAME MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5940 ADD ENDOSKEL BELW KNEE ULTRA-LGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5950 ADD ENDOSKEL ABVE KNEE ULTRA-LGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5960 ADD ENDOSKL HIP DISARTC ULTRA-LGHT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 277 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5961 ADD ENDO SYS POLYCNTRC HIP JOINT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5962 ADD ENDO BK FLEX PROTVE OUTER COVER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5964 ADD ENDO AK FLXBL PROTVE OUTR COVR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5966 ADD ENDO HIP DISRTC FLX PROTVE COVR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5968 ADD LW LIMB PROSTH MX-AXIAL ANKLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5970 ALL LW EXTRM PROSTH FOOT SACH FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5971 ALL LW EXT PROS SACH FOOT REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 278 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5972 ALL LOW EXT PROS FOOT FLEXIBLE KEEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5973 ENDO ANK FOOT MICROPROCSS CNTRL PWR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5974 ALL LW EXTRM PRSTH FT 1 AXIS ANK/FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5975 ALL LW EXTRM PROSTH COMB 1 AXIS ANK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5976 ALL LW EXTRM PROSTH ENERGY STOR FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5978 ALL LW EXTRM PRSTH FT MX-AXL ANK/FT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5979 ALL LW XTRM PRSTH MX-AXL ANK 1 PECE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 279 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5980 ALL LOW EXTREM PROSTH FLX-FOOT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5981 ALL LOW EXTRM PROSTH FLX-WALK SYS/= MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5982 ALL EXOSKEL LW EXT PROS AXIAL ROTAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5984 ALL ENDOSKEL LW EXT PRSTH AXL ROTAT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5985 ALL ENDOSKL LW XTRM PROSTH DYNAMIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5986 ALL LW EXTRM PROSTH MX-AXIAL ROT U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5987 ALL LW EXTRM PROSTH SHANK FOOT SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 280 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L5988 ADD LW LMB PRSTH VERTCL SHOCK RDUC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5990 ADD LW EXTRM PROSTH USE ADJ HEEL HT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L5999 LOWER EXTREMITY PROSTHESIS NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6000 PARTIAL HAND THUMB REMAINING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6010 PART HAND LITTLE &/ RING FINGER REM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6020 PARTIAL HAND NO FINGER REMAINING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6050 WRST DSRTC MOLD SOCKET FLEX ELB HNG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 281 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6055 WRST DSRTC MOLD SCKT W/XPND INTRFCE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6100 BELW ELB MOLD SOCKT FLXIBLE ELB HNG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6110 BELOW ELBOW MOLDED SOCKET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6120 BELW ELB STEP-UP HINGES HALF CUFF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6130 BELW ELB STMP ACTV LCK HNG 1/2 CUFF MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6200 ELB DSRTC MOLD SCKT OTSD LCK FORARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6205 ELB DSRTC MOLD SCKT XPND INTRFC ARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 282 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6250 ABOVE ELB INTERNAL LOCK ELB FOREARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6300 SHLDR DISARTC INTRL LOCK ELB FORARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6310 SHLDR DISART PASS REST COMPL PROSTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6320 SHLDR DISART PASS REST SHLDR CAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6350 INTRSCAP THOR INTRL LOCK ELB FORARM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6360 INTERSCAPULAR THOR COMPLT PROSTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6370 INTERSCAPULAR THOR SHLDR CAP ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 283 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6380 IMMED POSTSURG RIGD DRSG WRST DSRTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6382 IMMED POSTSURG RIGD DRSG ELB DISRTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6384 IMMED POSTSRG RIGD DRSG SHLDR DSRTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6386 IMMED POSTSURG EA ADD CAST CHANGE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6388 IMMED POSTSURG RIGID DRSG ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6400 BE MOLD SCKT ENDOSKEL-SFT PROS TISS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6450 ELB DISARTIC MOLD SOCKET ENDOSKEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 284 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6500 ABOVE ELBOW MOLD SOCKET ENDOSKEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6550 SHLDR DISARTC MOLD SOCKET ENDOSKEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6570 INTRSCAP THOR MOLD SOCKET ENDOSKEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6580 PREP WRST DISARTIC PLSTC SOCKT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6582 PREP WRST DISARTC ELB SCKT DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6584 PREP ELB DISARTC PLASTIC SOCKT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6586 PREP ELB DISARTIC SOCKET DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 285 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6588 PREP SHLDR DISRTC THOR PLSTC SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6590 PREP SHLDR DSRTC THOR SCKT DIR FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6600 UP EXTREM ADD POLYCNTRC HINGE PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6605 UPPER EXTREM ADD 1 PIVOT HINGE PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6610 UP EXT ADD FLEX METAL HINGE PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6611 ADD UP EXT PROS EXT PWR ADD SWITCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6615 UP EXTREM ADD DISCNCT LOCK WRST U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 286 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6616 UP EXT ADD-DSCNCT INSRT LCK WRST EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6620 UP EXT ADD FLEX/EXT WRIST UNIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6621 UP EXTREM PROS ADD FLEX/EXTEN WRIST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6623 UP EXT ADD ROTATL WRST W/LATCH RLSE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6624 UP EXT ADD FLX/EXT ROT WRIST UNIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6625 UP EXT ADD ROTAT WRST W/CABLE LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6628 UP EXTRM ADD QUICK DISCNCT HOOK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 287 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6629 UP EXT ADD QUIK DSCNCT LAMNAT COLLR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6630 UP EXTREM ADD STAINLESS STEEL WRIST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6632 UP EXTREM ADD LATX SUSP SLEEVE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6635 UPPER EXTREM ADD LIFT ASSIST ELB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6637 UP EXTREM ADD NUDGE CNTRL ELB LOCK MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6638 UP EXT ADD PROS LOCK W/MNL PWR ELB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6640 UP EXTREM ADD SHLDR ABDUCT JNT PAIR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 288 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6641 UP EXTRM ADD EXCURSN AMPL PULLEY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6642 UP EXTRM ADD EXCURSN AMPL LEVER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6645 UP EXT ADD SHLDR FLX-ABDUCT JNT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6646 UP EXT ADD SHLDR JNT MX PSTN SYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6647 UP EXT ADD SHLDR LOCK MECH BDY PWR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6648 UP EXT ADD SHLDR LOCK MECH EXT PWR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6650 UP EXTRM ADD SHLDR UNIVERSAL JNT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 289 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6655 UP EXTREM ADD STD CNTRL CABLE XTRA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6660 UP EXTREM ADD HEVY DUTY CNTRL CABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6665 UP EXTREM ADD TEFLON/= CABLE LINING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6670 UP EXTREM ADD HOOK HND CABLE ADAPTR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6672 UP EXT ADD HRNSS CHST/SHLDR SADDLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6675 UP EXT ADD HARNESS 1 CABLE DESIGN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6676 UP EXT ADD HARNESS 2 CABLE DESIGN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 290 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6677 UP EXT ADD HRNSS 3 CNTRL OP DVC&ELB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6680 UP EXTRM ADD TST SCKT WRIST DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6682 UP EXTRM ADD TST SOCKT ELB DISARTIC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6684 UP EXTRM ADD TST SCKT SHLDR DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6686 UPPER EXTREM ADDITION SUCTION SOCKT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6687 UP EXT ADD FRME TYPE SCKT BELW ELB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6688 UP EXT ADD FRME TYPE SOCKT ABVE ELB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 291 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6689 UP EXT ADD FRAME SCKT SHLDR DISARTC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6690 UP EXT ADD FRAME SCKT INTRSCAP-THOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6691 UPPER EXTREM ADD REMV INSERT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6692 UP EXTREM ADD SILCON GEL INSRT/=EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6693 UP EXT ADD LOCK ELB FORARM CNTRBAL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6694 ADD UP EXT PROS CSTM W/LOCK MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6695 ADD UP EXT PROS CSTM W/O LOCK MECH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 292 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6696 ADD UP EXT PROS CNGN/TRAUMAT AMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6697 ADD UP EXT PROS NOT CNGN/TRAUM AMP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6698 ADD UP EXT PROS LOCK MECH EXC INSRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6703 TERMINAL DEVICE PASSIVE HAND/MITT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6704 TERMINAL DEVC SPORT/REC/WORK ATTACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6706 TERMINAL DEVC HOOK MECH VOL OPENING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6707 TERMINAL DEVC HOOK MECH VOL CLOSING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 293 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6708 TERMINAL DEVC HAND MECH VOL OPENING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6709 TERMINAL DEVC HAND MECH VOL CLOSING MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6711 TERM DVC HOOK MECH VOL OPN PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6712 TERM DVC HOOK MECH VOL CLOS PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6713 TERM DVC HAND MECH VOL OPN PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6714 TERM DEVC HAND MECH VOL CLOS PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6715 TERM DEVC MX ARTC DIG INIT ISS/REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 294 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6721 TERM DEVC HOOK/HAND HD MECH VOL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. OPN No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6722 TERM DEVC HOOK/HND HD MECH VOL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. CLOS No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6805 ADD TERM DEVICE MODIFIER WRIST UNIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6810 ADD TERM DEVC PRECISION PINCH DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6880 ELEC HND SW/MYOLELEC CNTRL ARTC DIG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6881 AUTO GRASP ADD UPPER LIMB PROS DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6882 MICRPROCSS CNTRL ADD UP LIMB PROSTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 295 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6883 REPL SOCKET BE/WD MOLDED TO PT MDL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6884 REPL SOCKT ABOVE ELB DISART MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6885 REPL SOCKT SD/INTRSCAP THOR MOLD PT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6890 ADD UP EXT PROSTH GLOV TERM PRFAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6895 ADD UP EXT PROSTH GLOV TERM CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6900 HND REST PART W/GLOV THUMB/1 FNGR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6905 HND REST PART HND W/GLOV MX FNGR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 296 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6910 HND REST PART HND W/GLOV NO FNGR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6915 HAND REST REPL GLOVE FOR ABOVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6920 WRST DISARTC OTTO BOCK/=SWTCH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6925 WRST DSRTC OTTO BOCK/=MYOELC CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6930 BELW ELB OTTO BOCK/=SWITCH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6935 BELW ELB OTTO BOCK/=MYOELEC CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6940 ELB DISRTC OTTO BOCK/=SWITCH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 297 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L6945 ELB DISRTC OTTO BOCK/=MYOELC CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6950 ABVE ELB OTTO BOCK/=SWITCH CONTROL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6955 ABVE ELB OTTO BOCK/=MYOELEC CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6960 SHLDR DSRTC OTTO BOCK/=SWTCH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6965 SHLDR DSRTC OTTO BOCK/=MYOELC CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6970 INTERSCAP-THOR OTTO BOCK/=SWITCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L6975 INTERSCAP-THOR OTTO BOCK/=MYOELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 298 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L7007 ELEC HND SWTCH/MYOELEC CNTRL ADULT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7008 ELEC HAND SWITCH/MYOELEC CNTRL PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7009 ELEC HOOK SWITCH/MYOELC CNTRL ADULT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7040 PREHENSILE ACTUATOR SWITCH CONTROL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7045 ELEC HOOK SWITCH MYOELEC CONTRL PED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7170 ELEC ELB HOSMER/EQUAL SWITCH CNTRL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7180 ELEC ELB SEQENTL CNTRL ELB&TRM DEV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 299 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L7181 ELEC ELB SIMULTAN CNTRL ELB&TRM DEV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7185 ELEC ELB ADOLES VRITY VILL/=SWITCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7186 ELEC ELB CHLD VRITY VILL/=SWITCH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7190 ELEC ELB ADOLES VRITY VILL/=MYOELC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7191 ELEC ELB CHLD VRITY VILL/=MYOELEC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7360 SIX VOLT BATTERY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7362 BATTERY CHARGER 6 VOLT EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 300 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L7364 TWELVE VOLT BATTERY EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7366 BATTERY CHARGER TWELVE VOLT EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7367 LITHIUM ION BATT RECHARGEABLE REPL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7368 LITHIUM ION BATT CHARGER REPL ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7400 ADD UP EXT PROS BE/WD ULTRALT MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7401 ADD UP EXT PROS ABV ED ULTRALT MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7402 ADD UP EXT PROS SD/INTRSCAP THOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 301 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L7403 ADD UP EXT PROS BE/WD ACRYLIC MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7404 ADD UP EXT PROS ABVE ED ACRYLC MATL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7405 ADD UP EXT PROS SD/INTERSCAP THOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7499 UPPER EXTREMITY PROSTHESIS NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7510 REP PROS DEVC REP/REPL MINOR PART MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7520 REPR PROSTH DEVC LABR CMPNT-15 MIN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7600 PROSETIC DONNING SLEEVE MATERIAL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 302 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L7900 MALE VACUUM ERECTION SYSTEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L7902 TENSION RING VAC ERECT DEVC REPL EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8000 BREAST PROS MAST BRA NO INTEG FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8001 BREAST PROS MAST BRA INTEG FORM UNI MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8002 BREAST PROS MAST BRA INTEG FORM BIL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8010 BREAST PROSTHESIS MASTECTOMY SLEEVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8015 EXT BREAST PROS GARMNT POST-MASTECT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 303 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8020 BREAST PROSTHESIS MASTECTOMY FORM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8030 BREAST PROS SILCON/=NO INTGRL ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8031 BREAST PROS SILCON/= W/NTGRL ADHES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8032 NIPPLE PROSTH REUSABLE ANY TYPE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8035 CSTM BRST PROSTH POST MASTECT MOLD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8039 BREAST PROSTHESIS NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8040 NASL PROSTH PROVIDED NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 304 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8041 MIDFCE PROSTH PROV NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8042 ORB PROSTH PROVIDED NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8043 UPPER FCE PROSTH PROV NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8044 HEMI-FCE PROSTH PROV NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8045 AURICULAR PROSTH PROV NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8046 PART FCE PROSTH PROV NON-PHYSICIAN MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8047 NASL SEPTAL PROSTH PROV NON-PHYS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 305 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8048 UNS MAXLOFCE PROSTH BR PROV NON-MD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8049 REP MAXLOFCE PROS EA 15 MIN NON-MD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8300 TRUSS SINGLE WITH STANDARD PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8310 TRUSS DOUBLE WITH STANDARD PADS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8320 TRUSS ADDITION STANDARD PAD H2O PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8330 TRUSS ADD STANDARD PAD SCROTAL PAD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8400 PROSTHETIC SHEATH BELOW KNEE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 306 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8410 PROSTHETIC SHEATH ABOVE KNEE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8415 PROSTHETIC SHEATH UPPER LIMB EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8417 PROS SHEATH/SOCK-GEL CUSHN BK/AK EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8420 PROSTHETIC SOCK MX PLY BELW KNEE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8430 PROSTHETIC SOCK MX PLY ABVE KNEE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8435 PROSTH SOCK MX PLY UPPER LIMB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8440 PROSTHETIC SHRINKER BELOW KNEE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 307 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8460 PROSTHETIC SHRINKER ABOVE KNEE EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8465 PROSTHETIC SHRINKER UPPER LIMB EACH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8470 PROSTH SOCK 1 PLY FIT BELW KNEE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8480 PROSTH SOCK 1 PLY FIT ABVE KNEE EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8485 PROSTH SOCK 1 PLY FIT UPPER LIMB EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8499 UNLISTED PROC MISC PROSTH SERVICES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8500 ARTIFICIAL LARYNX ANY TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 308 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8501 TRACHEOSTOMY SPEAKING VALVE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8505 ARTFICL LARYNX REPLCMT BATTRY/ACSS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8507 TRACHEO-ESOPH VOICE PROSTH PT INSRT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8509 TRACHEO-ESOPH VOICE PROS INSRT PROV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8510 VOICE AMPLIFIER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8511 INSRT INDWLL TRACHEOESOPH PROS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. W/WO No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8512 GELATIN CAPS/EQUVALNT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. W/TRACHEOESOP No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 309 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8513 CLEANING DEVC USED W/TRACHEOESOPH V MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8514 TRACHEOESOPH PUNCT DILAT REPLCMT ON MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8515 GELATN CAP APPLC DEV TE VOICE PRSTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

L8600 IMPL BREAST PROSTH SILICONE/EQUAL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Breast Reconstruction Breast Reconstruction (Eff 5/1/21)

L8614 COCHLEAR DEVC INCL INT&EXT COMPNENT MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8615 HEADSET/HEADPIECE COCHLR IMPL REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8616 MICROPHONE COCHLEAR IMPL DEVC REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 310 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8617 TRNSMTTING COIL COCHLEAR IMPL REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8618 TRANSMITER CABLE COCHLEAR IMPL REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8619 COCHLR IMPL SPCH PRCSSR/CNTLR REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8627 COCHLEAR IMPL EXT PROCSSR CMPNT RPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8628 COCHLR IMPL EXT CONTRLLR CMPNT REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

L8629 TRANSMIT COIL CABLE COCHLR DEV RPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 311 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8679 IMPL NEUROSTIMULATOR PULSE GEN ANY MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) PA required for SCO Products Policy: InterQual® criteria is available

L8680 IMPL NEUROSTIMULATOR ELECTRODE EA MH QHP SCO Please review the BMCHP policy for authorization/criteria details or InterQual® criteria used. Provide Yes Yes No clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8681 PT PRG IMP NEURO PLSE GEN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8682 IMPL NEUROSTIMULATOR RADIOFREQ RECV MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes Yes clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8683 RF TRNSMT W/IMPL NEUROSTIM RF RECV MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes Yes clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8684 RAD TRSM IMP SAC ROOT STIM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 312 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8685 IMPL NEUROSTIM 1 ARRAY RECHARGEABLE MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes No clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8686 IMPL NEUROSTIM 1 ARRAY NON-RECHARGE MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes No clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8687 IMPL NEUROSTIM 2 ARRAY RECHARGEABLE MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes No clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8688 IMPL NEUROSTIM 2 ARRAY NON-RECHARGE MH QHP SCO Please review the BMCHP policy for authorization/criteria details OR InterQual® criteria used. Provide Yes Yes No clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

L8689 EXT CHRG BATT IMP STIM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 313 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L8690 AUDITORY OSSEOINTEGRTD INT/EXT COMP MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21)

L8691 AUDITORY OSSEOINTEGRTD EXT SND REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21)

L8692 AUDITORY OSSEOINTEGRAT DEV BDY WORN MH QHP SCO Yes Yes

L8693 AUD OSSEOINTEGRATED DEVC ABUT REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21)

L8694 AUD OI DVC TRNSDUCR/ACTUATR REPL EA MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21)

L8695 EXT RECHARG SYS IMPL NEUROSTIM REPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Eff 10/1/20)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 314 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

L9900 ORTHO/PROSTH SUPP ACCES &/ SERV MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

M0075 CELLULAR THERAPY MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes No No Policy: Complementary and Alternative Medicine, Including Acupuncture Complementary and Alternative Medicine, Including Acupuncture (Eff 1/1/21)

M0076 PROLOTHERAPY MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Prolotherapy Prolotherapy (Eff 8/1/20) Retired 8/31/21 Prolotherapy (Eff 9/1/21)

Q2028 INJECTION SCULPTRA 0.5 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

Q2041 AXICABTAGENE CILOLEUCEL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Car T-Cell Therapy to Treat Hematological Malignancies Car T-Cell Therapy to Treat Hematological Malignancies (Eff 5/1/21) Retired 10/31/21 Car T-Cell Therapy to Treat Hematological Malignancies (Eff 11/1/21)

Q2042 CTIL019 TO 600 M CAR-+ VI T CE P TD MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Car T-Cell Therapy to Treat Hematological Malignancies Car T-Cell Therapy to Treat Hematological Malignancies (Eff 5/1/21) Retired 10/31/21 Car T-Cell Therapy to Treat Hematological Malignancies (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 315 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q2053 Brexucabtagene car pos t MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Car T-Cell Therapy to Treat Hematological Malignancies Car T-Cell Therapy to Treat Hematological Malignancies (Eff 5/1/21) Retired 10/31/21 Car T-Cell Therapy to Treat Hematological Malignancies (Eff 11/1/21)

Q4074 ILOPROST INHAL UNIT DOSE TO 20 MCG MH QHP SCO See Pharmacy Policy Yes Yes Policy: Pharmacy Pharmacy Policies

Q4081 INJ EPOETIN ALFA 100 UNITS MH QHP SCO No No Policy: Pharmacy Pharmacy Policies

Q4100 SKIN SUBSTITUTE NOT OTHERWISE SPECI MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4101 APLIGRAF PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4102 OASIS WOUND MATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4103 OASIS BURN MATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 316 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4104 INTEGRA BMWD PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4105 INTGRA DRT/OMNIGR DERM RGN MTX P SC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4106 DERMAGRAFT PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4107 GRAFTJACKET PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4108 INTEGRA MATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4110 PRIMATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4111 GAMMAGRAFT PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 317 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4112 CYMETRA INJECTABLE 1 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4113 GRAFTJACKET XPRESS INJECTABLE 1CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4114 INTEGRA FLOWABL WND MATRIX INJ 1 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4115 ALLOSKIN PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4116 ALLODERM PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4117 HYALOMATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4118 MATRISTEM MICROMATRIX 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 318 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4121 THERASKIN PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4122 DERMACELL PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4123 ALLOSKIN RT PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4124 OASIS ULTRA TRI-LAY WND MATRX SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4125 ARTHROFLEX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4126 MEMODERM TRANZGRAFT/INTEGUPLY SQ MH QHP SCO Please review the BMCHP policy for authorization/criteria details CM Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4127 TALYMED PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 319 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4128 FLEX HD OR ALLOPATCH HD PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4130 STRATTICE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4132 GRAFIX CORE PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4133 GRAFIX PRIME PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4134 HMATRIX PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4135 MEDISKIN PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4136 E-Z DERM PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 320 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4137 AMNIOEXCEL OR BIODEXCEL PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4138 BIODFENCE DRYFLEX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4139 AMNIOMATRIX OR BIODMATRIX INJ 1 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4140 BIODFENCE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4141 ALLOSKIN AC PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4142 XCM BIOLOGIC TISSUE MATRIX PER SQ C MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4143 REPRIZA PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 321 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4145 EPIFIX INJECTABLE 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4146 TENSIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4147 ARCHITECT EXTRACELLULAR MATRIX PER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4148 NEOX 1K PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4149 EXCELLAGEN 0.1 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4150 ALLOWRAP DS/DRY PER SQ CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4151 AMNIOBAND/GUARDIAN PER SQ MH QHP SCO Please review the BMCHP policy for authorization/criteria details CENTIMETR Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 322 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4152 DERMAPURE PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4153 DERMAVEST AND PLURIVEST PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4154 BIOVANCE PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4155 NEOXFLO OR CLARIXFLO 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4156 NEOX 100 PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4157 REVITALON PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4158 MARIGEN PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 323 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4159 AFFINITY PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4160 NUSHIELD PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4161 BIO-CONNEKT WOUND MATRIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4162 AMNIOPRO FLOW AMNIOGEN-C 0.5 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4163 AMNIOPRO AMNIOGEN-200 PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4164 HELICOLL PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4165 KERAMATRIX PER SQUARE CENTIMETER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 324 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4166 CYTAL PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4167 TRUSKIN PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4168 AMNIOBAND 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4169 ARTACENT WOUND PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4170 CYGNUS PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4171 INTERFYL 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4173 PALINGEN/PALINGEN XPLUS PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 325 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4174 PALINGEN/PROMATRX 0.36 MG P 0.25 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4175 MIRODERM PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4176 NEOPATCH PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4177 FLOW AMNIOPATCH 0.1CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4178 FLOWERAMNIOPATCH PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4179 FLOWERDERM PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4180 REVITA PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 326 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4181 AMNIO WOUND PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4182 TRANSCYTE PER SQUARE CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4183 SURGIGRAFT PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4184 CELLESTA PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4185 CELLESTA FLOWABLE AMNION;PER 0.5 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4186 EPIFIX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4187 EPICORD PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 327 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4188 AMNIOARMOR PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4189 ARTACENT AC 1 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4190 ARTACENT AC PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4191 RESTORIGIN PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4192 RESTORIGIN 1 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4193 COLL-E-DERM PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4194 NOVACHOR PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 328 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4195 PURAPLY PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4196 PURAPLY AM PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4197 PURAPLY XT PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4198 GENESIS AMNIOTIC MEMBRANE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4200 SKINTE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4201 MATRION PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4202 KEROXX (2.5G/CC) 1CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 329 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4203 DERMA-GIDE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4204 XWRAP PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4205 Membrane graft or membrane wrap, per MH QHP SCO Please review the BMCHP policy for authorization/criteria details square centimeter Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4206 Fluid flow or fluid GF, 1 cc MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4208 Novafix, per square cenitmeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4209 Surgraft, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4210 Axolotl graft or axolotl dualgraft, per square MH QHP SCO Please review the BMCHP policy for authorization/criteria details centimeter Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 330 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4211 Amnion bio or Axobiomembrane, per MH QHP SCO Please review the BMCHP policy for authorization/criteria details square centimeter Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4212 Allogen, per cc MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4213 Ascent, 0.5 mg MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4214 Cellesta cord, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4215 Axolotl ambient or axolotl cryo, 0.1 mg MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4216 Artacent cord, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4217 Woundfix, BioWound, Woundfix Plus, MH QHP SCO Please review the BMCHP policy for authorization/criteria details BioWound Plus, Woundfix Xplus or Yes Yes Yes BioWound Xplus, per square centimeter Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 331 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4218 Surgicord, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4219 Surgigraft-dual, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4220 BellaCell HD or Surederm, per square MH QHP SCO Please review the BMCHP policy for authorization/criteria details centimeter Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4221 Amniowrap2, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4222 Progenamatrix, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4226 MyOwn Skin, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4227 AMNIOCORETM PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 332 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4228 BIONEXTPATCH PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4229 COGENEX AMNIOTIC MEMBRANE PER SQ MH QHP SCO Please review the BMCHP policy for authorization/criteria details CM Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4230 COGENEX FLOWABLE AMNION PER 0.5 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4231 CORPLEX P PER CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4232 CORPLEX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4233 SURFACTOR OR NUDYN PER 0.5 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4234 XCELLERATE PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 333 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4235 AMNIOREPAIR OR ALTIPLY PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4236 CAREPATCH PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4237 CRYO-CORD PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4238 DERM-MAXX PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4239 AMNIO-MAXX OR AMNIO-MAXX LITE PER MH QHP SCO Please review the BMCHP policy for authorization/criteria details SQ CM Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4240 CORECYTE FOR TOPICAL USE ONLY PER 0.5 MH QHP SCO Please review the BMCHP policy for authorization/criteria details CC Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4241 POLYCYTE FOR TOPICAL USE ONLY PER 0.5 MH QHP SCO Please review the BMCHP policy for authorization/criteria details CC Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 334 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4242 AMNIOCYTE PLUS PER 0.5 CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4244 PROCENTA PER 200 MG MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4245 AMNIOTEXT PER CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4246 CORETEXT OR PROTEXT PER CC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4247 AMNIOTEXT PATCH PER SQ CM MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4248 DERMACYTE AMNIOTIC MEMBRANE MH QHP SCO Please review the BMCHP policy for authorization/criteria details ALLOGRAFT PER SQ CM Yes Yes Yes Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 335 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

Q4249 Amniply, for topical use only, per square MH QHP SCO Please review the BMCHP policy for authorization/criteria details centimeter Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4250 Amnioamp-mp, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4254 Novafix dl, per square centimeter MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

Q4255 Reguard, for topical use only, per square MH QHP SCO Please review the BMCHP policy for authorization/criteria details centimeter Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Skin Substitutes in the Outpatient Setting Skin Substitutes in the Outpatient Setting (Eff 1/1/21)

S0207 PARAMED INTERCEPT NON-HOS-BASED ALS MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix.

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 336 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S0208 PARAMED INTRCPT ALS NON-TRNSPRT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix.

S0209 WHEELCHAIR VAN MILEAGE PER MILE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No Yes Yes via information located in plan Auth Matrix.

S0215 NON-EMERG TRANSPORTATION; PER MILE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

S1001 DELUXE ITEM PATIENT AWARE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S1002 CUSTOMIZED ITEM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S1015 IV TUBING EXTENSION SET MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S1016 NON-PVC IV ADMN SET RX NOT STABLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S1034 ARTIF PANC DEVC SYS CMNCT ALL DEVC MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 337 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S1035 SNSR;INVASV DSPBL ART PANC DEVC SYS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

S1036 TRANSMTTR;EXT USE ART PANC DEVC SYS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

S1037 RECVER; EXT USE ARTIF PANC DEVC SYS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Eff 12/1/20)

S1040 CRANIAL REMOLD ORTHOT PED CUST FAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S2053 TPLNT SM INTESTINE&LIVER ALLOGFTS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Eff 4/1/20) Retired 6/30/21 Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Eff 7/1/21)

S2054 TRANSPLANTATION MULTIVISCERAL ORGN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Eff 4/1/20) Retired 6/30/21 Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 338 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S2060 LOBAR LUNG TRANSPLANTATION MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Transplantation of Lung or Lobar Lung Transplantation of Lung or Lobar Lung (Eff 6/1/21)

S2061 DONOR LOBECT TPLNT LIVING DONOR MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Transplantation of Lung or Lobar Lung Transplantation of Lung or Lobar Lung (Eff 6/1/21)

S2065 SIMULTANEOUS PANC KIDNEY TPLNT MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Transplantation of Pancreas or Pancreas-Kidney Transplantation of Pancreas or Pancreas-Kidney (Eff 6/1/21)

S2102 ISLET CELL TISS TPLNT PANC; ALLOGEN MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

S2112 ARTHROSCOPY KNEE SURG HARVEST CART MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Eff 3/1/21)

S2230 IMPL MAGNT CMPNT SEMI-IMPL HEAR DVC MH QHP SCO Please review the BMCHP policy for authorization/criteria details No No No Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21) Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 339 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S2325 HIP CORE DECOMPRESSION MH QHP SCO

Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

S2348 DECOMP PERQ DISC RF 1/MX LUMB MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Minimally Invasive Procedures and Associated Devices used to Treat Back Pain Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Eff 6/1/21) Retired 8/31/21 Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Eff 9/1/21)

S2404 REPAIR MMG FETUS IN UTERO MH QHP SCO

Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

S3840 DNA ANALYSIS RET PROTO-ONCOGENE MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3841 GENETIC TESTING FOR RETINOBLASTOMA MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3842 GENETIC TST VON HIPPEL-LINDAU DZ MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 340 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S3844 DNA ANALY GJB2 CONGN PFND DEAFNESS MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3845 GENETIC TESTING ALPHA-THALASSEMIA MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3846 GENETIC TST HGB E BETA-THALASSEMIA MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc. Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3849 GENETIC TESTING NIEMANN-PICK DZ MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3850 GENETIC TESTING SICKLE CELL ANEMIA MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3852 DNA ANALY APOE EPSILON 4 ALLELE ALZ MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3853 GENETIC TST MYOTONIC MUSC DYSTROPHY MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 341 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S3854 GENE EXPRESSION PROFILING PANEL MH QHP SCO InterQual® criteria used. Provide clinical documentation supporting rationale for request (e.g., notes, lab Yes Yes Yes values, X-rays, etc.) Policy: InterQual® criteria is available

S3861 GENETIC TEST SCN5A&VARIANTS SPCT BS MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3865 COMP GENE SEQUENCE ANALYSIS HCM MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3866 GENETIC ANALYSIS GENE MUTAT HCM MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S3870 CGH MICROARRAY TEST DD ASD &/OR ID MH QHP SCO InterQual® criteria used in conjunction with medical policy. Provide clinical documentation supporting Yes Yes No rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies Policy: Genetic/Genomic Testing and Pharmacogenetics Genetic/Genomic Testing and Pharmacogenetics (Eff 7/1/21)

S4011 IN VITRO FERTILIZATION; MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4013 COMPLETE CYCLE GIFT CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 342 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S4014 COMPLETE CYCLE ZIFT CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4015 COMPLETE IVF CYCLE CASE RATE NOS MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4016 FROZEN IVF CYCLE CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4017 INCPL CYCL TX CANCELD PRIOR TO STIM MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4018 FRZN EMB TRANS CANCL CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4020 IVF PROC CANCL BEFR ASPIR CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 343 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S4021 IVF PROC CANCL AFTR ASPIR CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4022 ASSIST OOCYTE FERTILIZ CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4023 DONOR EGG CYCLE INCPL CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4025 DONOR SRVC IN VITRO FERTILIZATION MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4026 PROCUREMENT DONR SPERM SPERM BANK MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4028 MICSURG EPIDIDYMAL SPERM ASPIR MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 344 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S4030 SPERM PROCUREMENT&CRYOPRES; 1 VISIT MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4031 SPERM PROCURE&CRYOPRES; SUBSQT VST MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4035 STIM INTRAUTERINE INSEMIN CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S4037 CRYOPRESERVD EMBRYO TRNSF CASE RATE MH QHP SCO Please review the BMCHP policy for authorization/criteria details No Yes No Policy: Infertility Services Infertility Services (Eff 10/1/20) Retired 10/31/21 Infertility Services (Eff 11/1/21)

S5102 DAY CARE SERVICES ADULT; PER DIEM MH QHP SCO

Policy: Adult Medical Day Care

S5160 EMERG RESPONSE SYSTEM; INSTL&TST MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 345 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S5161 EMERG RESPONSE SYS; SRVC FEE-MONTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S5162 EMERG RESPONSE SYS; PURCHASE ONLY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S5523 HIT INSRT ML VEN CATH NRS SRVC ONLY MH QHP SCO

Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

S5560 INSULIN DEVC REUSABLE PEN;1.5 ML SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S5561 INSULIN DEVC REUSABLE PEN; 3 ML SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S5565 INSULIN CARTRIDGE NOT PUMP; 150 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 346 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S5566 INSULIN CARTRIDGE NOT PUMP; 300 U MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8032 LDCT LUNG CANCER SCREENING MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

S8035 MAGNETIC SOURCE IMAGING MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

S8037 MR CHOLANGIOPANCREATOGRAPHY MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

S8042 MAGNETIC RESONANCE IMAG LOW-FIELD MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

S8085 F-18 FDG IMAG 2-HD COINCDENC DETCT MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 Yes Yes Policy: eviCore eviCore

S8092 ELECTRON BEAM COMPUTED MH QHP SCO For information about PA requirements, please contact eviCore via FAX 888-693-3210 TOMOGRAPHY Yes Yes Policy: eviCore eviCore

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 347 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S8096 PORTABLE PEAK FLOW METER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8097 ASTHMA KIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8100 HOLD CHAMB W/INHAL/NEBULIZR;NO MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. MASK No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8101 HOLD CHAMB W/INHAL/NEBULIZR; MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. W/MASK No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8120 O2 CNTN GASEOUS 1 U = 1 CUBIC FOOT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8121 O2 CONTENTS LQD 1 U EQUALS 1 POUND MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8130 INTERFERENTIAL CURR STIM 2 CHANNEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 348 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S8131 INTERFERENTIAL CURR STIM 4 CHANNEL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8185 FLUTTER DEVICE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8186 SWIVEL ADAPTOR MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8189 TRACHEOSTOMY SUPPLY NOC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8210 MUCUS TRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8265 HABERMAN FEEDER CLEFT LIP/PALATE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8270 ENURESIS ALARM BUZZ&/VIBRATION DEVC MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 349 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S8301 INFECTION CONTROL SUPPLIES NOS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8420 GRADENT PRESS AID SLEEVE&GLOVE CSTM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8421 GRADENT PRESS AID SLV&GLOV RDY MADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8422 GRADENT PRESS AID SLEEV CSTM MED WT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8423 GRADENT PRESS AID SLEEV CSTM HVY WT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8424 GRADENT PRESS AID SLEEVE READY MADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8425 GRADENT PRESS AID GLOVE CSTM MED WT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 350 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S8426 GRADENT PRESS AID GLOVE CSTM HVY WT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8427 GRADENT PRESS AID GLOVE READY MADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8428 GRADENT PRESS AID GAUNTLET RDY MADE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8429 GRADIENT PRESSURE EXTERIOR WRAP MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8430 PADDING COMPRESSION BANDAGE ROLL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8431 COMPRESSION BANDAGE ROLL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8450 SPLINT PREFABRICATED DIGIT MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 351 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S8451 SPLINT PREFABRICATED WRIST OR ANKLE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8452 SPLINT PREFABRICATED ELBOW MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8460 CAMISOLE POST-MASTECTOMY MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8490 INSULIN SYRINGES MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S8930 E-STIM AUR ACP PNT;EA 15 MIN 1-1 PT MH QHP SCO Please review the BMCHP policy for authorization/criteria details and/or PA Matrix category for Yes No Yes Acupuncture Policy: Complementary and Alternative Medicine, Including Acupuncture Complementary and Alternative Medicine, Including Acupuncture (Eff 1/1/21)

S8940 EQUESTRIAN/HIPPOTHERAPY PER SESSION MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes No No Policy: Complementary and Alternative Medicine, Including Acupuncture Complementary and Alternative Medicine, Including Acupuncture (Eff 1/1/21)

S9055 PROCUREN/OTH GROWTH FACTOR PREP MH QHP SCO

Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 352 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S9090 VERT AXIAL DECOMPRS PER SESSION MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes No Policy: Mechanized Spinal Distraction Therapy Mechanized Spinal Distraction Therapy (Eff 3/1/21)

S9123 NRS CARE HOM; REGISTERED NURSE-HOUR MH QHP SCO

Policy: Private Duty Nursing Services Private Duty Nursing Services (Eff 6/1/20)

S9124 NURSING CARE THE HOME; LPN PER HOUR MH QHP SCO

Policy: Private Duty Nursing Services Private Duty Nursing Services (Eff 6/1/20)

S9430 PHARM COMPOUNDING & DISPENSING MH QHP SCO SERV No No Policy: Pharmacy Pharmacy Policies

S9433 MED FOOD NUTR ORAL 100% NUTR INTAKE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S9434 MOD SOLID FOOD SUP INBORN ERR METAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

S9435 MEDICAL FOODS INBORN ERRORS METAB MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 353 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S9470 NUTRITIONAL CNSL DIETITIAN VISIT MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP: InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

S9472 CARD REHAB PROGM NON-PHYS PROV MH QHP SCO Please review the BMCHP policy for authorization/criteria details DIEM Yes Yes Yes Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21) Policy: Medically Necessary Medically Necessary (Eff 7/1/21) Retired 8/31/21 Medically Necessary (Eff 9/1/21)

S9960 AMB SERVC AIR NON-ER 1 WAY FIX WING MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

S9961 AMB SERVC AIR NON-ER 1 WAY ROT WING MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

S9990 SRVC PROV PART PHASE II CLIN TRIAL MH QHP SCO No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 354 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

S9991 SRVC PROV PART PHASE III CLIN TRIAL MH QHP SCO No No Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

T1002 RN SERVICES UP TO 15 MINUTES MH QHP SCO Special Kids Special Care Program-Please review the BMCHP policy for authorization/criteria details Yes No No Policy: Private Duty Nursing Services Private Duty Nursing Services (Eff 6/1/20)

T1003 LPN/LVN SERVICES UP TO 15 MINUTES MH QHP SCO Special Kids Special Care Program-Please review the BMCHP policy for authorization/criteria details Yes No No Policy: Private Duty Nursing Services Private Duty Nursing Services (Eff 6/1/20)

T1019 PERSONAL CARE SERVICES PER 15 MINS MH QHP SCO

Policy: Personal Care Assistant Services

T1021 HOME HLTH AIDE/CERT NURSE ASST VST MH QHP SCO

Policy: Home Health Care for Maintenance Services Policy: Home Health Care Services for an Acute Episode of Care

T1030 NRS CARE HOME REGISTERED NURSE-DIEM MH QHP SCO

Policy: Home Health Care for Maintenance Services Policy: Home Health Care Services for an Acute Episode of Care

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 355 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

T1502 ADMN ORL IM&/SUBQ MED HLTH PROF MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP; InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

T1503 ADMN MED NOT ORAL&/INJ AGENCY/PROF MH QHP SCO Please review the BMCHP policy for authorization/criteria details. QHP: InterQual® criteria used in Yes Yes Yes conjunction with medical policy. Provide clinical documentation supporting rationale for request (e.g., notes, lab values, X-rays, etc.) Policy: Home Health Care MH and SCO Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: Home Health Care QHP Home Health Care (Eff 9/1/20) Retired 6/30/21 Home Health Care (Eff 7/1/21) Policy: InterQual® criteria is available

T2001 N-EMERG TRNSPRT; PT ATTENDNT/ESCORT MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes No Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

T2002 NON-EMERG TRANSPORTATION; PER DIEM MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation No No Yes via information located in plan Auth Matrix.

T2003 NON-EMERG TRNSPRT; ENCOUNTER/TRIP MH QHP SCO

Policy: Adult Medical Day Care

T2004 Non-emergency transport; commercial MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation carrier, multi-pass No No Yes via information located in plan Auth Matrix.

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 356 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

T2005 NONEMERGENCY TRNSPRT; STRETCHER MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation VAN Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

T2028 SPECIALIZED SUPPLY NOS WAIVER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T2049 NON-EMERG TRNSPRT; VAN MILEAGE;MILE MH QHP SCO SCO plan-For information regarding PA requirements, please contact BMC HealthNet Plan Transportation Yes Yes Yes via information located in plan Auth Matrix. Policy: Ambulance and Transportation Services Ambulance and Transportation Services (Eff 5/1/21)

T4521 ADLT SZ DISPBL INCONT BRF/DIAPER SM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4522 ADLT SZ DISPBL INCONT BRF/DIAPER MD MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4523 ADLT SZ DISPBL INCONT BRF/DIAPER LG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4524 ADLT DISPBL INCONT BRF/DIAPER X-LG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 357 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

T4525 ADLT SZD DISPBL INCONT UNDWEAR SM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4526 ADLT SZD DISPBL INCONT UNDWEAR MED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4527 ADLT SZD DISPBL INCONT UNDWEAR LG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4528 ADLT SZD DISPBL INCONT UNDWEAR X-LG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4529 PED SZ DISPBL INCONT BRF/DIAPER S/M MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4530 PED SZ DISPBL INCONT BRF/DIAPER LG MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4531 PED SZ DISPBL INCONT UNDWEAR SM/MED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 358 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

T4532 PED SZ DISPBL INCONT UNDWEAR LG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4533 YOUTH SZD DISPBL INCONT BRF/DIAPER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4534 YOUTH SZD DISPBL INCONT UNDWEAR EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4535 DISPBL LINER/PAD/UNDGRMNT INCONT EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4536 INCONT PROD UNDWEAR/PULLON REUSE SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4537 INCONT PROD UNDPAD REUSBL BED SZ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4538 DIAPER SRVC REUSBL DIAPER EA DIAPER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 359 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

T4539 INCONT PROD DIAPER/BRF REUSBL SZ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4540 INCONT PROD UNDPAD REUSBL CHAIR SZ MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4541 INCONT PRODUCT DISPBL UNDPAD LG EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4542 INCONT PROD DISPBL UNDPAD SM SZ EA MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T4543 ADULT DISP INCONTINENCE PROD ABV XL MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T5001 PSTN SEAT PERSON SPECL/ORTHO NEEDS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

T5999 SUPPLY NOT OTHERWISE SPECIFIED MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 360 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

V2500 CNTC LENS PMMA SPHERICAL PER LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2501 CNTC LENS PMMA/PRISM BALLST LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2502 CONTACT LENS PMMA BIFOCAL PER LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2503 CNTC LENS PMMA COLR VISN DEFIC LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2510 CNTC LENS GAS PRMEABL SPHERICL LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2511 CNTC LENS GAS PRMEABL PRSM BLLST EA MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2512 CNTC LENS GAS PERMEABLE BIFOCL LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 361 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

V2513 CNTC LENS GAS PRMEABL EXT WEAR LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2520 CNTC LENS HYDROPHIL SPHERICAL LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2521 CNTC LENS HYDROPHL/PRISM BLLST LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2522 CNTC LENS HYDROPHIL BIFOCAL LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2523 CNTC LENS HYDROPHIL EXT WEAR LENS MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2524 Contact lens, hydrophilic, spherical, MH QHP SCO Please review the BMCHP policy for authorization/criteria details photochromic additive, per lens Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21) Policy: Experimental and Investigational Treatment Experimental and Investigational Treatment (Eff 7/1/20) Retired 6/30/21 Experimental and Investigational Treatment (Eff 7/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 362 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

V2530 CNTC LENS SCLERAL GAS IMPERMEBL PER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2531 CNTC LENS SCLERAL GAS PERMEABLE PER MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2599 CONTACT LENS OTHER TYPE MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2623 PROSTHETIC EYE PLASTIC CUSTOM MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

V2624 POLISHING/RESURFACING OCULR PROSTH MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

V2625 ENLARGEMENT OF OCULAR PROSTHESIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

V2626 REDUCTION OF OCULAR PROSTHESIS MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 363 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

V2627 SCLERAL COVER SHELL MH QHP SCO Please review the BMCHP policy for authorization/criteria details. DME providers, for auth details, please Yes Yes Yes see plan's Auth Matrix for Northwood information Policy: Contact Lens and Scleral Lens Contact Lens and Scleral Lens (Eff 4/1/21)

V2628 FABRICATION&FIT OCULAR CONFORMER MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

V2629 PROSTHETIC EYE OTHER TYPE MH QHP SCO *ALL Providers please CLICK link to determine if your request is handled by Northwood or the Plan. No No No Policy: How provider types are handled by Northwood and the Plan How provider types are handled by Northwood and the Plan

V2630 ANTERIOR CHAMBER INTRAOCULAR LENS MH QHP SCO No No No Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

V2631 IRIS SUPPORTED INTRAOCULAR LENS MH QHP SCO No No Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

V2790 AMNIOTIC MEMBRANE SURG RECNSTR- MH QHP SCO PROC No No Policy: Cosmetic Reconstructive, and Restorative Services Cosmetic Reconstructive, and Restorative Services (Eff 7/1/20) Retired 8/31/21 Cosmetic Reconstructive and Restorative Services (Eff 9/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 364 of 365 Code Short Description BMCHP PA Required? Note Yes= Auth Required via Medical Policy or InterQual No= Auth not applicable, review Benefits and/or Payment Policies

V5095 SEMI-IMPL MID EAR HEARING PROSTH MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Implantable Bone-Conduction (Bone-Anchored) Hearing Aids Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 6/1/20) Retired 7/31/21 Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Eff 8/1/21)

V5273 ASSTIVE LISTEN DEVC W/COCHLEAR IMPL MH QHP SCO Please review the BMCHP policy for authorization/criteria details Yes Yes Yes Policy: Cochlear Implants Cochlear Implants (Eff 10/1/20) Retired 10/31/21 Cochlear Implants (Eff 11/1/21)

Friday, September 17, 2021 Boston Medical Center HealthNet Plan Page 365 of 365