MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0001F hrt failure assessed 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0005F osteoarthritis composite 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0012F community-acquired bacterial pneumonia assmt 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0014F comp preop assess cataract surg w/iol placemnt 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0015F melanoma follow up completed 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0016T dstrj loclzd les choroid transpupillary thermoth 1/1/2002 12/31/2078 Services BENE - Maine Excluded 0017T dstrj macular drusen pc 1/1/2002 12/31/2078 Services BENE - Maine Excluded 0019T extracorporeal shock wave muscskel nos low enrgy 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0030T antiprothrombin antibody each ig class 1/1/2003 12/31/2078 Services BENE - Maine Excluded 0042T cerebral perfusion analys ct w/blood flow&volume 1/1/2003 12/31/2078 Services BENE - Maine Excluded 0048T impltj ventr assist dev xtrcorp prq t-septal 1/1/2004 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 1 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0050T rmvl ventr dev xtrcorp prq t-septal 1/dual 1/1/2004 12/31/2078 Services BENE - Maine Excluded 0051T impltj tot rplcmt hrt sys w/rcp cardiectomy 1/1/2004 12/31/2078 Services BENE - Maine Excluded 0052T rplcmt/rpr thrc unit tot rplcmt hrt sys 1/1/2004 12/31/2078 Services BENE - Maine Excluded 0053T rplcmt/rpr impltbl compnt tot rplcmt hrt ex thrc 1/1/2004 12/31/2078 Services BENE - Maine Excluded 0054T cptr-asst muscskel navigj ortho fluor images 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0055T cptr-asst muscskel navigj ortho ct/mri 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0071T us ablatj uterine leiomyomata < 200 cc tissue 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0072T us ablatj uterine leiomyomat >/equal 200 cc tiss 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0073T compnstr-based beam modlj tx dlvr inverse 3> fld 1/1/2005 12/31/2014 Services BENE - Maine Excluded 0075T tcat plmt xtrc vrt crtd stent rs&i prq 1st vsl 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0076T tcat plmt xtrc vrt crtd stent rs&iprq ea vsl 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0078T evasc rpr aaa pseudoarysm abdl aorta visc 1/1/2006 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 2 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0079T plmt visc xtn prosth evasc rpr aaa ea visc 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0080T evasc rpr aaa pseudoarysm abdl aorta visc rs&i 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0081T plmt visc xtn prosth evasc rpr aaa ea visc rs&i 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0085T breath test heart transplant rejection 1/1/2005 12/31/2078 Services BENE - Maine Excluded 0092T tot disc arthrp ant appr dskc prep crv ea ntrspc 1/1/2009 12/31/2014 Services BENE - Maine Excluded 0095T rmvl tot disc arthrp ant appr crv ea ntrspc 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0098T revj tot disc arthrp ant appr crv ea ntrspc 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0099T impltj intrastromal corneal ring segments 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0100T plmt scjncl rta prosth&pls&impltj intra-oc rta 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0101T extrcorpl shock wave muscskele nos high energy 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0102T extrcrpl shock wave w/anes lat humerl epicondyle 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0103T holotranscobalamin quantitative 1/1/2006 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 3 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0104T inert gas rbrthing car output meas rest 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0105T inert gas rbrthing car output meas xers 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0106T quant sensory test&interpj/xtr w/touch stimuli 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0107T quant sensory test&interpj/xtr w/vibrj stimuli 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0108T quant sensory test&interpj/xtr w/cool stimuli 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0109T quant senaory test&interpj/xtr w/ht-pn stimuli 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0110T quant sensory test&interpj/xtr other stimuli 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0111T long-chain omega-3 fatty acids rbc membs 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0123T fistulization sclera glaucoma ciliary body 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0124T conjunctvl inc w/post xtrsclera plcmt pharm agnt 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0126T common carotid intima media thickness study 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0130T 1-pt chrnc care drugs invstgj 1/1/2006 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 4 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0140T exhaled breath condensate ph 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0141T pncrtc islet cell trnsplj portal perq 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0142T pncrtc islet cell trnsplj portal opn 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0143T laps pncrtc islet cell trnsplj 1/1/2006 12/31/2078 Services BENE - Maine Excluded 0153T IMPLANT ANEUR SENSOR ADD-ON 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0154T IMPLANT ANEUR SENSOR STUDY 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0155T laparoscopic impltj/rplcmt gastric electrode 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0156T laps revj/rmvl gastric eltrd < curvature 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0157T laparotomy impltj/rplcmt gastric electrode 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0158T lapt revj/rmvl gastric eltrd < curvature 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0159T computer aided detection breast mri 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0160T transcranial mag stimj tx planning 1/1/2007 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 5 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0161T transcranial mag stimj tx dlvr & mgmt 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0163T tot disc arthrp ant appr dskc prep lmbr ea 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0164T rmvl tot disc arthrp ant appr lmbr ea ntrspc 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0165T revj tot disc arthrp ant appr lmbr ea ntrspc 1/1/2009 12/31/2078 Services BENE - Maine Excluded 0166T transmyocardial closure v-septl dfct w/o bypass 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0167T transmyocardial closure v-septl dfct w/bypass 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0168T rhinophototherapy application light bilateral 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0169T stereotactic placement catheter brain 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0171T pst spinous process device insert lmbr 1 lvl 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0172T pst spinous process device insert lmbr ea lvl 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0173T monitor intraocular press during vitrectomy 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0174T cad chest radiograph concurrent w/interpretation 1/1/2007 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 6 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0175T cad chest radiograph remote from primary interpj 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0176T aqueous canal trluml dilat w/o stent retention 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0177T aqueous canal trluml dilat w stent retention 1/1/2007 12/31/2078 Services BENE - Maine Excluded 0178T 64 lead ecg w/interpretation & report 7/1/2007 12/31/2078 Services BENE - Maine Excluded 0179T 64 lead ecg w/tracing & graphics 7/1/2007 12/31/2078 Services BENE - Maine Excluded 0180T 64 lead ecg w/interpretation & report only 7/1/2007 12/31/2078 Services BENE - Maine Excluded 0181T corneal hysteresis air impulse stimj bi w/i&r 7/1/2007 12/31/2014 Services BENE - Maine Excluded 0182T hdr electronic brachytherapy per fraction 7/1/2007 12/31/2078 Services BENE - Maine Excluded 0183T low frequency wound ultrasound 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0184T rectal tumor excision transanal endoscopic 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0185T multivariate alys pt findings cptr probability 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0186T suprachoroidal pharmacologic agent delivery 1/1/2008 12/31/2078 Services 09/27/2021 Non-Covered Codes.xls Page 7 of 233 MaineCare Excluded/Non-Covered List Category Service Code Code Description Effective Date Termination Date BENE - Maine Excluded 0187T scanning cptrized oph dx img anterior i&r uni 1/1/2008 12/31/2078 Services BENE - Maine Excluded 0188T videoconferenced critical care first 30- 74 min 7/1/2008 12/31/2078 Services