Notification of Revised Preauthorization Requirements by Code update

Effective August 1, 2022, the following codes will be removed from the Preauthorization Requirements Code List:

Code Description

0009M

FETAL ANEUPLOIDY 21 18 SEQ ANALY TRISOM RISK

0014M

LIVER DS ALYS 3 BMRK SRM ALG

0015M

ADRNL CORTCL TUM BCHM ASY 25

0016M

ONC BLADDER MRNA 209 GEN ALG

0026U

ONCOLOGY (THYROID), DNA AND MMA OF 112 GENES, NEXT-GENERATION SEQUENCING, FINE NEEDLE ASPIRATE OF TH

0080U

ONC LUNG 5 CLINICAL RISK FACTORS ALG PRBLTY MAL

0081U

ONC UVEAL MLNMA MRNA GEN XPRS PRFL 15 GENE ALG

0085U

CYTOLETHAL DISTENDING TOXIN B (CdtB) AND VINCULIN IgG ANTIBODIES BY IMMUNOASSAY (ie., ELISA)

0086U

INFECTIOUS DISEASE (BACTERIAL AND FUNGAL), ORGANISM IDENTIFICATION , BLOOD CULTURE, USING rRNA FISH,

0087U

CARDIOLOGY (HEART TRANSPLANT), mRNA GENE EXPRESSION PROFILING BY MICROARRAY OF 1283 GENES, TRANSPLAN

0088U

TRANSPLANTATION MEDICINE (KIDNEY ALLOGRAFT REJECTION) MICROARRAY GENE EXPRESSION PROFILING 1494 GENE

0089U

ONCOLOGY (MELANOMA), GENE EXPRESSION PROFILING BY RTqPCR, PRAME AND LIC00518, SUPERFICIAL COLLECTION

0090U

ONCOLOGY (CUTANEOUS MELANOMA) mRNA GENE EXPRESSION PROFILING BY RT-PCR OF 23 GENES (14 CONTENT AND 9

0091U

ONCOLOGY (COLORECTAL) SCREENING, CELL ENUMERATION OF CIRCULATING TUMOR CELLS, UTILIZING WHOLE BLOOD,

0092U

ONCOLOGY (LUNG), THREE PROTEIN BIOMARKERS, IMMUNOASSAY USING MAGNETIC NANOSENSER TECHNOLOGY, PLASMA,

0093U

PRESCRIPTION DRUG MONITORING, EVALUATION OF 65 COMMON DRUGS BY LC-MS/MS, URINE, EACH DRUG REPORTED D

0095U

INFLAMMATION (EOSINOPHILIC ESOPHAGITIS), ELISA ANALYSIS OF EOTAXIN-3 (CCL216 [C-C MOTIF CHEMOKINE LI

0096U

HUMAN PAPILLOMAVIRUS (HPV), HIGH-RISK TYPES (ie, 16,18, 31, 33, 35, 39, 45, 51, 52, 56, 58,, 59, 66,

0097U

GASTROINTESTINAL PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE,

0098U

RESPIRATORY PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTI

0099U

RESPIRATORY PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTI

0100T

PROSTH RETINA RECEIVE&GEN

0100U

RESPIRATORY PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTI

0101U

HEREDITARY COLON CANCER DISORDERS (eg, LYNCH SYNDROME, PTEN HAMARTOMA SYNDROME, COWDEN SYNDROME, FAM

0102U

HEREDITARY BREAST CANCER-RELATED DISORDERS (eg, HEREDITARY BREAST CANCER, HEREDITARY OVARIAN CANCER,

0103U

HEREDITARY OVARIAN CANCER DISORDERS (eg, HEREDITARY OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCER);

0104U

HEREDITARY PAN CANCER (eg, HEREDITARY BREAST CANCER AND OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCE

0105U

NEPHROLOGY CKD ECLIA TUMOR NECROSIS ALG RKFD

0106U

GASTRIC EMPTYING SERIAL COOJ 7 TIMED BRTH SPEC

0107U

C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL

0108U

GI BARRETS ESPH QUAN IMMUNOLABEL 9 PRTN BMRK

0109U

ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU/TISS

0110U

RX MNTR 1+ORAL ONC RX & SBSTS SRM/PLSM CAP/VEN BLD

0112U

IADI TRGT SEQ ALYS 16S & 18S RRNA GENES

0113U

ONCOLOGY PRST8 MEAS PCA3 & TMPRSS2-ERG UR & PSA SRM

0114U

GI BARRETS ESOPHAGUS VIM & CCNA1 MTHYLTN ALYS ALG

0115U

RESPRI IADNA 18 VIRAL TYPE & SUBTYPE & 2 BACT TRGT

0116U

RX MNTR NZM IA 35+ DRUGS LC-MS/MS ORAL FLUID ALG

0117U

PAIN MGMT ALYS 11 ENDOGENOUS ANALYTES URINE ALG

0118U

TRANSPLANTATION MED QUAN DON-DRV CLL-FR DNA PLSM

0119U

CARDIOLOGY CERAMIDES LIQ CHROM TANDEM MS PLASMA

0120U

ONC B CLL LYMPHM MRNA GENE XPRSN PRFL 58 GEN ALG

0121U

SICKLE CELL DISEASE VCAM-1 WHOLE BLOOD

0122U

SICKLE CELL DISEASE P-SELECTION WHOLE BLOOD

0123U

MCHNL FRGLTY RBC SHEAR STRS & SPECTRAL ALYS PRFLG

0124U

FTL CGEN ABNORM BIOCHEM ASSAY 3 ANALYTES ALG

0125U

FTL CGEN ABNOR & PRNT COMP 5 ANALYTES ALG

0126U

FTL CGEN ABNOR & PRNT COMP 5 ANAL ASSMT Y CHRMSM

0127U

OB PREECLAMPSIA BIOCHEM ASSAY 3 ANALYTES ALG

0128U

OB PE BIOCHEM ASSAY 3 ANAL QUAL ASSMT Y CHRMSM

0139U

NEURO AUSTM MEAS 6 C METABLT

0140U

NFCT DS FUNGI DNA 15 TRGT

0141U

NFCT DS BACT&FNG GRAM POS

0142U

NFCT DS BACT&FNG GRAM NEG

0143U

DRUG ASSAY 120+ RX/METABLT

0144U

DRUG ASSAY 160+ RX/METABLT

0145U

DRUG ASSAY 65+ RX/METABLT

0146U

DRUG ASSAY 80+ RX/METABLT

0147U

DRUG ASSAY 85+ RX/METABLT

0148U

DRUG ASSAY 100+ RX/METABLT

0149U

DRUG ASSAY 60+ RX/METABLT

0150U

DRUG ASSAY 120+ RX/METABLT

0151U

NFCT BCT/VIR RESP NFCTJ 33

0156U

COPY NUMBER SEQUENCE ALYS

0157U

APC MRNA SEQ ALYS

0158U

MLH1 MRNA SEQ ALYS

0159U

MSH2 MRNA SEQ ALYS

0160U

MSH6 MRNA SEQ ALYS

0161U

PMS2 MRNA SEQ ALYS

0163U

ONC CLRCT SCR 3 PRTN ALG

0164U

GI IBS IA ANTI-CDTB&VINCULIN

0165U

PEANUT ALLG SPEC ASMT 64 EPI

0166U

LIVER DS 10 BIOCHEM ASY SRM

0167U

CHORNC GONADOTROPIN HCG IA

0168U

FTL ANEUPLOIDY DNA SEQ ALYS

0170U

NEURO ASD RNA NEXT GEN SEQ

0174U

ONC SOLID TUMOR 30 PRTN TRGT

0175U

PSYC GEN ALYS PANEL 15 GENES

0176U

CDTB&VINCULIN IGG ANTB IA

0178U

PEANUT ALLG ASMT EPI CLIN RX

0179U

ONC NONSM CLL LNG CA ALYS 23

0206U

NEURO ALZHEIMER CELL AGGREGJ

0207U

NEURO ALZHEIMER QUAN IMAGING

0208U

ONC MTC MRNA XPRSN ALYS 108

0209U

CYTOG CONST ALYS INTERROG

0210U

SYPHILIS TST ANTB IA QUAN

0211U

ONC PAN-TUM DNA&RNA GNRJ SEQ

0216U

NEURO INH ATAXIA DNA 12 COM

0217U

NEURO INH ATAXIA DNA 51 GENE

0218U

NEURO MUSC DYS DMD SEQ ALYS

0219U

NFCT AGT HIV GNRJ SEQ ALYS

0220U

ONC BRST CA AI ASSMT 12 FEAT

0221U

ABO GNOTYP NEXT GNRJ SEQ ABO

0222U

RHD&RHCE GNTYP NEXT GNRJ SEQ

0227U

RX ASY PRSMV 30+RX/METABLT

0228U

ONC PRST8 MA MOLEC PRFL ALG

0229U

BCAT1 PROMOTER MTHYLTN ALYS

0236U

SMN1&SMN2 FULL GENE ANALYSIS

0238U

ONC LNCH SYN GEN DNA SEQ ALY

0242U

TRGT GEN SEQ ALYS PNL 55-74

0243U

OB PE BIOCHEM ASSAY PGF ALG

0245U

ONC THYR MUT ALYS 10 GEN&37

0246U

RBC DNA GNOTYP 16 BLD GROUPS

0247U

OB PRTRM BRTH IBP4 SHBG MEAS

0248U

Oncology (brain), spheroid cell culture in a 3D microenvironment, 12 drug panel, tumor-response prediction for each drug

0249U

Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative r

0251U

Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma

0253U

Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm report

0254U

Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA sc

0255U

ANDROLOGY INFERTILITY SPERM CAPACITATION ASSMT

0256U

TMA/TMAO PROFILE MS/MS URINE ALG ALYS&REPORT

0257U

VLCAD LEUKOCYTE ENZYME ACTIVITY WHOLE BLOOD

0259U

NEPHROLOGY CKD NUCLEAR MRS MEAS GFR SRM QUAN

0261U

ONC CLRCT CA IMG ANALYSIS W/AI ASSMT 4 FEATURES

0262U

ONC SOLID TUM GEN XPRSN PRFL RT-PCR 7 GEN PTHWY

0263U

NEURO AUTISM QUAN MEAS 16 CTR CARBON METABOLITES

0275U

HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM

0279U

HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA

0280U

HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA

0281U

HEM VW DS VW PROPEPTIDE ELISA AG LEVEL

0283U

VON WILLEBRAND FACTOR TYPE 2B PLASMA

0284U

VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA

0288U

ONC LUNG MRNA QUAN PCR ALYS 11 GEN&3 REF GEN ALG

0295U

ONC BRST DUX CARC PRTN XPRSN PRFL IMHCHEM 7 PRTN

0296U

ONC ORL&/OROP CA GEN XPRSN PRFL RNA 20 MLEC FEAT

0297U

ONC PAN TUM WHL GEN SEQ PAIRED MAL&NML DNA SPEC

0299U

ONC PAN TUM WHL GEN OPT MAPG MAL&NML DNA SPEC

0301U

IADNA BARTONELLA HENSELAE & QUINTANA DDPCR

0302U

IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT

0303U

HEM RBC ADS NDOTHL/SUBNDOTHL ADS MOLEC HYPOXIC

0304U

HEM RBC ADS NDOTHL/SUBNDOTHL ADS MOLEC NORMOXIC

0305U

HEM RBC FNCLTY&DFRM FUNCJ SHEAR STRS WHL BLOOD

0306U

Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient specific pan

0307U

Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison

0308U

Cardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, adiponectin, and kidney injury molecule-1 [KIM-1]), plasma, algorithm

0309U

Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1

0310U

Pediatrics (vasculitis, Kawasaki disease [KD}), analysis of 3 biomarkers (NT-proBNP, C-reactive protein, and T-uptake), plasma, algorithm reported as a risk score for KD

0311U

Infectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)–based antimicrobial susceptibility

0312U

Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunoso

0313U

Oncology (pancreas), DNA and mRNA next-generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported

0314U

Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tis

0315U

Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embe

0316U

Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine?

0319U

Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute

0320U

Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cell

0321U

Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated a

0322U

Neurology (autism spectrum disorder [ASD]), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, liquid chromatography with tandem mass spe

0482T

ABSOLUTE QUAN MYOCARD BLD FLO PET STRESS & REST

15822

BLEPHAROPLASTY, UPPER EYELID;

15823

BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID

19324

MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT

20700

MNL PREP&INSJ DP RX DLVR DEV

20701

RMVL DEEP RX DELIVERY DEVICE

20702

MNL PREP&INSJ IMED RX DEV

20703

RMVL IMED RX DELIVERY DEVICE

20704

MNL PREP&INSJ I-ARTIC RX DEV

20705

RMVL I-ARTIC RX DELIVERY DEV

27700

ARTHROPLASTY, ANKLE;

33928

REMOVAL & RPLCMT TOTAL RPLCMT HEART SYS

33929

REMOVAL TOTAL RPLCMT HEART SYS FOR HEART TRNSPL

34111

EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION

34201

EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG IN

34203

EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; POPLITEAL-TIBIO-PERONEAL ARTERY, BY LEG INCIS

34421

THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC, FEMOROPOPLITEAL VEIN, BY LEG INCISION

34471

THROMBECTOMY, DIRECT OR WITH CATHETER; SUBCLAVIAN VEIN, BY NECK INCISION

35011

DIR REP ANEUR; OCCL DZ AX-BRACH ART ARM INCI

35184

REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; EXTREMITIES

35190

REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; EXTREMITIES

35201

REPAIR BLOOD VESSEL, DIRECT; NECK

35206

REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY

35226

REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY

35231

REPAIR BLOOD VESSEL WITH VEIN GRAFT; NECK

35236

REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY

35256

REPAIR BLOOD VESSEL WITH VEIN GRAFT; LOWER EXTREMITY

35261

REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; NECK

35266

REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; UPPER EXTREMITY

35286

REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; LOWER EXTREMITY

35321

THROMBOENDARTERECTOMY, WITH OR WITHOUT PATCH GRAFT; AXILLARY-BRACHIAL

35500

HARVEST UP EXTREM VEIN 1 SEGMENT-LOW EXTREM/CABG

35685

PLCMT VEIN PATCH/CUFF DIST ANASTM BYPS GFT SYNTH

35686

CREAT DIST AV FIST DURING LOWER EXTREM BYPS SURG

35860

EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; EXTREMITY

35879

REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH VEIN PATCH ANGIOPLASTY

35881

REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH SEGMENTAL VEIN INTERPOSI

35883

REVISION FEMORAL ANAST OPEN NONAUTOG GRAFT

35884

REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS GRAFT IN GROIN, OPEN; WITH AUTOGENOUS VEI

35903

EXCISION OF INFECTED GRAFT; EXTREMITY

36260

INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (EG, FOR CHEMOTHERAPY OF LIVER)

36261

REVISION OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP

36262

REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP

36456

PRTL EXCHANGE TRANSFUSE BLOOD/PLSM/CRYST NEWBORN

37183

REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT

37184

PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA 1ST

37185

PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA SBSQ

37186

SEC PRQ TRLUML THRMBC N-CORONARY N-INTRACRANIAL

37187

PRQ TRLUML MCHNL THRMBC VEIN

37188

PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX

37191

INS INTRVAS VC FILTR W/WO VAS ACS VSL SELXN RS&I

37192

REPSNG INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

37193

RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

37195

THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION

37197

PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING

37200

TRANSCATHETER BIOPSY

37211

THROMBOLYSIS ARTERIAL INFUSION ICRA RS&I INIT TX

37212

THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX

37213

THROMBOLYSIS ART/VENOUS INFSN W/IMAGE SUBSQ TX

37214

CESSATION THROMBOLYTIC THRPY W/CATHETER REMOVAL

37220

REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL

37221

REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI

37222

REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL

37223

REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL

37224

REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI

37225

REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL

37227

REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL

37229

REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL

37230

REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL

37231

REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL

37233

REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL

37234

REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL

37235

REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL

37236

OPEN/PERQ PLACEMENT INTRAVASCULAR STENT INITIAL

37237

OPEN/PERQ PLACEMENT INTRAVASCULAR STENT EA ADDL

37238

OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST

37239

OPEN/PERQ PLACEMT INTRAVASC STENT SAME EA ADDL

37242

VASCULAR EMBOLIZATION OR OCCLUSION ARTERIAL RS&I

37243

VASCULAR EMBOLIZE/OCCLUDE ORGAN TUMOR INFARCT

37244

VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE

37246

TRLML BALO ANGIOP OPEN/PERQ IMG S&I 1ST ART

37247

TRLML BALO ANGIOP OPEN/PERQ IMG S&I EA ADDL ART

37248

TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN

37249

TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I ADDL VEIN

37252

INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL

37253

INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL

43886

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY

43887

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY

43888

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT COMPONENT ONLY

44132

DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; FROM CADAVER DONOR

44133

DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; PARTIAL, FROM LIVING DONOR

44135

INTESTINAL ALLOTRANSPLANTATION; FROM CADAVER DONOR

44136

INTESTINAL ALLOTRANSPLANTATION; FROM LIVING DONOR

50220

NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN APPROACH INCLUDING RIB RESECTION;

50225

NEPHRECT URETERECT OPN W/RIB RES; COMP PREV SURG

50230

NEPHRECT URETERECT OPN W/RIB RES; RADL W/THRMBCT

50234

NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; THROUGH SAME INCISION

50236

NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; THROUGH SEPARATE INCISION

50240

NEPHRECTOMY, PARTIAL

50370

REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT

57465

CAM CERVIX UTERI DRG COLP

58340

CATH & INTRO SALINE/CONTRAST MATL SIS/HSG

61885

INSRT/REPL CRANIAL NEUROSTIM GEN/RECV; W/1 ARRAY

61886

INSRT/REPL CRANIAL NEUROSTIM GEN; W/ 2/> ARRAY

64553

PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE

64568

INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER

64569

REVISION/REPLMT NSTIM CRNL ELTRDS

64625

RF ABLTJ NRV NRVTG SI JT

69715

OSSEOINTGRTED IMPLNT-TEMP BONE; W/MASTOIDECT

69718

REPLAC OSSEO IMPLNT TEMP BONE; W/MASTOIDEC

69930

COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY

78803

RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); TOMOGRAPH

78830

RP LOCLZJ TUM SPECT W/CT 1

78831

RP LOCLZJ TUM SPECT 2 AREAS

78832

RP LOCLZJ TUM SPECT W/CT 2

78835

RP QUAN MEAS SINGLE AREA

81210

BRAF GENE ANALYSIS V600 VARIANT(S)

81275

KRAS GENE ANALYSIS VARIANTS IN EXON 2

81313

PCA3/KLK3 PROSTATE SPECIFIC ANTIGEN RATIO

81320

PLCG2 GENE ANALYSIS COMMON VARIANTS

81327

SEPT9 GENE PROMOTER METHYLATION ANALYSIS

81346

TYMS GENE ANALYSIS COMMON VARIANTS

81357

U2AF1 GENE COMMON VARIANTS

81360

ZRSR2 GENE COMMON VARIANTS

81401

MOLECULAR PATHOLOGY PROCEDURE LEVEL 2

81419

EPILEPSY GEN SEQ ALYS PANEL

81420

FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS

81427

GENOME RE-EVALUATION OF PREC OBTAINED GENOME SEQ

81445

GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE

81513

NFCT DS BV RNA VAG FLU ALG

81514

NFCT DS BV&VAGINITIS DNA ALG

81518

ONCOLOGY BREAST MRNA GENE EXPRESSION 11 GENES

81520

ONC BREAST MRNA GENE XPRSN PRFL HYBRD 58 GENES

81521

ONC BREAST MRNA MICRORA GENE XPRSN PRFL 70 GENES

81522

ONC BREAST MRNA 12 GENES

81523

ONC BRST MRNA NEXT GNRJ SEQ GEN XPRSN 70 CNT&31

81529

ONC CUTAN MLNMA MRNA 31 GENE

81546

ONC THYR MRNA 10,196 GEN ALG

81551

ONC PRST8 PRMTR METHYLATION PRFL R-T PCR 3 GENES

81554

PULM DS IPF MRNA 190 GEN ALG

81560

TRNSPLJ PED LVR&BWL MES CD154+T CLL WHL PRPH BLD

87563

M. GENITALIUM AMP PROBE

91113

GI TRACT IMAGING INTRALUMINAL COLON I&R

92507

TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL

92508

TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 O

92521

EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER)

92522

EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE

92523

EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION

92524

BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE

92526

TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING

93319

3D ECHO IMG&PST-PXESSING TEE/TTE CGEN CAR ANOMAL

93320

DOPPLER ECHO CONT WAVE W/SPECTRAL DISPLY; CMPL

93321

DOPPLER ECHO CONT WAVE W/SPECTRL DISPLY; F/U-LTD

93325

DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOC

93356

MYOCRD STRAIN IMG SPCKL TRCK

93797

OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR

93798

OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING

96125

STANDARDIZED COGNITIVE PERFORMANCE TESTING

97001

PHYSICAL THERAPY EVALUATION

97026

APPL MODALITY 1+ AREAS INFRARED

97033

APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN

97532

DEVELOPMENT OF COGNITIVE SKILLS EACH 15 MINUTES

97762

CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED PATIENT, EACH 15 MINUTES

98925

OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGIONS

98926

OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS

98927

OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS

98928

OSTEOPATHIC MANIPULATIVE TX 7-8 BDY REGIONS

98929

OSTEOPATHIC MANIPULATIVE TX 9-10 BDY REGIONS

99483

ASSMT & CARE PLANNING PT W/COGNITIVE IMPAIRMENT

A2006

NOVOSORB SYNPATH DERMAL MATRIX PER SQ CM

A2007

RESTRATA PER SQ CM

A2008

THERAGENESIS PER SQ CM

A2009

SYMPHONY PER SQ CM

A2010

APIS PER SQ CM

A2011

Supra sdrm, per square centimeter

A2012

Suprathel, per square centimeter

A2013

Innovamatrix fs, per square centimeter

B4187

OMEGAVEN 10 G LIPIDS

C1748

ENDO 1-USE UPPER GI IMAG/ILLUM DEVC

C1849

SKIN SUBST SYNTH RESORB PER SQ CM

C9759

TRANSCATH IO BLD VES MICROINFUS TX

C9760

PC AVF DIR TISS APP TR E&SEC RDR BF

C9762

CMRI MRPHOL&FNC Q SEG DYSF;STR IMAG

C9764

REV EVAR OPEN/PERQ ANY VES;IV LITHO

C9765

REV EVAR ANY VES;IV LITH&TL STNT PL

C9766

REV EVAR ANY VES;IV LITHO&ATHERECT

C9767

REV EVAR VES;IV LTHO&TL STNT&ATHRCT

G0237

MUSCLES FACE TO FACE ONE ON ONE EACH 15 MINUTES

G0238

TX PROC IMPRV RESP FUNCT NOT G0237 FCE-FCE 15MIN

G0239

TX PROC IMPRV RESP FUNCT/INCR RESP MUSC 2/> IND

G0281

E-STIM 1/> AREAS CHRONIC STAGE III&IV ULCERS

G0329

ELECMAGNET TX ULCERS NOT HEALING 30 DAYS CARE

G0422

INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING WITH EXERCISE, PER SESSI

G0423

INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING; WITHOUT EXERCISE, PER S

G0424

PULMONARY REHAB W EXER

G0460

AUTOLOGOUS PLATELET RICH PLASMA FOR CHRONIC WOUNDS/ULCERS, INCLUDING PHLEBOTOMY, CENTRIFUGATION, AND

G0515

DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY

G2000

BLINDED ADMINISTRATION OF CONVULSIVE THERAPY PROCEDURE, EITHER ELECTROCONVULSIVE THERAPY (ECT, CURRE

G2170

PC AVF DIR TISS APP TR E&SEC RDR BF

G2171

PRQ AVF DR ANY MG-GD ART&V CTH&RF E

J1952

LEUPROLIDE INJECTABLE CAMCEVI, 1 MG

J7168

PRT COMPLEX CONC KCENTRA PER IU FIX ACT

J9061

INJECTION, AMIVANTAMAB-VMJW 2 MG

J9144

INJ DARA 10 MG & HYALURONIDASE-FIHJ INJECTION DARATUMUMAB 10 MG & HYALURONIDASE-FIHJ

J9272

INJECTION, DOSTARLIMAB-GXLY 10 MG

K0606

AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT TYPE

K1002

CES SYS INCL ALL SPL & ACCESS ANY T

K1003

WHIRLPOOL TUB WALK IN PORTABLE

K1004

LOW FREQ U/S DIA TX DVC HOME USE

K1005

DISP COLL & STRG BAG BM ANY SZ T EA

K1006

SP HOME MODEL ELEC USE EXT URINE MS

K1007

BIL HKAFO DEVC PWR PELV COMP UP KJ

K1016

TRANSCUT ELEC NERVE STIM FOR ELEC STIM TG NERVE

K1017

MONTHLY SUPPLIES FOR USE OF DEVICE CODED K1016

K1018

EXTERNAL UL TREMOR STIM PERIPH NERVES WRIST

K1019

MONTHLY SUPPLIES FOR USE OF DEVICE CODED K1018

K1020

NONINVASIVE VAGUS NERVE STIMULATOR

L8033

NIP PRS CSTM FB RUSABL ANY MTL T EA

Q4112

CYMETRA, INJECTABLE, 1CC

Q4113

GRAFTJACKET XPRESS, INJECTABLE, 1CC

Q4114

INTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CC

Q4125

ARTHROFLEX, PER SQUARE CENTIMETER

Q4130

STRATTICE TM, PER SQUARE CENTIMETER

Q4131

EPIFIX OR EPICORD, PER SQUARE CENTIMETER

Q4132

GRAFIX CORE AND GRAFIXPL CORE, PER SQUARE CENTIMETER

Q4133

GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER

Q4138

BIODFENCE DRYFLEX, PER SQUARE CENTIMETER

Q4139

AMNIOMATRIX OR BIODMATRIX, INJECTABLE, 1 CC

Q4142

XCM BIOLOGIC TISSUE MATRIX, PER SQUARE CENTIMETER

Q4143

REPRIZA, PER SQUARE CENTIMETER

Q4145

EPIFIX, INJECTABLE, 1 MG

Q4148

NEOX CORD 1K, NEOX CORD RT, OR CLARIX CORD 1K, PER SQUARE CENTIMETER

Q4149

EXCELLAGEN, 0.1 CC

Q4150

ALLOWRAP DS OR DRY, PER SQUARE CENTIMETER

Q4151

AMNIOBAND OR GUARDIAN, PER SQUARE CENTIMETER

Q4154

BIOVANCE, PER SQUARE CENTIMETER

Q4155

NEOXFLO OR CLARIXFLO, 1 MG

Q4159

AFFINITY, PER SQUARE CENTIMETER

Q4162

WOUNDEX FLOW, BIOSKIN FLOW, 0.5 CC

Q4167

TRUSKIN, PER SQUARE CENTIMETER

Q4169

ARTACENT WOUND, PER SQUARE CENTIMETER

Q4170

CYGNUS, PER SQUARE CENTIMETER

Q4171

INTERFYL, 1 MG

Q4172

PURAPLY OR PURAPLY AM, PER SQUARE CENTIMETER

Q4174

PALINGEN OR PROMATRX, 0.36 MG PER 0.25 CC

Q4176

NEOPATCH, PER SQUARE CENTIMETER

Q4177

FLOWERAMNIOFLO, 0.1 CC

Q4179

FLOWERDERM, PER SQUARE CENTIMETER

Q4181

AMNIO WOUND, PER SQUARE CENTIMETER

Q4182

TRANSCYTE, PER SQUARE CENTIMETER

Q4183

SURGIGRAFT, PER SQUARE CENTIMETER

Q4184

CELLESTA OR CELLESTA DUO, PER SQUARE CENTIMETER

Q4185

CELLESTA FLOWABLE AMNION (25 MG PER CC); PER 0.5 CC

Q4186

EPIFIX, PER SQUARE CENTIMETER

Q4187

EPICORD, PER SQUARE CENTIMETER

Q4188

AMNIOARMOR, PER SQUARE CENTIMETER

Q4189

ARTACENT AC, 1 MG

Q4190

ARTACENT AC, PER SQUARE CENTIMETER

Q4191

RESTORIGIN, PER SQUARE CENTIMETER

Q4192

RESTORIGIN, 1 CC

Q4193

COLL-E-DERM, PER SQUARE CENTIMETER

Q4194

NOVACHOR, PER SQUARE CENTIMETER

Q4195

PURAPLY, PER SQUARE CENTIMETER

Q4196

PURAPLY AM, PER SQUARE CENTIMETER

Q4197

PURAPLY XT, PER SQUARE CENTIMETER

Q4198

GENESIS AMNIOTIC MEMBRANE, PER SQUARE CENTIMETER

Q4199

CYGNUS MATRIX PER SQ CM

Q4200

SKIN TE, PER SQUARE CENTIMETER

Q4201

MATRION, PER SQUARE CENTIMETER

Q4202

KEROXX (2.5G/CC), 1CC

Q4203

DERMA-GIDE, PER SQUARE CENTIMETER

Q4204

XWRAP, PER SQUARE CENTIMETER

Q4205

MEMBRANE GRAFT OR MEMBRANE WRAP, PER SQUARE CENTIMETER

Q4206

FLUID FLOW OR FLUID GF, 1 CC

Q4208

NOVAFIX, PER SQUARE CENTIMETER

Q4209

SURGRAFT, PER SQUARE CENTIMETER

Q4210

AXOLOTL GRAFT OR AXOLOTL DUALGRAFT, PER SQAURE CENTIMETER

Q4211

AMNION BIO OR AXOBIOMEMBRANE, PER SQUARE CENTIMETER

Q4212

ALLOGEN, PER CC

Q4213

ASCENT, 0.5 MG

Q4214

CELLESTA CORD, PER SQUARE CENTIMETER

Q4215

AXOLOTL AMBIENT OR AXOLOTL CRYO, 0.1 MG

Q4216

ARTACENT CORD, PER SQUARE CENTIMETER

Q4217

WOUNDFIX, BIOWOUND, WOUNDFIX PLUS, BIOWOUND PLUS, WOUNDFIX XPLUS OR BIOWOUND XPLUS, PER SQUARE CENTI

Q4218

SURGICORD, PER SQUARE CENTIMETER

Q4219

SURGIGRAFT-DUAL, PER SQUARE CENTIMETER

Q4220

BELLACELL HD OR SUREDERM, PER SQUARE CENTIMETER

Q4221

AMNIOWRAP2, PER SQUARE CENTIMETER

Q4222

PROGENAMATRIX, PER SQUARE CENTIMETER

Q4224

Human health factor 10 amniotic patch (hhf10-p), per square centimeter

Q4225

Amniobind, per square centimeter

Q4226

MYOWN SKIN, INCLUDES HARVESTING AND PREPARATION PROCEDURES, PER SQUARE CENTIMETER

Q4227

AMNIOCORETM PER SQ CM

Q4228

BIONEXTPATCH PER SQ CM

Q4229

COGENEX AMNIOTIC MEMBRANE PER SQ CM

Q4230

COGENEX FLOWABLE AMNION PER 0.5 CC

Q4231

CORPLEX P PER CC

Q4232

CORPLEX PER SQ CM

Q4233

SURFACTOR OR NUDYN PER 0.5 CC

Q4234

XCELLERATE PER SQ CM

Q4235

AMNIOREPAIR OR ALTIPLY PER SQ CM

Q4236

CAREPATCH PER SQ CM

Q4237

CRYO-CORD PER SQ CM

Q4238

DERM-MAXX PER SQ CM

Q4239

AMNIO-MAXX/AMNIO-MAXX LITE P-SQ CM

Q4240

CORECYTE TOP USE ONLY PER 0.5 CC

Q4241

POLYCYTE TOP USE ONLY PER 0.5 CC

Q4242

AMNIOCYTE PLUS PER 0.5 CC

Q4244

PROCENTA PER 200 MG

Q4245

AMNIOTEXT PER CC

Q4246

CORETEXT OR PROTEXT PER CC

Q4247

AMNIOTEXT PATCH PER SQ CM

Q4248

DERMACYTE AM ALLOGFT PER SQ CM

Q4249

AMNIPLY TOPICAL USE ONLY PER SQ CM

Q4250

AMNIOAMP-MP PER SQ CM

Q4251

VIM PER SQ CM

Q4252

VENDAJE PER SQ CM

Q4253

ZENITH AMNIOTIC MEMBRANE PER SQ CM

Q4254

NOVAFIX DL PER SQ CM

Q4255

REGUARD TOPICAL USE ONLY PER SQ CM

Q4256

Mlg-complete, per square centimeter

Q4257

Relese, per square centimeter

Q4258

Enverse, per square centimeter

Q9001

ASSESSMENT BY DVA CHAPLAIN SERVICES

Q9002

COUNSELING IND BY DVA CHAPLAIN SVCS

Q9003

COUNSELING GRP BY DVA CHAPLAIN SVCS

S8037

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)

S8092

ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINE CT)


Codes requiring preauthorization are maintained in the Preauthorization Requirements Code List.

Updated August 20, 2018
H9408_18_47546MBI Approved