New / Changed in 2020: |
|
Service Description: |
Skilled Nursing Facility |
Restricted to Preferred Facilities: |
|
Service Code: |
0022 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to prior authorization for admission and notify Medical Management of admission to permit continuity of care review. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Skilled Nursing Facility |
0022 |
New / Changed in 2020: |
|
Service Description: |
Room and Board, Subacute Pediatric (Private Hospital) |
Restricted to Preferred Facilities: |
|
Service Code: |
0190 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Pediatric (Private Hospital) |
0190 |
New / Changed in 2020: |
|
Service Description: |
Subacute Care - Level I |
Restricted to Preferred Facilities: |
|
Service Code: |
0191 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level I |
0191 |
New / Changed in 2020: |
|
Service Description: |
Subacute Care - Level II |
Restricted to Preferred Facilities: |
|
Service Code: |
0192 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level II |
0192 |
New / Changed in 2020: |
|
Service Description: |
Subacute Care - Level III |
Restricted to Preferred Facilities: |
|
Service Code: |
0193 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level III |
0193 |
New / Changed in 2020: |
|
Service Description: |
Subacute Care - Level IV |
Restricted to Preferred Facilities: |
|
Service Code: |
0194 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level IV |
0194 |
New / Changed in 2020: |
|
Service Description: |
Room and Board, Subacute Adult (Private Hospital) |
Restricted to Preferred Facilities: |
|
Service Code: |
0199 |
Service Code Type: |
REV |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Providers are required to notify the Health Plan of admission(s)/discharge(s). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Adult (Private Hospital) |
0199 |
New / Changed in 2020: |
|
Service Description: |
Electroshock Behavioral Health Treatments/Services |
Restricted to Preferred Facilities: |
|
Service Code: |
0901 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Outpatient electro-convulsive treatment |
Electroshock Behavioral Health Treatments/Services |
0901 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
Restricted to Preferred Facilities: |
|
Service Code: |
46505 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
46505 |
New / Changed in 2020: |
|
Service Description: |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
Restricted to Preferred Facilities: |
|
Service Code: |
52287 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
52287 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
Restricted to Preferred Facilities: |
|
Service Code: |
64611 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
64611 |
New / Changed in 2020: |
|
Service Description: |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
Restricted to Preferred Facilities: |
|
Service Code: |
64612 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
64612 |
New / Changed in 2020: |
|
Service Description: |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
Restricted to Preferred Facilities: |
|
Service Code: |
64615 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
64615 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
Restricted to Preferred Facilities: |
|
Service Code: |
64616 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
64616 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
Restricted to Preferred Facilities: |
|
Service Code: |
64617 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
64617 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
Restricted to Preferred Facilities: |
|
Service Code: |
64642 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
64642 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
Restricted to Preferred Facilities: |
|
Service Code: |
64643 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
Restricted to Preferred Facilities: |
|
Service Code: |
64644 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
64644 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
Restricted to Preferred Facilities: |
|
Service Code: |
64645 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
64645 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
Restricted to Preferred Facilities: |
|
Service Code: |
64646 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
64646 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
Restricted to Preferred Facilities: |
|
Service Code: |
64647 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
64647 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
Restricted to Preferred Facilities: |
|
Service Code: |
64650 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
64650 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
Restricted to Preferred Facilities: |
|
Service Code: |
64653 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
64653 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
Restricted to Preferred Facilities: |
|
Service Code: |
67345 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2000 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
67345 |
New / Changed in 2020: |
|
Service Description: |
Unlisted procedure, therapeutic radiology clinical treatment planning |
Restricted to Preferred Facilities: |
|
Service Code: |
77299 |
Service Code Type: |
CPT |
Effective Date: |
8/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Unlisted procedure, therapeutic radiology clinical treatment planning |
77299 |
New / Changed in 2020: |
|
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81201 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
81201 |
New / Changed in 2020: |
|
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81202 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
81202 |
New / Changed in 2020: |
|
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
Restricted to Preferred Facilities: |
|
Service Code: |
81203 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
81203 |
New / Changed in 2020: |
|
Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81288 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81288 |
New / Changed in 2020: |
|
Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81292 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81292 |
New / Changed in 2020: |
|
Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81293 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81293 |
New / Changed in 2020: |
|
Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81294 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81294 |
New / Changed in 2020: |
|
Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81295 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81295 |
New / Changed in 2020: |
|
Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81296 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81296 |
New / Changed in 2020: |
|
Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Restricted to Preferred Facilities: |
|
Service Code: |
81297 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81297 |
New / Changed in 2020: |
|
Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81298 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis |
81298 |
New / Changed in 2020: |
|
Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81299 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants |
81299 |
New / Changed in 2020: |
|
Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion va |
Restricted to Preferred Facilities: |
|
Service Code: |
81300 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion va |
81300 |
New / Changed in 2020: |
|
Service Description: |
Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue |
Restricted to Preferred Facilities: |
|
Service Code: |
81301 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue |
81301 |
New / Changed in 2020: |
|
Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
Restricted to Preferred Facilities: |
|
Service Code: |
81317 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81317 |
New / Changed in 2020: |
|
Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
Restricted to Preferred Facilities: |
|
Service Code: |
81318 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81318 |
New / Changed in 2020: |
|
Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
Restricted to Preferred Facilities: |
|
Service Code: |
81319 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81319 |
New / Changed in 2020: |
|
Service Description: |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2 |
Restricted to Preferred Facilities: |
|
Service Code: |
81435 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2 |
81435 |
New / Changed in 2020: |
|
Service Description: |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH |
Restricted to Preferred Facilities: |
|
Service Code: |
81436 |
Service Code Type: |
CPT |
Effective Date: |
4/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH |
81436 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, al |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81519 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, al |
81519 |
New / Changed in 2020: |
|
Service Description: |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
Restricted to Preferred Facilities: |
|
Service Code: |
81525 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
81525 |
New / Changed in 2020: |
|
Service Description: |
Electroconvulsive therapy; includes necessary monitoring |
Restricted to Preferred Facilities: |
|
Service Code: |
90870 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Outpatient electro-convulsive treatment |
Electroconvulsive therapy; includes necessary monitoring |
90870 |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0537T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0537T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0537T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0537T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0538T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 106.0 |
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0538T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0538T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0538T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0539T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 78.0 |
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0539T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0539T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0539T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0540T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 63.0 |
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0540T |
New / Changed in 2020: |
|
Service Description: |
Kymriah or Yescarta |
Restricted to Preferred Facilities: |
|
Service Code: |
0540T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0540T |
New / Changed in 2020: |
|
Service Description: |
Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
A4555 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 306 |
|
Radiation Oncology-Tumor Treatment Fields |
Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only |
A4555 |
New / Changed in 2020: |
|
Service Description: |
Lutetium lu 177, dotatate, therapeutic, 1 millicurie |
Restricted to Preferred Facilities: |
|
Service Code: |
A9513 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Lutathera (luteum Lu 177 dotate) |
Lutetium lu 177, dotatate, therapeutic, 1 millicurie |
A9513 |
New / Changed in 2020: |
|
Service Description: |
Unclassified drugs or biologicals |
Restricted to Preferred Facilities: |
|
Service Code: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs or biologicals |
C9399 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cranial prosthesis |
Restricted to Preferred Facilities: |
|
Service Code: |
D5924 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial prosthesis |
D5924 |
New / Changed in 2020: |
|
Service Description: |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
E0766 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 306 |
|
Radiation Oncology-Tumor Treatment Fields |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
E0766 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
Injection, benralizumab, 1 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0517 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Fasenra (benralizumab) |
Injection, benralizumab, 1 mg |
J0517 |
New / Changed in 2020: |
|
Service Description: |
Injection, bezlotoxumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0565 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zinplava (bezlotoxumab) |
Injection, bezlotoxumab, 10 mg |
J0565 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
Injection, onabotulinumtoxina, 1 unit |
Restricted to Preferred Facilities: |
|
Service Code: |
J0585 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
Injection, onabotulinumtoxina, 1 unit |
J0585 |
New / Changed in 2020: |
|
Service Description: |
Injection, etelcalcetide, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0606 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Parsabiv (etelcalcetide) |
Injection, etelcalcetide, 0.1 mg |
J0606 |
New / Changed in 2020: |
|
Service Description: |
Injection, edaravone, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1301 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Radicava (edaravone) |
Injection, edaravone, 1 mg |
J1301 |
New / Changed in 2020: |
|
Service Description: |
Inj, granisetron, xr, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1627 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sustol (granisetron extended release) |
Inj, granisetron, xr, 0.1 mg |
J1627 |
New / Changed in 2020: |
|
Service Description: |
Injection, meropenem and vaborbactam, 10mg/10mg (20mg) |
Restricted to Preferred Facilities: |
|
Service Code: |
J2186 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Vabomere (meropenem/vaborbactam) |
Injection, meropenem and vaborbactam, 10mg/10mg (20mg) |
J2186 |
New / Changed in 2020: |
|
Service Description: |
Injection, ocrelizumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2350 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ocrevus (ocrelizumab) |
Injection, ocrelizumab, 1 mg |
J2350 |
New / Changed in 2020: |
|
Service Description: |
Injection, olanzapine, long-acting, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2358 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 106.0 |
|
Zyprexa Relprevv® (olanzapine) |
Injection, olanzapine, long-acting, 1 mg |
J2358 |
New / Changed in 2020: |
|
Service Description: |
Injection, Durvalumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3304 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zilretta (triamcinolone acetonide ER injection) |
Injection, Durvalumab, 10 mg |
J3304 |
New / Changed in 2020: |
|
Service Description: |
Ustekinumab, for intravenous injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3358 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Stelara™ (ustekinumab) |
Ustekinumab, for intravenous injection, 1 mg |
J3358 |
New / Changed in 2020: |
|
Service Description: |
Inj., vestronidase alfa-vjbk |
Restricted to Preferred Facilities: |
|
Service Code: |
J3397 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Mepsevii (vestronidase alfa-vjbk) |
Inj., vestronidase alfa-vjbk |
J3397 |
New / Changed in 2020: |
|
Service Description: |
Inj luxturna 1 billion vec g |
Restricted to Preferred Facilities: |
|
Service Code: |
J3398 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Luxturna (voretigeneneparvovec-rzyl) |
Inj luxturna 1 billion vec g |
J3398 |
New / Changed in 2020: |
|
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
|
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 135.0 |
|
Unituxin (dinutuximab) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
|
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 135.0 |
|
Unituxin (dinutuximab) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
|
Service Description: |
Injection, atezolizumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9022 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Tecentriq™ (atezolizumab) |
Injection, atezolizumab, 10 mg |
J9022 |
New / Changed in 2020: |
|
Service Description: |
Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine |
Restricted to Preferred Facilities: |
|
Service Code: |
J9153 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 164.0 |
|
Vyxeos (daunorubicin/cytarabine liposomal) |
Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine |
J9153 |
New / Changed in 2020: |
|
Service Description: |
Injection, durvalumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9173 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Imfinzi (durvalumab) |
Injection, durvalumab, 10 mg |
J9173 |
New / Changed in 2020: |
|
Service Description: |
Gemtuzumab ozogamicin 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9203 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Mylotarg (gemfuzumab ozogamicin) |
Gemtuzumab ozogamicin 0.1 mg |
J9203 |
New / Changed in 2020: |
|
Service Description: |
Inj, olaratumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9285 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Lartruvo (olaratumab) |
Inj, olaratumab, 10 mg |
J9285 |
New / Changed in 2020: |
|
Service Description: |
Injection, rituximab 10 mg and hyaluronidase |
Restricted to Preferred Facilities: |
|
Service Code: |
J9311 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Rituxin Hycela (rituximab/hyaluronidase) |
Injection, rituximab 10 mg and hyaluronidase |
J9311 |
New / Changed in 2020: |
|
Service Description: |
Injection, rituximab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9312 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Rituxan for Non-Hodgkin’s Lymphoma does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Rituxan® (rituximab) Rituxan for Non-Hodgkin’s Lymphoma does not require prior authorization. |
Injection, rituximab, 10 mg |
J9312 |
New / Changed in 2020: |
|
Service Description: |
Injection, thiotepa, 15 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9340 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Tepadina (thiotepa) |
Injection, thiotepa, 15 mg |
J9340 |
New / Changed in 2020: |
|
Service Description: |
Not otherwise classified, antineoplastic drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 135.0 |
|
Unituxin (dinutuximab) |
Not otherwise classified, antineoplastic drugs |
J9999 |
New / Changed in 2020: |
|
Service Description: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L0112 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
L0112 |
New / Changed in 2020: |
|
Service Description: |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L0113 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
L0113 |
New / Changed in 2020: |
|
Service Description: |
Durable Medical Equipment (Outpatient - see Comments) |
Restricted to Preferred Facilities: |
|
Service Code: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Purchased/Rented DME items with an allowed amount of
$500 or less DO NOT require prior authorization except:
• Incontinence Supplies, when a covered benefit
• Equipment Repairs
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Durable Medical Equipment (Outpatient - see Comments) |
Durable Medical Equipment (Outpatient - see Comments) |
N/A |
New / Changed in 2020: |
|
Service Description: |
|
Restricted to Preferred Facilities: |
|
Service Code: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Health Care Services associated with Non-covered Services (including but not limited to deep sedation and general anesthesia) |
|
N/A |
New / Changed in 2020: |
|
Service Description: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
Restricted to Preferred Facilities: |
|
Service Code: |
Q2041 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 162.0 |
|
Yescarta (axicabtagene ciloleucel) |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
Q2041 |
New / Changed in 2020: |
|
Service Description: |
Injection, hydroxyprogesterone caproate, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q2042 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Kymriah (tisagenleclencel) |
Injection, hydroxyprogesterone caproate, 1 mg |
Q2042 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
Q5103 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Inflectra (infliximab-dyyb) |
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg |
Q5103 |
New / Changed in 2020: |
|
Service Description: |
Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q9991 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Sublocade (buprenorphine ER injection for subcutaneous use ) |
Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg |
Q9991 |
New / Changed in 2020: |
|
Service Description: |
Injection, buprenorphine extended-release (sublocade), greater than 100 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q9992 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Sublocade (buprenorphine ER injection for subcutaneous use ) |
Injection, buprenorphine extended-release (sublocade), greater than 100 mg |
Q9992 |
New / Changed in 2020: |
|
Service Description: |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
S1040 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
S1040 |
New / Changed in 2020: |
|
Service Description: |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
Restricted to Preferred Facilities: |
|
Service Code: |
S9475 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 62.0 |
|
Behavioral Health (Mental Health) and Substance Abuse: Outpatient treatment of Opioid dependence |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
S9475 |
New / Changed in 2020: |
|
Service Description: |
Private duty/independent nursing service(s), licensed, up to 15 minutes |
Restricted to Preferred Facilities: |
|
Service Code: |
T1000 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 297 |
|
Hospice |
Private duty/independent nursing service(s), licensed, up to 15 minutes |
T1000 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Medical/Surgical/Gynecological |
Restricted to Preferred Facilities: |
|
Service Code: |
0111 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Medical/Surgical/Gynecological |
0111 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, OB |
Restricted to Preferred Facilities: |
|
Service Code: |
0112 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, OB |
0112 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0113 |
Service Code Type: |
REV |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Pediatric |
0113 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0114 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Private, Psychiatric |
0114 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0114 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Psychiatric |
0114 |
New / Changed in 2020: |
|
Service Description: |
Detoxification Room and Board Private (one bed) |
Restricted to Preferred Facilities: |
|
Service Code: |
0116 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Private (one bed) |
0116 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Oncology |
Restricted to Preferred Facilities: |
|
Service Code: |
0117 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Oncology |
0117 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Rehabilitation |
Restricted to Preferred Facilities: |
|
Service Code: |
0118 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Rehabilitation |
0118 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Private, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0119 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Other |
0119 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Medical/Surgical/Gynecological |
Restricted to Preferred Facilities: |
|
Service Code: |
0121 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Medical/Surgical/Gynecological |
0121 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Obstetric |
Restricted to Preferred Facilities: |
|
Service Code: |
0122 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Obstetric |
0122 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0123 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Pediatric |
0123 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0124 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 2 Bed, Psychiatric |
0124 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0124 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Psychiatric |
0124 |
New / Changed in 2020: |
|
Service Description: |
Detoxification Room and Board Semiprivate (two beds) |
Restricted to Preferred Facilities: |
|
Service Code: |
0126 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Semiprivate (two beds) |
0126 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Oncology |
Restricted to Preferred Facilities: |
|
Service Code: |
0127 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Oncology |
0127 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 2 Bed, Rehabilitation |
Restricted to Preferred Facilities: |
|
Service Code: |
0128 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Rehabilitation |
0128 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate, 2 Beds, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0129 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate, 2 Beds, Other |
0129 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Medical/Surgical/Gynecological |
Restricted to Preferred Facilities: |
|
Service Code: |
0131 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Medical/Surgical/Gynecological |
0131 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Obstetric |
Restricted to Preferred Facilities: |
|
Service Code: |
0132 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Obstetric |
0132 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0133 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Pediatric |
0133 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0134 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
0134 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0134 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
0134 |
New / Changed in 2020: |
|
Service Description: |
Detoxification Room and Board (3 and 4 beds) |
Restricted to Preferred Facilities: |
|
Service Code: |
0136 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board (3 and 4 beds) |
0136 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Oncology |
Restricted to Preferred Facilities: |
|
Service Code: |
0137 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Oncology |
0137 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Rehabilitation |
Restricted to Preferred Facilities: |
|
Service Code: |
0138 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Rehabilitation |
0138 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Semiprivate, 3 and 4 Beds, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0139 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate, 3 and 4 Beds, Other |
0139 |
New / Changed in 2020: |
|
Service Description: |
Psychiatric Room and Board Deluxe Private |
Restricted to Preferred Facilities: |
|
Service Code: |
0144 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Psychiatric Room and Board Deluxe Private |
0144 |
New / Changed in 2020: |
|
Service Description: |
Detoxification Room and Board Deluxe Private |
Restricted to Preferred Facilities: |
|
Service Code: |
0146 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Deluxe Private |
0146 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Medical/Surgical/Gynecological |
Restricted to Preferred Facilities: |
|
Service Code: |
0151 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Medical/Surgical/Gynecological |
0151 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Obstetric |
Restricted to Preferred Facilities: |
|
Service Code: |
0152 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Obstetric |
0152 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0153 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Pediatric |
0153 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0154 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Ward (Medical or General), Psychiatric |
0154 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0154 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Psychiatric |
0154 |
New / Changed in 2020: |
|
Service Description: |
Detoxification Room and Board Ward |
Restricted to Preferred Facilities: |
|
Service Code: |
0156 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Ward |
0156 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Oncology |
Restricted to Preferred Facilities: |
|
Service Code: |
0157 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Oncology |
0157 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward (Medical or General), Rehabilitation |
Restricted to Preferred Facilities: |
|
Service Code: |
0158 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Rehabilitation |
0158 |
New / Changed in 2020: |
|
Service Description: |
Room and Board – Ward, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0159 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board – Ward, Other |
0159 |
New / Changed in 2020: |
|
Service Description: |
Room and Board, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0169 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board, Other |
0169 |
New / Changed in 2020: |
|
Service Description: |
Nursery, General Classification |
Restricted to Preferred Facilities: |
|
Service Code: |
0170 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Nursery, General Classification |
0170 |
New / Changed in 2020: |
|
Service Description: |
Nursery, Newborn, Level I |
Restricted to Preferred Facilities: |
|
Service Code: |
0171 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level I |
0171 |
New / Changed in 2020: |
|
Service Description: |
Nursery, Newborn, Level II |
Restricted to Preferred Facilities: |
|
Service Code: |
0172 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level II |
0172 |
New / Changed in 2020: |
|
Service Description: |
Nursery, Newborn, Level III |
Restricted to Preferred Facilities: |
|
Service Code: |
0173 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level III |
0173 |
New / Changed in 2020: |
|
Service Description: |
Nursery, Newborn, Level IV |
Restricted to Preferred Facilities: |
|
Service Code: |
0174 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level IV |
0174 |
New / Changed in 2020: |
|
Service Description: |
Room and Board, Subacute Pediatric (Private Hospital) |
Restricted to Preferred Facilities: |
|
Service Code: |
0190 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board, Subacute Pediatric (Private Hospital) |
0190 |
New / Changed in 2020: |
|
Service Description: |
Room and Board, Subacute Adult (Private Hospital) |
Restricted to Preferred Facilities: |
|
Service Code: |
0199 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Room and Board, Subacute Adult (Private Hospital) |
0199 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, General Classification |
Restricted to Preferred Facilities: |
|
Service Code: |
0200 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, General Classification |
0200 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Surgical |
Restricted to Preferred Facilities: |
|
Service Code: |
0201 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Surgical |
0201 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Medical |
Restricted to Preferred Facilities: |
|
Service Code: |
0202 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Medical |
0202 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0203 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Pediatric |
0203 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0204 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Intensive Care, Psychiatric |
0204 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Psychiatric |
Restricted to Preferred Facilities: |
|
Service Code: |
0204 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Psychiatric |
0204 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Intermediate ICU |
Restricted to Preferred Facilities: |
|
Service Code: |
0206 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Intermediate ICU |
0206 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Burn Care |
Restricted to Preferred Facilities: |
|
Service Code: |
0207 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Burn Care |
0207 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Trauma |
Restricted to Preferred Facilities: |
|
Service Code: |
0208 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Trauma |
0208 |
New / Changed in 2020: |
|
Service Description: |
Intensive Care, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0209 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Intensive Care, Other |
0209 |
New / Changed in 2020: |
|
Service Description: |
Coronary Care, General Classification |
Restricted to Preferred Facilities: |
|
Service Code: |
0210 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Coronary Care, General Classification |
0210 |
New / Changed in 2020: |
|
Service Description: |
Coronary Care, Myocardial Infarction |
Restricted to Preferred Facilities: |
|
Service Code: |
0211 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Coronary Care, Myocardial Infarction |
0211 |
New / Changed in 2020: |
|
Service Description: |
Coronary Care, Pulmonary Care |
Restricted to Preferred Facilities: |
|
Service Code: |
0212 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Coronary Care, Pulmonary Care |
0212 |
New / Changed in 2020: |
|
Service Description: |
Coronary Care, Intermediate CCU |
Restricted to Preferred Facilities: |
|
Service Code: |
0214 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Coronary Care, Intermediate CCU |
0214 |
New / Changed in 2020: |
|
Service Description: |
Coronary Care, Other |
Restricted to Preferred Facilities: |
|
Service Code: |
0219 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Coronary Care, Other |
0219 |
New / Changed in 2020: |
|
Service Description: |
Inpatient respite care |
Restricted to Preferred Facilities: |
|
Service Code: |
0655 |
Service Code Type: |
REV |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hospice |
Inpatient respite care |
0655 |
New / Changed in 2020: |
|
Service Description: |
General inpatient care (nonrespite) |
Restricted to Preferred Facilities: |
|
Service Code: |
0656 |
Service Code Type: |
REV |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hospice |
General inpatient care (nonrespite) |
0656 |
New / Changed in 2020: |
|
Service Description: |
Lithotripsy, General Classification |
Restricted to Preferred Facilities: |
|
Service Code: |
0790 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required no less than two (2) business days prior to ALL PLANNED admissions. Urgent and emergent hospital admissions do not require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Inpatient Facility Admission - Planned |
Lithotripsy, General Classification |
0790 |
New / Changed in 2020: |
|
Service Description: |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
Restricted to Preferred Facilities: |
|
Service Code: |
0912 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
0912 |
New / Changed in 2020: |
|
Service Description: |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
Restricted to Preferred Facilities: |
|
Service Code: |
0913 |
Service Code Type: |
REV |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
0913 |
New / Changed in 2020: |
|
Service Description: |
SUBCUTANEOUS HORMONE PELLET IMPLANTATION |
Restricted to Preferred Facilities: |
|
Service Code: |
11980 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Gender Dysphoria and Gender Confirmation Treatment |
SUBCUTANEOUS HORMONE PELLET IMPLANTATION |
11980 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq. cm or less of wound surface area |
Restricted to Preferred Facilities: |
|
Service Code: |
15271 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq. cm or less of wound surface area |
15271 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
Restricted to Preferred Facilities: |
|
Service Code: |
15272 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
15272 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Application of skin substitute graft to trunk, arms, legs, total wound surface greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
Restricted to Preferred Facilities: |
|
Service Code: |
15273 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Application of skin substitute graft to trunk, arms, legs, total wound surface greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
15273 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof) (List separately in addition to code for primary procedure |
Restricted to Preferred Facilities: |
|
Service Code: |
15274 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 68 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof) (List separately in addition to code for primary procedure |
15274 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Application of skin substitute graft to face, scalp, feet, etc., total wound surface area up to 100 sq. cm; first 25 sq. cm or less |
Restricted to Preferred Facilities: |
|
Service Code: |
15275 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Application of skin substitute graft to face, scalp, feet, etc., total wound surface area up to 100 sq. cm; first 25 sq. cm or less |
15275 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
Restricted to Preferred Facilities: |
|
Service Code: |
15276 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 250 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
15276 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Application of skin substitute graft to face, scalp, feet, etc., total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
Restricted to Preferred Facilities: |
|
Service Code: |
15277 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 250 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Application of skin substitute graft to face, scalp, feet, etc., total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children |
15277 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children) (List separately in addition to code for primary procedure |
Restricted to Preferred Facilities: |
|
Service Code: |
15278 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children) (List separately in addition to code for primary procedure |
15278 |
New / Changed in 2020: |
|
Service Description: |
BLEPHAROPLASTY LOWER EYELID |
Restricted to Preferred Facilities: |
|
Service Code: |
15820 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID |
15820 |
New / Changed in 2020: |
|
Service Description: |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
Restricted to Preferred Facilities: |
|
Service Code: |
15821 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
15821 |
New / Changed in 2020: |
|
Service Description: |
BLEPHAROPLASTY UPPER EYELID |
Restricted to Preferred Facilities: |
|
Service Code: |
15822 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID |
15822 |
New / Changed in 2020: |
|
Service Description: |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
Restricted to Preferred Facilities: |
|
Service Code: |
15823 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
15823 |
New / Changed in 2020: |
|
Service Description: |
MASTECTOMY PARTIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
19301 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
MASTECTOMY PARTIAL |
19301 |
New / Changed in 2020: |
|
Service Description: |
MASTECTOMY SIMPLE COMPLETE |
Restricted to Preferred Facilities: |
|
Service Code: |
19303 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
MASTECTOMY SIMPLE COMPLETE |
19303 |
New / Changed in 2020: |
|
Service Description: |
MASTECTOMY SUBCUTANEOUS |
Restricted to Preferred Facilities: |
|
Service Code: |
19304 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
MASTECTOMY SUBCUTANEOUS |
19304 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MASTOPEXY |
Restricted to Preferred Facilities: |
|
Service Code: |
19316 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
MASTOPEXY |
19316 |
New / Changed in 2020: |
|
Service Description: |
REDUCTION MAMMAPLASTY |
Restricted to Preferred Facilities: |
|
Service Code: |
19318 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Breast Reduction or Reconstructive Surgery |
REDUCTION MAMMAPLASTY |
19318 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19324 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT |
19324 |
New / Changed in 2020: |
|
Service Description: |
MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19324 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT |
19324 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MAMMAPLASTY, AUGMENTATION; W/PROSTHETIC IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
MAMMAPLASTY, AUGMENTATION; W/PROSTHETIC IMPLANT |
19325 |
New / Changed in 2020: |
|
Service Description: |
MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT |
19325 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
REMOVAL, INTACT MAMMARY IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19328 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
REMOVAL, INTACT MAMMARY IMPLANT |
19328 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
REMOVAL, MAMMARY IMPLANT MATL |
Restricted to Preferred Facilities: |
|
Service Code: |
19330 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
REMOVAL, MAMMARY IMPLANT MATL |
19330 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
Restricted to Preferred Facilities: |
|
Service Code: |
19340 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
19340 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
Restricted to Preferred Facilities: |
|
Service Code: |
19342 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
19342 |
New / Changed in 2020: |
|
Service Description: |
NIPPLE/AREOLA RECONSTRUCTION |
Restricted to Preferred Facilities: |
|
Service Code: |
19350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
NIPPLE/AREOLA RECONSTRUCTION |
19350 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CORRECTION OF INVERTED NIPPLES |
Restricted to Preferred Facilities: |
|
Service Code: |
19355 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
CORRECTION OF INVERTED NIPPLES |
19355 |
New / Changed in 2020: |
|
Service Description: |
BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ |
Restricted to Preferred Facilities: |
|
Service Code: |
19357 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Gender Dysphoria and Gender Confirmation Treatment |
BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ |
19357 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with latissimus dorsi flap, without prosthetic implant |
Restricted to Preferred Facilities: |
|
Service Code: |
19361 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with latissimus dorsi flap, without prosthetic implant |
19361 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with free flap |
Restricted to Preferred Facilities: |
|
Service Code: |
19364 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with free flap |
19364 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with other technique |
Restricted to Preferred Facilities: |
|
Service Code: |
19366 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with other technique |
19366 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site |
Restricted to Preferred Facilities: |
|
Service Code: |
19367 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site |
19367 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) |
Restricted to Preferred Facilities: |
|
Service Code: |
19368 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) |
19368 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site |
Restricted to Preferred Facilities: |
|
Service Code: |
19369 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site |
19369 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST |
Restricted to Preferred Facilities: |
|
Service Code: |
19370 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST |
19370 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PERIPROSTHETIC CAPSULECTOMY, BREAST |
Restricted to Preferred Facilities: |
|
Service Code: |
19371 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
PERIPROSTHETIC CAPSULECTOMY, BREAST |
19371 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
REVISION OF RECONSTRUCTED BREAST |
Restricted to Preferred Facilities: |
|
Service Code: |
19380 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
REVISION OF RECONSTRUCTED BREAST |
19380 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
REVISION OF RECONSTRUCTED BREAST |
Restricted to Preferred Facilities: |
|
Service Code: |
19380 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
REVISION OF RECONSTRUCTED BREAST |
19380 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
19396 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Breast Reduction or Reconstructive Surgery |
PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT |
19396 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ENZYME PALMAR FASCIAL CORD |
Restricted to Preferred Facilities: |
|
Service Code: |
20527 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 80.0 |
|
Xiaflex® (collagenase clostridium histolyticum) |
INJECTION ENZYME PALMAR FASCIAL CORD |
20527 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone graft, any donor area; minor or small (e.g., dowel or button) |
Restricted to Preferred Facilities: |
|
Service Code: |
20900 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Bone graft, any donor area; minor or small (e.g., dowel or button) |
20900 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone graft, any donor area; major or large |
Restricted to Preferred Facilities: |
|
Service Code: |
20902 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Bone graft, any donor area; major or large |
20902 |
New / Changed in 2020: |
|
Service Description: |
GENIOPLASTY AUGMENTATION |
Restricted to Preferred Facilities: |
|
Service Code: |
21120 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY AUGMENTATION |
21120 |
New / Changed in 2020: |
|
Service Description: |
GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE |
Restricted to Preferred Facilities: |
|
Service Code: |
21121 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE |
21121 |
New / Changed in 2020: |
|
Service Description: |
GENIOPLASTY 2/> SLIDING OSTEOTOMIES |
Restricted to Preferred Facilities: |
|
Service Code: |
21122 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY 2/> SLIDING OSTEOTOMIES |
21122 |
New / Changed in 2020: |
|
Service Description: |
GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS |
Restricted to Preferred Facilities: |
|
Service Code: |
21123 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS |
21123 |
New / Changed in 2020: |
|
Service Description: |
AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
21125 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL |
21125 |
New / Changed in 2020: |
|
Service Description: |
AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL |
Restricted to Preferred Facilities: |
|
Service Code: |
21127 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL |
21127 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
21141 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT |
21141 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
21142 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT |
21142 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
21143 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT |
21143 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS |
Restricted to Preferred Facilities: |
|
Service Code: |
21145 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS |
21145 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS |
Restricted to Preferred Facilities: |
|
Service Code: |
21146 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS |
21146 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS |
Restricted to Preferred Facilities: |
|
Service Code: |
21147 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 10 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS |
21147 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF |
Restricted to Preferred Facilities: |
|
Service Code: |
21193 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF |
21193 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
21194 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT |
21194 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD |
Restricted to Preferred Facilities: |
|
Service Code: |
21195 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD |
21195 |
New / Changed in 2020: |
|
Service Description: |
RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI |
Restricted to Preferred Facilities: |
|
Service Code: |
21196 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI |
21196 |
New / Changed in 2020: |
|
Service Description: |
OSTEOTOMY MANDIBLE SEGMENTAL |
Restricted to Preferred Facilities: |
|
Service Code: |
21198 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 04 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MANDIBLE SEGMENTAL |
21198 |
New / Changed in 2020: |
|
Service Description: |
OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT |
Restricted to Preferred Facilities: |
|
Service Code: |
21199 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 04 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT |
21199 |
New / Changed in 2020: |
|
Service Description: |
OSTEOTOMY MAXILLA SEGMENTAL |
Restricted to Preferred Facilities: |
|
Service Code: |
21206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MAXILLA SEGMENTAL |
21206 |
New / Changed in 2020: |
|
Service Description: |
HYOID MYOTOMY & SUSPENSION |
Restricted to Preferred Facilities: |
|
Service Code: |
21685 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
HYOID MYOTOMY & SUSPENSION |
21685 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Reconstructive repair of pectus excavatum or carinatum; open |
Restricted to Preferred Facilities: |
|
Service Code: |
21740 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; open |
21740 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy |
Restricted to Preferred Facilities: |
|
Service Code: |
21742 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy |
21742 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy |
Restricted to Preferred Facilities: |
|
Service Code: |
21743 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy |
21743 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
22533 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR |
22533 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR |
Restricted to Preferred Facilities: |
|
Service Code: |
22534 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR |
22534 |
New / Changed in 2020: |
|
Service Description: |
ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 |
Restricted to Preferred Facilities: |
|
Service Code: |
22551 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 |
22551 |
New / Changed in 2020: |
|
Service Description: |
ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC |
Restricted to Preferred Facilities: |
|
Service Code: |
22552 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC |
22552 |
New / Changed in 2020: |
|
Service Description: |
ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 |
Restricted to Preferred Facilities: |
|
Service Code: |
22554 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 |
22554 |
New / Changed in 2020: |
|
Service Description: |
ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC |
Restricted to Preferred Facilities: |
|
Service Code: |
22556 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC |
22556 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ARTHRODESIS ANTERIOR INTERBODY LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
22558 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS ANTERIOR INTERBODY LUMBAR |
22558 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC |
Restricted to Preferred Facilities: |
|
Service Code: |
22585 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC |
22585 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
22612 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL LUMBAR |
22612 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL EA ADDL |
Restricted to Preferred Facilities: |
|
Service Code: |
22614 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL EA ADDL |
22614 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS POSTERIOR INTERBODY LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
22630 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR INTERBODY LUMBAR |
22630 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS POSTERIOR INTERBODY EA ADDL |
Restricted to Preferred Facilities: |
|
Service Code: |
22632 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR INTERBODY EA ADDL |
22632 |
New / Changed in 2020: |
|
Service Description: |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTERBODY LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
22633 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTERBODY LUMBAR |
22633 |
New / Changed in 2020: |
|
Service Description: |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTRBDYADL SPC/ SEG |
Restricted to Preferred Facilities: |
|
Service Code: |
22634 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Spinal Fusion (Elective) |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTRBDYADL SPC/ SEG |
22634 |
New / Changed in 2020: |
|
Service Description: |
INJECT SI JOINT ARTHRGRPHY&/ ANES/ STEROID W/ IMA |
Restricted to Preferred Facilities: |
|
Service Code: |
27096 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Sacroiliac Joint Injection |
INJECT SI JOINT ARTHRGRPHY&/ ANES/ STEROID W/ IMA |
27096 |
New / Changed in 2020: |
|
Service Description: |
ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS |
Restricted to Preferred Facilities: |
|
Service Code: |
27279 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Sacroiliac Joint Fusion |
ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS |
27279 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
Restricted to Preferred Facilities: |
|
Service Code: |
27412 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Autologous cultured chondrocyte (MACI) |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
27412 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia |
Restricted to Preferred Facilities: |
|
Service Code: |
28890 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia |
28890 |
New / Changed in 2020: |
|
Service Description: |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
Restricted to Preferred Facilities: |
|
Service Code: |
30400 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
30400 |
New / Changed in 2020: |
|
Service Description: |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
Restricted to Preferred Facilities: |
|
Service Code: |
30400 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
30400 |
New / Changed in 2020: |
|
Service Description: |
RHINP PRIM COMPLETE XTRNL PARTS |
Restricted to Preferred Facilities: |
|
Service Code: |
30410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINP PRIM COMPLETE XTRNL PARTS |
30410 |
New / Changed in 2020: |
|
Service Description: |
RHINP PRIM COMPLETE XTRNL PARTS |
Restricted to Preferred Facilities: |
|
Service Code: |
30410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINP PRIM COMPLETE XTRNL PARTS |
30410 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
Restricted to Preferred Facilities: |
|
Service Code: |
30420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
30420 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
Restricted to Preferred Facilities: |
|
Service Code: |
30420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
30420 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY MINOR REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30430 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY MINOR REVISION |
30430 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY MINOR REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30430 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY MINOR REVISION |
30430 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30435 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
30435 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30435 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
30435 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY MAJOR REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30450 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY MAJOR REVISION |
30450 |
New / Changed in 2020: |
|
Service Description: |
RHINOPLASTY SECONDARY MAJOR REVISION |
Restricted to Preferred Facilities: |
|
Service Code: |
30450 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard February 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MP 17 |
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY MAJOR REVISION |
30450 |
New / Changed in 2020: |
|
Service Description: |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
Restricted to Preferred Facilities: |
|
Service Code: |
30520 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 25 |
|
Rhinoplasty including major septal repair |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
30520 |
New / Changed in 2020: |
|
Service Description: |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
Restricted to Preferred Facilities: |
|
Service Code: |
30520 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 25 |
|
Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
30520 |
New / Changed in 2020: |
|
Service Description: |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
Restricted to Preferred Facilities: |
|
Service Code: |
30620 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 157.0 |
|
Rhinoplasty including major septal repair |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
30620 |
New / Changed in 2020: |
|
Service Description: |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
Restricted to Preferred Facilities: |
|
Service Code: |
30620 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
30620 |
New / Changed in 2020: |
|
Service Description: |
LARYNGOPLASTY CRICOID SPLIT |
Restricted to Preferred Facilities: |
|
Service Code: |
31587 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LARYNGOPLASTY CRICOID SPLIT |
31587 |
New / Changed in 2020: |
|
Service Description: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
Restricted to Preferred Facilities: |
|
Service Code: |
31660 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bronchial Thermoplasty |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
31660 |
New / Changed in 2020: |
|
Service Description: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
Restricted to Preferred Facilities: |
|
Service Code: |
31661 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bronchial Thermoplasty |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
31661 |
New / Changed in 2020: |
|
Service Description: |
TRACHEOPLASTY CERVICAL |
Restricted to Preferred Facilities: |
|
Service Code: |
31750 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
TRACHEOPLASTY CERVICAL |
31750 |
New / Changed in 2020: |
|
Service Description: |
RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG |
Restricted to Preferred Facilities: |
|
Service Code: |
32491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 25 |
|
Lung Volume Reduction Surgery |
RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG |
32491 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
32701 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment |
32701 |
New / Changed in 2020: |
|
Service Description: |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
32850 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
32850 |
New / Changed in 2020: |
|
Service Description: |
LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS |
Restricted to Preferred Facilities: |
|
Service Code: |
32851 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS |
32851 |
New / Changed in 2020: |
|
Service Description: |
LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS |
Restricted to Preferred Facilities: |
|
Service Code: |
32852 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS |
32852 |
New / Changed in 2020: |
|
Service Description: |
LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS |
Restricted to Preferred Facilities: |
|
Service Code: |
32853 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS |
32853 |
New / Changed in 2020: |
|
Service Description: |
LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS |
Restricted to Preferred Facilities: |
|
Service Code: |
32854 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS |
32854 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI |
Restricted to Preferred Facilities: |
|
Service Code: |
32855 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI |
32855 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI |
Restricted to Preferred Facilities: |
|
Service Code: |
32856 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI |
32856 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Transmyocardial laser revascularization, by thoracotomy (separate procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
33140 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart) |
Transmyocardial laser revascularization, by thoracotomy (separate procedure) |
33140 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
33141 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart) |
Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) |
33141 |
New / Changed in 2020: |
|
Service Description: |
DONOR CARDIECTOMY-PNEUMONECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
33930 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR CARDIECTOMY-PNEUMONECTOMY |
33930 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
33933 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT |
33933 |
New / Changed in 2020: |
|
Service Description: |
HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC |
Restricted to Preferred Facilities: |
|
Service Code: |
33935 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC |
33935 |
New / Changed in 2020: |
|
Service Description: |
DONOR CARDIECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
33940 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR CARDIECTOMY |
33940 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
33944 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT |
33944 |
New / Changed in 2020: |
|
Service Description: |
HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
33945 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY |
33945 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Insertion of ventricular assist device; extracorporeal, single ventricle |
Restricted to Preferred Facilities: |
|
Service Code: |
33975 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device; extracorporeal, single ventricle |
33975 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Insertion of ventricular assist device; extracorporeal, biventricular |
Restricted to Preferred Facilities: |
|
Service Code: |
33976 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device; extracorporeal, biventricular |
33976 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Removal of ventricular assist device; extracorporeal, single ventricle |
Restricted to Preferred Facilities: |
|
Service Code: |
33977 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device; extracorporeal, single ventricle |
33977 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Removal of ventricular assist device; extracorporeal, biventricular |
Restricted to Preferred Facilities: |
|
Service Code: |
33978 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device; extracorporeal, biventricular |
33978 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Insertion of ventricular assist device, implantable intracorporeal, single ventricle |
Restricted to Preferred Facilities: |
|
Service Code: |
33979 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, implantable intracorporeal, single ventricle |
33979 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Removal of ventricular assist device, implantable intracorporeal, single ventricular |
Restricted to Preferred Facilities: |
|
Service Code: |
33980 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device, implantable intracorporeal, single ventricular |
33980 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump |
Restricted to Preferred Facilities: |
|
Service Code: |
33981 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump |
33981 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass |
Restricted to Preferred Facilities: |
|
Service Code: |
33982 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass |
33982 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass |
Restricted to Preferred Facilities: |
|
Service Code: |
33983 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass |
33983 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only |
Restricted to Preferred Facilities: |
|
Service Code: |
33990 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only |
33990 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture |
Restricted to Preferred Facilities: |
|
Service Code: |
33991 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture |
33991 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Removal of percutaneous ventricular assist device at separate and distinct session from insertion |
Restricted to Preferred Facilities: |
|
Service Code: |
33992 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Removal of percutaneous ventricular assist device at separate and distinct session from insertion |
33992 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion |
Restricted to Preferred Facilities: |
|
Service Code: |
33993 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion |
33993 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein) |
Restricted to Preferred Facilities: |
|
Service Code: |
36465 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein) |
36465 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg |
Restricted to Preferred Facilities: |
|
Service Code: |
36466 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg |
36466 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK |
Restricted to Preferred Facilities: |
|
Service Code: |
36468 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK |
36468 |
New / Changed in 2020: |
|
Service Description: |
NJX SCLEROSING SOLUTION SINGLE VEIN |
Restricted to Preferred Facilities: |
|
Service Code: |
36470 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
NJX SCLEROSING SOLUTION SINGLE VEIN |
36470 |
New / Changed in 2020: |
|
Service Description: |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
Restricted to Preferred Facilities: |
|
Service Code: |
36471 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
36471 |
New / Changed in 2020: |
|
Service Description: |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
Restricted to Preferred Facilities: |
|
Service Code: |
36471 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
36471 |
New / Changed in 2020: |
|
Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED |
Restricted to Preferred Facilities: |
|
Service Code: |
36473 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED |
36473 |
New / Changed in 2020: |
|
Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
Restricted to Preferred Facilities: |
|
Service Code: |
36474 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
36474 |
New / Changed in 2020: |
|
Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN |
Restricted to Preferred Facilities: |
|
Service Code: |
36475 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN |
36475 |
New / Changed in 2020: |
|
Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
36476 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS |
36476 |
New / Changed in 2020: |
|
Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN |
Restricted to Preferred Facilities: |
|
Service Code: |
36478 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN |
36478 |
New / Changed in 2020: |
|
Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
36479 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS |
36479 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED |
Restricted to Preferred Facilities: |
|
Service Code: |
36482 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED |
36482 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
Restricted to Preferred Facilities: |
|
Service Code: |
36483 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
36483 |
New / Changed in 2020: |
|
Service Description: |
Insertion of tunneled centrally inserted central venous access device with subcutaneous pump |
Restricted to Preferred Facilities: |
|
Service Code: |
36563 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293/MP298 |
|
Intrathecal Infusion Pump |
Insertion of tunneled centrally inserted central venous access device with subcutaneous pump |
36563 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX |
Restricted to Preferred Facilities: |
|
Service Code: |
37500 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX |
37500 |
New / Changed in 2020: |
|
Service Description: |
LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ |
Restricted to Preferred Facilities: |
|
Service Code: |
37700 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ |
37700 |
New / Changed in 2020: |
|
Service Description: |
LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN |
Restricted to Preferred Facilities: |
|
Service Code: |
37718 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN |
37718 |
New / Changed in 2020: |
|
Service Description: |
LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW |
Restricted to Preferred Facilities: |
|
Service Code: |
37722 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW |
37722 |
New / Changed in 2020: |
|
Service Description: |
LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS |
Restricted to Preferred Facilities: |
|
Service Code: |
37735 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS |
37735 |
New / Changed in 2020: |
|
Service Description: |
LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG |
Restricted to Preferred Facilities: |
|
Service Code: |
37760 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG |
37760 |
New / Changed in 2020: |
|
Service Description: |
LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG |
Restricted to Preferred Facilities: |
|
Service Code: |
37761 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG |
37761 |
New / Changed in 2020: |
|
Service Description: |
STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS |
Restricted to Preferred Facilities: |
|
Service Code: |
37765 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS |
37765 |
New / Changed in 2020: |
|
Service Description: |
STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS |
Restricted to Preferred Facilities: |
|
Service Code: |
37766 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS |
37766 |
New / Changed in 2020: |
|
Service Description: |
LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX |
Restricted to Preferred Facilities: |
|
Service Code: |
37780 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX |
37780 |
New / Changed in 2020: |
|
Service Description: |
LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG |
Restricted to Preferred Facilities: |
|
Service Code: |
37785 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG |
37785 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED PROCEDURE VASCULAR SURGERY |
Restricted to Preferred Facilities: |
|
Service Code: |
37799 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 33 |
|
Varicose Vein Treatments |
UNLISTED PROCEDURE VASCULAR SURGERY |
37799 |
New / Changed in 2020: |
|
Service Description: |
MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ |
Restricted to Preferred Facilities: |
|
Service Code: |
38204 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ |
38204 |
New / Changed in 2020: |
|
Service Description: |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC |
Restricted to Preferred Facilities: |
|
Service Code: |
38205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC |
38205 |
New / Changed in 2020: |
|
Service Description: |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL |
Restricted to Preferred Facilities: |
|
Service Code: |
38206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL |
38206 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR |
Restricted to Preferred Facilities: |
|
Service Code: |
38207 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR |
38207 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR |
Restricted to Preferred Facilities: |
|
Service Code: |
38208 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR |
38208 |
New / Changed in 2020: |
|
Service Description: |
TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR |
Restricted to Preferred Facilities: |
|
Service Code: |
38209 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR |
38209 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL |
Restricted to Preferred Facilities: |
|
Service Code: |
38210 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL |
38210 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ |
Restricted to Preferred Facilities: |
|
Service Code: |
38211 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ |
38211 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL |
Restricted to Preferred Facilities: |
|
Service Code: |
38212 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL |
38212 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ |
Restricted to Preferred Facilities: |
|
Service Code: |
38213 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ |
38213 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ |
Restricted to Preferred Facilities: |
|
Service Code: |
38214 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ |
38214 |
New / Changed in 2020: |
|
Service Description: |
TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM |
Restricted to Preferred Facilities: |
|
Service Code: |
38215 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM |
38215 |
New / Changed in 2020: |
|
Service Description: |
BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC |
Restricted to Preferred Facilities: |
|
Service Code: |
38230 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC |
38230 |
New / Changed in 2020: |
|
Service Description: |
BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS |
Restricted to Preferred Facilities: |
|
Service Code: |
38232 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS |
38232 |
New / Changed in 2020: |
|
Service Description: |
TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
38240 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR |
38240 |
New / Changed in 2020: |
|
Service Description: |
TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
38241 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR |
38241 |
New / Changed in 2020: |
|
Service Description: |
ALLOGENEIC LYMPHOCYTE INFUSIONS |
Restricted to Preferred Facilities: |
|
Service Code: |
38242 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
ALLOGENEIC LYMPHOCYTE INFUSIONS |
38242 |
New / Changed in 2020: |
|
Service Description: |
TRNSPLJ HEMATOPOIETIC CELL BOOST |
Restricted to Preferred Facilities: |
|
Service Code: |
38243 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ HEMATOPOIETIC CELL BOOST |
38243 |
New / Changed in 2020: |
|
Service Description: |
ALVEOLOPLASTY EACH QUADRANT SPECIFY |
Restricted to Preferred Facilities: |
|
Service Code: |
41874 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly March 2007 |
Geisinger Medical Policy # from Former Plan: |
MBP 43 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
ALVEOLOPLASTY EACH QUADRANT SPECIFY |
41874 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES |
Restricted to Preferred Facilities: |
|
Service Code: |
41899 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard July 2013 |
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES |
41899 |
New / Changed in 2020: |
|
Service Description: |
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed |
Restricted to Preferred Facilities: |
|
Service Code: |
43284 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 90.0 |
|
Magnetic Esophageal Sphincter Augmentation (LINX) |
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed |
43284 |
New / Changed in 2020: |
|
Service Description: |
Removal of esophageal sphincter augmentation device |
Restricted to Preferred Facilities: |
|
Service Code: |
43285 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 157.0 |
|
Magnetic Esophageal Sphincter Augmentation (LINX) |
Removal of esophageal sphincter augmentation device |
43285 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43644 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11 |
|
Obesity Surgery |
LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM |
43644 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43645 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 84.0 |
|
Obesity Surgery |
LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ |
43645 |
New / Changed in 2020: |
|
Service Description: |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
Restricted to Preferred Facilities: |
|
Service Code: |
43647 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 132.0 |
|
Gastric Electrical Stimulation |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
43647 |
New / Changed in 2020: |
|
Service Description: |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
Restricted to Preferred Facilities: |
|
Service Code: |
43648 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Gastric Electrical Stimulation |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
43648 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43770 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Obesity Surgery |
LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE |
43770 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43771 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard June 2017-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Obesity Surgery |
LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE |
43771 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43772 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly March 2006 |
Geisinger Medical Policy # from Former Plan: |
MBP 7 |
|
Obesity Surgery |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE |
43772 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43773 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 106.0 |
|
Obesity Surgery |
LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE |
43773 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43774 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Obesity Surgery |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT |
43774 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43775 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Obesity Surgery |
LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY |
43775 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43842 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Obesity Surgery |
GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY |
43842 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43843 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 116.0 |
|
Obesity Surgery |
GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP |
43843 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43845 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly June 2010 |
Geisinger Medical Policy # from Former Plan: |
MBP 76.0 |
|
Obesity Surgery |
GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM |
43845 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43846 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< |
43846 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43847 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ |
43847 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43848 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE |
43848 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
Restricted to Preferred Facilities: |
|
Service Code: |
43881 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gastric Electrical Stimulation |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
43881 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43886 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY |
43886 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43887 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY |
43887 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
43888 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Obesity Surgery |
GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT |
43888 |
New / Changed in 2020: |
|
Service Description: |
INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
44135 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR |
44135 |
New / Changed in 2020: |
|
Service Description: |
INTESTINAL ALLOTRANSPLANTATION LIVING DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
44136 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
INTESTINAL ALLOTRANSPLANTATION LIVING DONOR |
44136 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREP CADAVER/LIVING DONOR INTESTINE |
Restricted to Preferred Facilities: |
|
Service Code: |
44715 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREP CADAVER/LIVING DONOR INTESTINE |
44715 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
44720 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA |
44720 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
44721 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA |
44721 |
New / Changed in 2020: |
|
Service Description: |
DONOR HEPATECTOMY CADAVER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
47133 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY CADAVER DONOR |
47133 |
New / Changed in 2020: |
|
Service Description: |
LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE |
Restricted to Preferred Facilities: |
|
Service Code: |
47135 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE |
47135 |
New / Changed in 2020: |
|
Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG II & III |
Restricted to Preferred Facilities: |
|
Service Code: |
47140 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG II & III |
47140 |
New / Changed in 2020: |
|
Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG II III & IV |
Restricted to Preferred Facilities: |
|
Service Code: |
47141 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG II III & IV |
47141 |
New / Changed in 2020: |
|
Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI |
Restricted to Preferred Facilities: |
|
Service Code: |
47142 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI |
47142 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREP CADAVER DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
47143 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREP CADAVER DONOR |
47143 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII |
Restricted to Preferred Facilities: |
|
Service Code: |
47144 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII |
47144 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI |
Restricted to Preferred Facilities: |
|
Service Code: |
47145 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI |
47145 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
47146 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA |
47146 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ LVR GRF ARTL ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
47147 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ LVR GRF ARTL ANAST EA |
47147 |
New / Changed in 2020: |
|
Service Description: |
PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS |
Restricted to Preferred Facilities: |
|
Service Code: |
48160 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS |
48160 |
New / Changed in 2020: |
|
Service Description: |
DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT |
Restricted to Preferred Facilities: |
|
Service Code: |
48550 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT |
48550 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
48551 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT |
48551 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
48552 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA |
48552 |
New / Changed in 2020: |
|
Service Description: |
TRANSPLANTATION PANCREATIC ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
48554 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRANSPLANTATION PANCREATIC ALLOGRAFT |
48554 |
New / Changed in 2020: |
|
Service Description: |
RMVL TRANSPLANTED PANCREATIC ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
48556 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RMVL TRANSPLANTED PANCREATIC ALLOGRAFT |
48556 |
New / Changed in 2020: |
|
Service Description: |
DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL |
Restricted to Preferred Facilities: |
|
Service Code: |
50300 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL |
50300 |
New / Changed in 2020: |
|
Service Description: |
DONOR NEPHRECTOMY OPEN LIVING DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
50320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR NEPHRECTOMY OPEN LIVING DONOR |
50320 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
50323 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT |
50323 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
50325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT |
50325 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
50327 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA |
50327 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
50328 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA |
50328 |
New / Changed in 2020: |
|
Service Description: |
BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA |
Restricted to Preferred Facilities: |
|
Service Code: |
50329 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA |
50329 |
New / Changed in 2020: |
|
Service Description: |
RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE |
Restricted to Preferred Facilities: |
|
Service Code: |
50340 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE |
50340 |
New / Changed in 2020: |
|
Service Description: |
RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
50360 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY |
50360 |
New / Changed in 2020: |
|
Service Description: |
RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
50365 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY |
50365 |
New / Changed in 2020: |
|
Service Description: |
RMVL TRNSPLED RENAL ALLOGRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
50370 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RMVL TRNSPLED RENAL ALLOGRAFT |
50370 |
New / Changed in 2020: |
|
Service Description: |
RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY |
Restricted to Preferred Facilities: |
|
Service Code: |
50380 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY |
50380 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR |
Restricted to Preferred Facilities: |
|
Service Code: |
50547 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR |
50547 |
New / Changed in 2020: |
|
Service Description: |
URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT |
Restricted to Preferred Facilities: |
|
Service Code: |
53415 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT |
53415 |
New / Changed in 2020: |
|
Service Description: |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE |
Restricted to Preferred Facilities: |
|
Service Code: |
53420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE |
53420 |
New / Changed in 2020: |
|
Service Description: |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
Restricted to Preferred Facilities: |
|
Service Code: |
53425 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
53425 |
New / Changed in 2020: |
|
Service Description: |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
Restricted to Preferred Facilities: |
|
Service Code: |
53425 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
53425 |
New / Changed in 2020: |
|
Service Description: |
URETHROPLASTY RCNSTJ FEMALE URETHRA |
Restricted to Preferred Facilities: |
|
Service Code: |
53430 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
URETHROPLASTY RCNSTJ FEMALE URETHRA |
53430 |
New / Changed in 2020: |
|
Service Description: |
AMPUTATION PENIS PARTIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
54120 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
AMPUTATION PENIS PARTIAL |
54120 |
New / Changed in 2020: |
|
Service Description: |
AMPUTATION PENIS COMPLETE |
Restricted to Preferred Facilities: |
|
Service Code: |
54125 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
AMPUTATION PENIS COMPLETE |
54125 |
New / Changed in 2020: |
|
Service Description: |
INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID |
Restricted to Preferred Facilities: |
|
Service Code: |
54400 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID |
54400 |
New / Changed in 2020: |
|
Service Description: |
INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED |
Restricted to Preferred Facilities: |
|
Service Code: |
54401 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED |
54401 |
New / Changed in 2020: |
|
Service Description: |
INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH |
Restricted to Preferred Facilities: |
|
Service Code: |
54405 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH |
54405 |
New / Changed in 2020: |
|
Service Description: |
RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH |
Restricted to Preferred Facilities: |
|
Service Code: |
54406 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH |
54406 |
New / Changed in 2020: |
|
Service Description: |
RPR COMPONENT INFLATABLE PENILE PROSTHESIS |
Restricted to Preferred Facilities: |
|
Service Code: |
54408 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RPR COMPONENT INFLATABLE PENILE PROSTHESIS |
54408 |
New / Changed in 2020: |
|
Service Description: |
RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS |
Restricted to Preferred Facilities: |
|
Service Code: |
54410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS |
54410 |
New / Changed in 2020: |
|
Service Description: |
RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL |
Restricted to Preferred Facilities: |
|
Service Code: |
54411 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL |
54411 |
New / Changed in 2020: |
|
Service Description: |
RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT |
Restricted to Preferred Facilities: |
|
Service Code: |
54415 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT |
54415 |
New / Changed in 2020: |
|
Service Description: |
RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI |
Restricted to Preferred Facilities: |
|
Service Code: |
54416 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI |
54416 |
New / Changed in 2020: |
|
Service Description: |
RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD |
Restricted to Preferred Facilities: |
|
Service Code: |
54417 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD |
54417 |
New / Changed in 2020: |
|
Service Description: |
ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH |
Restricted to Preferred Facilities: |
|
Service Code: |
54520 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH |
54520 |
New / Changed in 2020: |
|
Service Description: |
INSJ TESTICULAR PROSTH SEPARATE PROCEDURE |
Restricted to Preferred Facilities: |
|
Service Code: |
54660 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard March 2017 |
Geisinger Medical Policy # from Former Plan: |
MBP 149.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
INSJ TESTICULAR PROSTH SEPARATE PROCEDURE |
54660 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY SURGICAL ORCHIECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
54690 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 152.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY SURGICAL ORCHIECTOMY |
54690 |
New / Changed in 2020: |
|
Service Description: |
SCROTOPLASTY SIMPLE |
Restricted to Preferred Facilities: |
|
Service Code: |
55175 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 117.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
SCROTOPLASTY SIMPLE |
55175 |
New / Changed in 2020: |
|
Service Description: |
SCROTOPLASTY COMPLICATED |
Restricted to Preferred Facilities: |
|
Service Code: |
55180 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
SCROTOPLASTY COMPLICATED |
55180 |
New / Changed in 2020: |
|
Service Description: |
UNLISTED PROCEDURE MALE GENITAL SYSTEM |
Restricted to Preferred Facilities: |
|
Service Code: |
55899 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 128.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
UNLISTED PROCEDURE MALE GENITAL SYSTEM |
55899 |
New / Changed in 2020: |
|
Service Description: |
INTERSEX SURG MALE FEMALE |
Restricted to Preferred Facilities: |
|
Service Code: |
55970 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 166.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
INTERSEX SURG MALE FEMALE |
55970 |
New / Changed in 2020: |
|
Service Description: |
INTERSEX SURG FEMALE MALE |
Restricted to Preferred Facilities: |
|
Service Code: |
55980 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 161.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
INTERSEX SURG FEMALE MALE |
55980 |
New / Changed in 2020: |
|
Service Description: |
VULVECTOMY SIMPLE COMPLETE |
Restricted to Preferred Facilities: |
|
Service Code: |
56625 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 91.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
VULVECTOMY SIMPLE COMPLETE |
56625 |
New / Changed in 2020: |
|
Service Description: |
PLASTIC REPAIR INTROITUS |
Restricted to Preferred Facilities: |
|
Service Code: |
56800 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 64.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
PLASTIC REPAIR INTROITUS |
56800 |
New / Changed in 2020: |
|
Service Description: |
CLITOROPLASTY INTERSEX STATE |
Restricted to Preferred Facilities: |
|
Service Code: |
56805 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly March 2006 |
Geisinger Medical Policy # from Former Plan: |
MBP 36 |
|
Gender Dysphoria and Gender Confirmation Treatment |
CLITOROPLASTY INTERSEX STATE |
56805 |
New / Changed in 2020: |
|
Service Description: |
PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX |
Restricted to Preferred Facilities: |
|
Service Code: |
56810 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 73.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX |
56810 |
New / Changed in 2020: |
|
Service Description: |
VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL |
Restricted to Preferred Facilities: |
|
Service Code: |
57106 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL |
57106 |
New / Changed in 2020: |
|
Service Description: |
VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T |
Restricted to Preferred Facilities: |
|
Service Code: |
57107 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T |
57107 |
New / Changed in 2020: |
|
Service Description: |
VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL |
Restricted to Preferred Facilities: |
|
Service Code: |
57110 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL |
57110 |
New / Changed in 2020: |
|
Service Description: |
VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS |
Restricted to Preferred Facilities: |
|
Service Code: |
57111 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS |
57111 |
New / Changed in 2020: |
|
Service Description: |
CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
57291 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT |
57291 |
New / Changed in 2020: |
|
Service Description: |
CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT |
Restricted to Preferred Facilities: |
|
Service Code: |
57292 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT |
57292 |
New / Changed in 2020: |
|
Service Description: |
REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP |
Restricted to Preferred Facilities: |
|
Service Code: |
57295 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP |
57295 |
New / Changed in 2020: |
|
Service Description: |
REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR |
Restricted to Preferred Facilities: |
|
Service Code: |
57296 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR |
57296 |
New / Changed in 2020: |
|
Service Description: |
VAGINOPLASTY INTERSEX STATE |
Restricted to Preferred Facilities: |
|
Service Code: |
57335 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINOPLASTY INTERSEX STATE |
57335 |
New / Changed in 2020: |
|
Service Description: |
TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58150 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY |
58150 |
New / Changed in 2020: |
|
Service Description: |
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58180 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY |
58180 |
New / Changed in 2020: |
|
Service Description: |
VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
Restricted to Preferred Facilities: |
|
Service Code: |
58260 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
58260 |
New / Changed in 2020: |
|
Service Description: |
VAG HYST 250 GM/< W/RMVL TUBE&/OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAG HYST 250 GM/< W/RMVL TUBE&/OVARY |
58262 |
New / Changed in 2020: |
|
Service Description: |
VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY |
Restricted to Preferred Facilities: |
|
Service Code: |
58275 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY |
58275 |
New / Changed in 2020: |
|
Service Description: |
VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE |
Restricted to Preferred Facilities: |
|
Service Code: |
58280 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE |
58280 |
New / Changed in 2020: |
|
Service Description: |
VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION |
Restricted to Preferred Facilities: |
|
Service Code: |
58285 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION |
58285 |
New / Changed in 2020: |
|
Service Description: |
VAGINAL HYSTERECTOMY UTERUS > 250 GM |
Restricted to Preferred Facilities: |
|
Service Code: |
58290 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAGINAL HYSTERECTOMY UTERUS > 250 GM |
58290 |
New / Changed in 2020: |
|
Service Description: |
VAG HYST > 250 GM RMVL TUBE&/OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58291 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
VAG HYST > 250 GM RMVL TUBE&/OVARY |
58291 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< |
Restricted to Preferred Facilities: |
|
Service Code: |
58541 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< |
58541 |
New / Changed in 2020: |
|
Service Description: |
LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR |
Restricted to Preferred Facilities: |
|
Service Code: |
58542 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR |
58542 |
New / Changed in 2020: |
|
Service Description: |
LAPS SUPRACERVICAL HYSTERECTOMY >250 |
Restricted to Preferred Facilities: |
|
Service Code: |
58543 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS SUPRACERVICAL HYSTERECTOMY >250 |
58543 |
New / Changed in 2020: |
|
Service Description: |
LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58544 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY |
58544 |
New / Changed in 2020: |
|
Service Description: |
LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
Restricted to Preferred Facilities: |
|
Service Code: |
58550 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
58550 |
New / Changed in 2020: |
|
Service Description: |
LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES |
Restricted to Preferred Facilities: |
|
Service Code: |
58552 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES |
58552 |
New / Changed in 2020: |
|
Service Description: |
LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS |
Restricted to Preferred Facilities: |
|
Service Code: |
58553 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS |
58553 |
New / Changed in 2020: |
|
Service Description: |
LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR |
Restricted to Preferred Facilities: |
|
Service Code: |
58554 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR |
58554 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< |
Restricted to Preferred Facilities: |
|
Service Code: |
58570 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< |
58570 |
New / Changed in 2020: |
|
Service Description: |
LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY |
Restricted to Preferred Facilities: |
|
Service Code: |
58571 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard June 2017-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MBP 60.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY |
58571 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM |
Restricted to Preferred Facilities: |
|
Service Code: |
58572 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly June 2010 |
Geisinger Medical Policy # from Former Plan: |
MBP 74.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM |
58572 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR |
Restricted to Preferred Facilities: |
|
Service Code: |
58573 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly June 2010 |
Geisinger Medical Policy # from Former Plan: |
MBP 74.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR |
58573 |
New / Changed in 2020: |
|
Service Description: |
LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES |
Restricted to Preferred Facilities: |
|
Service Code: |
58661 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard November 2016 |
Geisinger Medical Policy # from Former Plan: |
MBP 145.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES |
58661 |
New / Changed in 2020: |
|
Service Description: |
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX |
Restricted to Preferred Facilities: |
|
Service Code: |
58720 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Postcard May 2016-Annual Policy Review |
Geisinger Medical Policy # from Former Plan: |
MBP 85.0 |
|
Gender Dysphoria and Gender Confirmation Treatment |
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX |
58720 |
New / Changed in 2020: |
|
Service Description: |
OOPHORECTOMY PARTIAL/TOTAL UNI/BI |
Restricted to Preferred Facilities: |
|
Service Code: |
58940 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Briefly March 2006 |
Geisinger Medical Policy # from Former Plan: |
MBP 38 |
|
Gender Dysphoria and Gender Confirmation Treatment |
OOPHORECTOMY PARTIAL/TOTAL UNI/BI |
58940 |
New / Changed in 2020: |
|
Service Description: |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
Restricted to Preferred Facilities: |
|
Service Code: |
59072 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
59072 |
New / Changed in 2020: |
|
Service Description: |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
Restricted to Preferred Facilities: |
|
Service Code: |
59074 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 131.0 |
|
Fetal Surgery (surgery on the unborn child) |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
59074 |
New / Changed in 2020: |
|
Service Description: |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
Restricted to Preferred Facilities: |
|
Service Code: |
59076 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 131.0 |
|
Fetal Surgery (surgery on the unborn child) |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
59076 |
New / Changed in 2020: |
|
Service Description: |
INDUCED ABORTION DILATION AND CURETTAGE |
Restricted to Preferred Facilities: |
|
Service Code: |
59840 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 125.0 |
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION DILATION AND CURETTAGE |
59840 |
New / Changed in 2020: |
|
Service Description: |
INDUCED ABORTION DILATION & EVACUATION |
Restricted to Preferred Facilities: |
|
Service Code: |
59841 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 125.0 |
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION DILATION & EVACUATION |
59841 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ |
Restricted to Preferred Facilities: |
|
Service Code: |
59850 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 125.0 |
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ |
59850 |
New / Changed in 2020: |
|
Service Description: |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C |
Restricted to Preferred Facilities: |
|
Service Code: |
59851 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 125.0 |
|
Termination of Pregnancy (Abortion) |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C |
59851 |
New / Changed in 2020: |
|
Service Description: |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM |
Restricted to Preferred Facilities: |
|
Service Code: |
59852 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 134.0 |
|
Termination of Pregnancy (Abortion) |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM |
59852 |
New / Changed in 2020: |
|
Service Description: |
INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS |
Restricted to Preferred Facilities: |
|
Service Code: |
59855 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS |
59855 |
New / Changed in 2020: |
|
Service Description: |
INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC |
Restricted to Preferred Facilities: |
|
Service Code: |
59856 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC |
59856 |
New / Changed in 2020: |
|
Service Description: |
INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT |
Restricted to Preferred Facilities: |
|
Service Code: |
59857 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT |
59857 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion |
Restricted to Preferred Facilities: |
|
Service Code: |
61796 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion |
61796 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
61797 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) |
61797 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion |
Restricted to Preferred Facilities: |
|
Service Code: |
61798 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion |
61798 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
61799 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
61799 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
61800 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) |
61800 |
New / Changed in 2020: |
|
Service Description: |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
Restricted to Preferred Facilities: |
|
Service Code: |
61850 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
61850 |
New / Changed in 2020: |
|
Service Description: |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
Restricted to Preferred Facilities: |
|
Service Code: |
61860 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
61860 |
New / Changed in 2020: |
|
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
Restricted to Preferred Facilities: |
|
Service Code: |
61863 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
61863 |
New / Changed in 2020: |
|
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
Restricted to Preferred Facilities: |
|
Service Code: |
61864 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
61864 |
New / Changed in 2020: |
|
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
Restricted to Preferred Facilities: |
|
Service Code: |
61867 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
61867 |
New / Changed in 2020: |
|
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
Restricted to Preferred Facilities: |
|
Service Code: |
61868 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
61868 |
New / Changed in 2020: |
|
Service Description: |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
Restricted to Preferred Facilities: |
|
Service Code: |
61870 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
61870 |
New / Changed in 2020: |
|
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
Restricted to Preferred Facilities: |
|
Service Code: |
61885 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
61885 |
New / Changed in 2020: |
|
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
Restricted to Preferred Facilities: |
|
Service Code: |
61885 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 51 |
|
Vagal Nerve Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
61885 |
New / Changed in 2020: |
|
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
Restricted to Preferred Facilities: |
|
Service Code: |
61886 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
61886 |
New / Changed in 2020: |
|
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
Restricted to Preferred Facilities: |
|
Service Code: |
61886 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 51 |
|
Vagal Nerve Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
61886 |
New / Changed in 2020: |
|
Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
Restricted to Preferred Facilities: |
|
Service Code: |
62263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
62263 |
New / Changed in 2020: |
|
Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
Restricted to Preferred Facilities: |
|
Service Code: |
62264 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
62264 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
Restricted to Preferred Facilities: |
|
Service Code: |
62320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
62320 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
Restricted to Preferred Facilities: |
|
Service Code: |
62321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
62321 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
Restricted to Preferred Facilities: |
|
Service Code: |
62322 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
62322 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
Restricted to Preferred Facilities: |
|
Service Code: |
62323 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
62323 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
Restricted to Preferred Facilities: |
|
Service Code: |
62324 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293/MP298 |
|
Intrathecal Infusion Pump |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
62324 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
Restricted to Preferred Facilities: |
|
Service Code: |
62325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 294/MP298 |
|
Intrathecal Infusion Pump |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
62325 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
Restricted to Preferred Facilities: |
|
Service Code: |
62326 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 295/MP298 |
|
Intrathecal Infusion Pump |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
62326 |
New / Changed in 2020: |
|
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
Restricted to Preferred Facilities: |
|
Service Code: |
62327 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 296/MP298 |
|
Intrathecal Infusion Pump |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
62327 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM |
Restricted to Preferred Facilities: |
|
Service Code: |
62350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 297/MP298 |
|
Intrathecal Infusion Pump |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM |
62350 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM |
Restricted to Preferred Facilities: |
|
Service Code: |
62351 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP298 |
|
Intrathecal Infusion Pump |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM |
62351 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR |
Restricted to Preferred Facilities: |
|
Service Code: |
62360 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 298/MP299 |
|
Intrathecal Infusion Pump |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR |
62360 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ/RPLCMT FS NON-PRGRBL PUMP |
Restricted to Preferred Facilities: |
|
Service Code: |
62361 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 298/MP300 |
|
Intrathecal Infusion Pump |
IMPLTJ/RPLCMT FS NON-PRGRBL PUMP |
62361 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP |
Restricted to Preferred Facilities: |
|
Service Code: |
62362 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 298/MP301 |
|
Intrathecal Infusion Pump |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP |
62362 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP |
Restricted to Preferred Facilities: |
|
Service Code: |
62362 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Medication refill does not require prior authorization |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 298/MP301 |
|
Intrathecal Infusion Pump |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP |
62362 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
63005 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR |
63005 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
63012 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR |
63012 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
63017 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR |
63017 |
New / Changed in 2020: |
|
Service Description: |
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR |
Restricted to Preferred Facilities: |
|
Service Code: |
63030 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR |
63030 |
New / Changed in 2020: |
|
Service Description: |
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR |
Restricted to Preferred Facilities: |
|
Service Code: |
63035 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR |
63035 |
New / Changed in 2020: |
|
Service Description: |
LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
63042 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR |
63042 |
New / Changed in 2020: |
|
Service Description: |
LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR |
Restricted to Preferred Facilities: |
|
Service Code: |
63044 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR |
63044 |
New / Changed in 2020: |
|
Service Description: |
LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT LUMBAR |
Restricted to Preferred Facilities: |
|
Service Code: |
63047 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT LUMBAR |
63047 |
New / Changed in 2020: |
|
Service Description: |
LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR |
Restricted to Preferred Facilities: |
|
Service Code: |
63048 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR |
63048 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS |
Restricted to Preferred Facilities: |
|
Service Code: |
63185 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS |
63185 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS |
Restricted to Preferred Facilities: |
|
Service Code: |
63190 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS |
63190 |
New / Changed in 2020: |
|
Service Description: |
LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
63191 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE |
63191 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion |
Restricted to Preferred Facilities: |
|
Service Code: |
63620 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion |
63620 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
63621 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) |
63621 |
New / Changed in 2020: |
|
Service Description: |
Percutaneous implantation of neurostimulator electrode array, epidural |
Restricted to Preferred Facilities: |
|
Service Code: |
63650 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Percutaneous implantation of neurostimulator electrode array, epidural |
63650 |
New / Changed in 2020: |
|
Service Description: |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
Restricted to Preferred Facilities: |
|
Service Code: |
63655 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
63655 |
New / Changed in 2020: |
|
Service Description: |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
Restricted to Preferred Facilities: |
|
Service Code: |
63685 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
63685 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV |
Restricted to Preferred Facilities: |
|
Service Code: |
64405 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Occipital Nerve Block |
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV |
64405 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ANESTHETIC AGENT SUPRASCAPULAR NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
64418 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Suprascapular Nerve Block |
INJECTION ANESTHETIC AGENT SUPRASCAPULAR NERVE |
64418 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ANESTHETIC AGENT 1 INTERCOSTAL NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
64420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intercostal Nerve Block |
INJECTION ANESTHETIC AGENT 1 INTERCOSTAL NERVE |
64420 |
New / Changed in 2020: |
|
Service Description: |
MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES |
Restricted to Preferred Facilities: |
|
Service Code: |
64421 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intercostal Nerve Block |
MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES |
64421 |
New / Changed in 2020: |
|
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
64479 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
64479 |
New / Changed in 2020: |
|
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
Restricted to Preferred Facilities: |
|
Service Code: |
64480 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
64480 |
New / Changed in 2020: |
|
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
64483 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
64483 |
New / Changed in 2020: |
|
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
Restricted to Preferred Facilities: |
|
Service Code: |
64484 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
64484 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64490 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
64490 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
64491 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
64492 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64493 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
64493 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64493 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sacroiliac Joint Injection |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
64493 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sacroiliac Joint Injection |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64495 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
64495 |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
Restricted to Preferred Facilities: |
|
Service Code: |
64495 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 115.0 |
|
Sacroiliac Joint Injection |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
64495 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ANES AGENT SPHENOPALATINE GANGLION |
Restricted to Preferred Facilities: |
|
Service Code: |
64505 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 46.0 |
|
Sympathetic Nerve Block |
INJECTION ANES AGENT SPHENOPALATINE GANGLION |
64505 |
New / Changed in 2020: |
|
Service Description: |
NJX ANES STELLATE GANGLION CRV SYMPATHETIC |
Restricted to Preferred Facilities: |
|
Service Code: |
64510 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 121.0 |
|
Sympathetic Nerve Block |
NJX ANES STELLATE GANGLION CRV SYMPATHETIC |
64510 |
New / Changed in 2020: |
|
Service Description: |
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC |
Restricted to Preferred Facilities: |
|
Service Code: |
64520 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 139.0 |
|
Sympathetic Nerve Block |
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC |
64520 |
New / Changed in 2020: |
|
Service Description: |
INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG |
Restricted to Preferred Facilities: |
|
Service Code: |
64530 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Sympathetic Nerve Block |
INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG |
64530 |
New / Changed in 2020: |
|
Service Description: |
PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING |
Restricted to Preferred Facilities: |
|
Service Code: |
64561 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation prior to the device becoming permanent). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING |
64561 |
New / Changed in 2020: |
|
Service Description: |
INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER |
Restricted to Preferred Facilities: |
|
Service Code: |
64568 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 51 |
|
Vagal Nerve Stimulation |
INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER |
64568 |
New / Changed in 2020: |
|
Service Description: |
INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
64581 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation prior to the device becoming permanent). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE |
64581 |
New / Changed in 2020: |
|
Service Description: |
INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR |
Restricted to Preferred Facilities: |
|
Service Code: |
64590 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation prior to the device becoming permanent). |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 73 |
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR |
64590 |
New / Changed in 2020: |
|
Service Description: |
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
64620 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intercostal Nerve Block |
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE |
64620 |
New / Changed in 2020: |
|
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
Restricted to Preferred Facilities: |
|
Service Code: |
64633 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
64633 |
New / Changed in 2020: |
|
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
Restricted to Preferred Facilities: |
|
Service Code: |
64634 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 21 |
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
64634 |
New / Changed in 2020: |
|
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
Restricted to Preferred Facilities: |
|
Service Code: |
64635 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 21 |
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
64635 |
New / Changed in 2020: |
|
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
Restricted to Preferred Facilities: |
|
Service Code: |
64636 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
64636 |
New / Changed in 2020: |
|
Service Description: |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
Restricted to Preferred Facilities: |
|
Service Code: |
64640 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
64640 |
New / Changed in 2020: |
|
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
Restricted to Preferred Facilities: |
|
Service Code: |
64643 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 21 |
|
Facet or Sacroiliac Joint Denervation |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
New / Changed in 2020: |
|
Service Description: |
IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS |
Restricted to Preferred Facilities: |
|
Service Code: |
67027 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 34 |
|
Vitrasert® (ganciclovir intravitreal implant) |
IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS |
67027 |
New / Changed in 2020: |
|
Service Description: |
REPAIR BROW PTOSIS |
Restricted to Preferred Facilities: |
|
Service Code: |
67900 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
REPAIR BROW PTOSIS |
67900 |
New / Changed in 2020: |
|
Service Description: |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
67901 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
67901 |
New / Changed in 2020: |
|
Service Description: |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
Restricted to Preferred Facilities: |
|
Service Code: |
67902 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
67902 |
New / Changed in 2020: |
|
Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
Restricted to Preferred Facilities: |
|
Service Code: |
67903 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
67903 |
New / Changed in 2020: |
|
Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
Restricted to Preferred Facilities: |
|
Service Code: |
67904 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
67904 |
New / Changed in 2020: |
|
Service Description: |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
Restricted to Preferred Facilities: |
|
Service Code: |
67906 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
67906 |
New / Changed in 2020: |
|
Service Description: |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
Restricted to Preferred Facilities: |
|
Service Code: |
67908 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
67908 |
New / Changed in 2020: |
|
Service Description: |
MRI TEMPOROMANDIBULAR JOINT |
Restricted to Preferred Facilities: |
|
Service Code: |
70336 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI TEMPOROMANDIBULAR JOINT |
70336 |
New / Changed in 2020: |
|
Service Description: |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70450 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
70450 |
New / Changed in 2020: |
|
Service Description: |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70460 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
70460 |
New / Changed in 2020: |
|
Service Description: |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70470 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
70470 |
New / Changed in 2020: |
|
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
70480 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
70480 |
New / Changed in 2020: |
|
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
70481 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
70481 |
New / Changed in 2020: |
|
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
Restricted to Preferred Facilities: |
|
Service Code: |
70482 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
70482 |
New / Changed in 2020: |
|
Service Description: |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70486 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
70486 |
New / Changed in 2020: |
|
Service Description: |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70487 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
70487 |
New / Changed in 2020: |
|
Service Description: |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70488 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
70488 |
New / Changed in 2020: |
|
Service Description: |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70490 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
70490 |
New / Changed in 2020: |
|
Service Description: |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
70491 |
New / Changed in 2020: |
|
Service Description: |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
70492 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
70496 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
70496 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
70498 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
70498 |
New / Changed in 2020: |
|
Service Description: |
MRI ORBIT FACE &/NECK W/O CONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
70540 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE &/NECK W/O CONTRAST |
70540 |
New / Changed in 2020: |
|
Service Description: |
MRI ORBIT FACE & NECK W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70542 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE & NECK W/CONTRAST MATERIAL |
70542 |
New / Changed in 2020: |
|
Service Description: |
MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
70543 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL |
70543 |
New / Changed in 2020: |
|
Service Description: |
MRA HEAD W/O CONTRST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70544 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/O CONTRST MATERIAL |
70544 |
New / Changed in 2020: |
|
Service Description: |
MRA HEAD W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70545 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/CONTRAST MATERIAL |
70545 |
New / Changed in 2020: |
|
Service Description: |
MRA HEAD W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70546 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/O & W/CONTRAST MATERIAL |
70546 |
New / Changed in 2020: |
|
Service Description: |
MRA NECK W/O CONTRST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70547 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/O CONTRST MATERIAL |
70547 |
New / Changed in 2020: |
|
Service Description: |
MRA NECK W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70548 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/CONTRAST MATERIAL |
70548 |
New / Changed in 2020: |
|
Service Description: |
MRA NECK W/O &W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70549 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/O &W/CONTRAST MATERIAL |
70549 |
New / Changed in 2020: |
|
Service Description: |
MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70551 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 44.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL |
70551 |
New / Changed in 2020: |
|
Service Description: |
MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70552 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL |
70552 |
New / Changed in 2020: |
|
Service Description: |
MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
70553 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 113 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL |
70553 |
New / Changed in 2020: |
|
Service Description: |
MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION |
Restricted to Preferred Facilities: |
|
Service Code: |
70554 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 113 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION |
70554 |
New / Changed in 2020: |
|
Service Description: |
MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION |
Restricted to Preferred Facilities: |
|
Service Code: |
70555 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 113 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION |
70555 |
New / Changed in 2020: |
|
Service Description: |
CT THORAX W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71250 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 100.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O CONTRAST MATERIAL |
71250 |
New / Changed in 2020: |
|
Service Description: |
CT THORAX W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71260 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 29 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/CONTRAST MATERIAL |
71260 |
New / Changed in 2020: |
|
Service Description: |
CT THORAX W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71270 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O & W/CONTRAST MATERIAL |
71270 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CTA chest (noncoronary) |
Restricted to Preferred Facilities: |
|
Service Code: |
71275 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 140.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA chest (noncoronary) |
71275 |
New / Changed in 2020: |
|
Service Description: |
MRI CHEST W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71550 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 118.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/O CONTRAST MATERIAL |
71550 |
New / Changed in 2020: |
|
Service Description: |
MRI CHEST W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71551 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/CONTRAST MATERIAL |
71551 |
New / Changed in 2020: |
|
Service Description: |
MRI CHEST W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71552 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/O & W/CONTRAST MATERIAL |
71552 |
New / Changed in 2020: |
|
Service Description: |
MRA CHEST W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
71555 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA CHEST W/O & W/CONTRAST MATERIAL |
71555 |
New / Changed in 2020: |
|
Service Description: |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72125 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
72125 |
New / Changed in 2020: |
|
Service Description: |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72126 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
72126 |
New / Changed in 2020: |
|
Service Description: |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72127 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
72127 |
New / Changed in 2020: |
|
Service Description: |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72128 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
72128 |
New / Changed in 2020: |
|
Service Description: |
CT THORACIC SPINE W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72129 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/CONTRAST MATERIAL |
72129 |
New / Changed in 2020: |
|
Service Description: |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72130 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
72130 |
New / Changed in 2020: |
|
Service Description: |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72130 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
72130 |
New / Changed in 2020: |
|
Service Description: |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72131 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
72131 |
New / Changed in 2020: |
|
Service Description: |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72132 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
72132 |
New / Changed in 2020: |
|
Service Description: |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72133 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 151 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
72133 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72141 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 138 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL |
72141 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72142 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 138 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL |
72142 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72146 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL |
72146 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL THORACIC W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72147 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 53.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/CONTRAST MATRL |
72147 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72148 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL |
72148 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72149 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 95.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL |
72149 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72156 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL |
72156 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72157 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL |
72157 |
New / Changed in 2020: |
|
Service Description: |
MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
72158 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL |
72158 |
New / Changed in 2020: |
|
Service Description: |
MRA SPINAL CANAL W/WO CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72159 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA SPINAL CANAL W/WO CONTRAST MATERIAL |
72159 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
72191 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
72191 |
New / Changed in 2020: |
|
Service Description: |
CT PELVIS W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72192 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O CONTRAST MATERIAL |
72192 |
New / Changed in 2020: |
|
Service Description: |
CT PELVIS W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72193 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/CONTRAST MATERIAL |
72193 |
New / Changed in 2020: |
|
Service Description: |
CT PELVIS W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72194 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 148.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O & W/CONTRAST MATERIAL |
72194 |
New / Changed in 2020: |
|
Service Description: |
MRI PELVIS W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72195 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/O CONTRAST MATERIAL |
72195 |
New / Changed in 2020: |
|
Service Description: |
MRI PELVIS W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72196 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/CONTRAST MATERIAL |
72196 |
New / Changed in 2020: |
|
Service Description: |
MRI PELVIS W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72197 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/O & W/CONTRAST MATERIAL |
72197 |
New / Changed in 2020: |
|
Service Description: |
MRA PELVIS W/WO CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
72198 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA PELVIS W/WO CONTRAST MATERIAL |
72198 |
New / Changed in 2020: |
|
Service Description: |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73200 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
73200 |
New / Changed in 2020: |
|
Service Description: |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73201 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
73201 |
New / Changed in 2020: |
|
Service Description: |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
73202 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY UPPER EXTREMITY |
Restricted to Preferred Facilities: |
|
Service Code: |
73206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY UPPER EXTREMITY |
73206 |
New / Changed in 2020: |
|
Service Description: |
MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73218 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL |
73218 |
New / Changed in 2020: |
|
Service Description: |
MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73219 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL |
73219 |
New / Changed in 2020: |
|
Service Description: |
MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS |
Restricted to Preferred Facilities: |
|
Service Code: |
73220 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS |
73220 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73221 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL |
73221 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73222 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL |
73222 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73223 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL |
73223 |
New / Changed in 2020: |
|
Service Description: |
MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73225 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL |
73225 |
New / Changed in 2020: |
|
Service Description: |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73700 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
73700 |
New / Changed in 2020: |
|
Service Description: |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73701 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
73701 |
New / Changed in 2020: |
|
Service Description: |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73702 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
73702 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY LOWER EXTREMITY |
Restricted to Preferred Facilities: |
|
Service Code: |
73706 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY LOWER EXTREMITY |
73706 |
New / Changed in 2020: |
|
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73718 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL |
73718 |
New / Changed in 2020: |
|
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73719 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL |
73719 |
New / Changed in 2020: |
|
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR |
Restricted to Preferred Facilities: |
|
Service Code: |
73720 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR |
73720 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73721 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 18 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL |
73721 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73722 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL |
73722 |
New / Changed in 2020: |
|
Service Description: |
MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL |
Restricted to Preferred Facilities: |
|
Service Code: |
73723 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL |
73723 |
New / Changed in 2020: |
|
Service Description: |
MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
73725 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL |
73725 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74150 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O CONTRAST MATERIAL |
74150 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74160 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/CONTRAST MATERIAL |
74160 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74170 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
74170 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
Restricted to Preferred Facilities: |
|
Service Code: |
74174 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
74174 |
New / Changed in 2020: |
|
Service Description: |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
74175 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
74175 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74176 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
74176 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74177 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
74177 |
New / Changed in 2020: |
|
Service Description: |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
Restricted to Preferred Facilities: |
|
Service Code: |
74178 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
74178 |
New / Changed in 2020: |
|
Service Description: |
MRI ABDOMEN W/O CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74181 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 283 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/O CONTRAST MATERIAL |
74181 |
New / Changed in 2020: |
|
Service Description: |
MRI ABDOMEN W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74182 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/CONTRAST MATERIAL |
74182 |
New / Changed in 2020: |
|
Service Description: |
MRI ABDOMEN W/O & W/CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74183 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/O & W/CONTRAST MATERIAL |
74183 |
New / Changed in 2020: |
|
Service Description: |
MRA ABDOMEN W/WO CONTRAST MATERIAL |
Restricted to Preferred Facilities: |
|
Service Code: |
74185 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA ABDOMEN W/WO CONTRAST MATERIAL |
74185 |
New / Changed in 2020: |
|
Service Description: |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
74261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 132 |
|
Virtual Colonoscopy (Outpatient/Nonemergency) |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST |
74261 |
New / Changed in 2020: |
|
Service Description: |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
74262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 132 |
|
Virtual Colonoscopy (Outpatient/Nonemergency) |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST |
74262 |
New / Changed in 2020: |
|
Service Description: |
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST |
Restricted to Preferred Facilities: |
|
Service Code: |
75557 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST |
75557 |
New / Changed in 2020: |
|
Service Description: |
CARDIAC MRI W/O CONTRAST W/STRESS IMAGING |
Restricted to Preferred Facilities: |
|
Service Code: |
75559 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/O CONTRAST W/STRESS IMAGING |
75559 |
New / Changed in 2020: |
|
Service Description: |
CARDIAC MRI W/WO CONTRAST & FURTHER SEQ |
Restricted to Preferred Facilities: |
|
Service Code: |
75561 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 231 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/WO CONTRAST & FURTHER SEQ |
75561 |
New / Changed in 2020: |
|
Service Description: |
CARDIAC MRI W/W/O CONTRAST W/STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
75563 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/W/O CONTRAST W/STRESS |
75563 |
New / Changed in 2020: |
|
Service Description: |
CARDIAC MRI FOR VELOCITY FLOW MAPPING |
Restricted to Preferred Facilities: |
|
Service Code: |
75565 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI FOR VELOCITY FLOW MAPPING |
75565 |
New / Changed in 2020: |
|
Service Description: |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
Restricted to Preferred Facilities: |
|
Service Code: |
75571 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
75571 |
New / Changed in 2020: |
|
Service Description: |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
Restricted to Preferred Facilities: |
|
Service Code: |
75572 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
75572 |
New / Changed in 2020: |
|
Service Description: |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
Restricted to Preferred Facilities: |
|
Service Code: |
75573 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
75573 |
New / Changed in 2020: |
|
Service Description: |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
Restricted to Preferred Facilities: |
|
Service Code: |
75574 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
75574 |
New / Changed in 2020: |
|
Service Description: |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
Restricted to Preferred Facilities: |
|
Service Code: |
75635 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
75635 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation |
Restricted to Preferred Facilities: |
|
Service Code: |
76376 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation |
76376 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation |
Restricted to Preferred Facilities: |
|
Service Code: |
76377 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation |
76377 |
New / Changed in 2020: |
|
Service Description: |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
Restricted to Preferred Facilities: |
|
Service Code: |
76380 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
76380 |
New / Changed in 2020: |
|
Service Description: |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
Restricted to Preferred Facilities: |
|
Service Code: |
76497 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
76497 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CT guidance for placement of radiation therapy fields |
Restricted to Preferred Facilities: |
|
Service Code: |
77014 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 59 |
|
Radiation Oncology-Treatment Delivery |
CT guidance for placement of radiation therapy fields |
77014 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Magnetic resonance imaging, breast, without contrast material(s); unilateral |
Restricted to Preferred Facilities: |
|
Service Code: |
77046 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without contrast material(s); unilateral |
77046 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Magnetic resonance imaging, breast, without contrast material(s); bilateral |
Restricted to Preferred Facilities: |
|
Service Code: |
77047 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 61.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without contrast material(s); bilateral |
77047 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; unilateral |
Restricted to Preferred Facilities: |
|
Service Code: |
77048 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 61.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; unilateral |
77048 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; bilateral |
Restricted to Preferred Facilities: |
|
Service Code: |
77049 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; bilateral |
77049 |
New / Changed in 2020: |
|
Service Description: |
BONE MARROW BLOOD SUPPLY |
Restricted to Preferred Facilities: |
|
Service Code: |
77084 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
BONE MARROW BLOOD SUPPLY |
77084 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology treatment planning; simple |
Restricted to Preferred Facilities: |
|
Service Code: |
77261 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; simple |
77261 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology treatment planning; intermediate |
Restricted to Preferred Facilities: |
|
Service Code: |
77262 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; intermediate |
77262 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology treatment planning; complex |
Restricted to Preferred Facilities: |
|
Service Code: |
77263 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; complex |
77263 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology simulation-aided field setting; simple |
Restricted to Preferred Facilities: |
|
Service Code: |
77280 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; simple |
77280 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology simulation-aided field setting; intermediate |
Restricted to Preferred Facilities: |
|
Service Code: |
77285 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; intermediate |
77285 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology simulation-aided field setting; complex |
Restricted to Preferred Facilities: |
|
Service Code: |
77290 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; complex |
77290 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
4-D CT simulation study for conformal planning - Respiratory Management Simulation |
Restricted to Preferred Facilities: |
|
Service Code: |
77293 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Prep for Treatment |
4-D CT simulation study for conformal planning - Respiratory Management Simulation |
77293 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology simulation-aided field setting; 3-dimensional |
Restricted to Preferred Facilities: |
|
Service Code: |
77295 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Therapeutic radiology simulation-aided field setting; 3-dimensional |
77295 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Basic radiation dosimetry calculation |
Restricted to Preferred Facilities: |
|
Service Code: |
77300 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Basic radiation dosimetry calculation |
77300 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intensity modulated radiotherapy plan (IMRT), including dose-volume histograms for target and critical structure partial tolerance specifications |
Restricted to Preferred Facilities: |
|
Service Code: |
77301 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Intensity modulated radiotherapy plan (IMRT), including dose-volume histograms for target and critical structure partial tolerance specifications |
77301 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dosimetry device Isodose Planning |
Restricted to Preferred Facilities: |
|
Service Code: |
77306 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Dosimetry device Isodose Planning |
77306 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Teletherapy isodose plan complex |
Restricted to Preferred Facilities: |
|
Service Code: |
77307 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Teletherapy isodose plan complex |
77307 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations |
Restricted to Preferred Facilities: |
|
Service Code: |
77316 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations |
77316 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation |
Restricted to Preferred Facilities: |
|
Service Code: |
77317 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation |
77317 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations |
Restricted to Preferred Facilities: |
|
Service Code: |
77318 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations |
77318 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Special teletherapy port plan, particles, hemibody, total body |
Restricted to Preferred Facilities: |
|
Service Code: |
77321 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special teletherapy port plan, particles, hemibody, total body |
77321 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
Restricted to Preferred Facilities: |
|
Service Code: |
77331 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
77331 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment devices, design and construction; simple (simple block, simple bolus) |
Restricted to Preferred Facilities: |
|
Service Code: |
77332 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; simple (simple block, simple bolus) |
77332 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) |
Restricted to Preferred Facilities: |
|
Service Code: |
77333 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) |
77333 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) |
Restricted to Preferred Facilities: |
|
Service Code: |
77334 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) |
77334 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy |
Restricted to Preferred Facilities: |
|
Service Code: |
77336 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy |
77336 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan |
Restricted to Preferred Facilities: |
|
Service Code: |
77338 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan |
77338 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Special medical radiation physics consultation |
Restricted to Preferred Facilities: |
|
Service Code: |
77370 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special medical radiation physics consultation |
77370 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Special medical radiation physics consultation |
Restricted to Preferred Facilities: |
|
Service Code: |
77370 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special medical radiation physics consultation |
77370 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; multi-source Cobalt 60 based |
Restricted to Preferred Facilities: |
|
Service Code: |
77371 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; multi-source Cobalt 60 based |
77371 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; linear accelerator based |
Restricted to Preferred Facilities: |
|
Service Code: |
77372 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; linear accelerator based |
77372 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed 5 fractions |
Restricted to Preferred Facilities: |
|
Service Code: |
77373 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed 5 fractions |
77373 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple |
Restricted to Preferred Facilities: |
|
Service Code: |
77385 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple |
77385 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex |
Restricted to Preferred Facilities: |
|
Service Code: |
77386 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex |
77386 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed |
Restricted to Preferred Facilities: |
|
Service Code: |
77387 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed |
77387 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, superficial and/or ortho voltage |
Restricted to Preferred Facilities: |
|
Service Code: |
77401 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, superficial and/or ortho voltage |
77401 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 1 treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
77402 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 1 treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV |
77402 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3+ ports on a single treatment area, use of multiple blocks; up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
77407 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3+ ports on a single treatment area, use of multiple blocks; up to 5 MeV |
77407 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 3+ separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
77412 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3+ separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
77412 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Therapeutic radiology port film(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
77417 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Therapeutic radiology port film(s) |
77417 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
High energy neutron radiation treatment delivery; 1 treatment area using a single port or parallel-opposed ports with no blocks or simple blocking |
Restricted to Preferred Facilities: |
|
Service Code: |
77422 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
High energy neutron radiation treatment delivery; 1 treatment area using a single port or parallel-opposed ports with no blocks or simple blocking |
77422 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
One or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
77423 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
One or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) |
77423 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intraoperative radiation treatment delivery, x-ray, single treatment session |
Restricted to Preferred Facilities: |
|
Service Code: |
77424 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Intraoperative radiation treatment delivery, x-ray, single treatment session |
77424 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intraoperative radiation treatment delivery, electrons, single treatment session |
Restricted to Preferred Facilities: |
|
Service Code: |
77425 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Intraoperative radiation treatment delivery, electrons, single treatment session |
77425 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment management, 5 treatments |
Restricted to Preferred Facilities: |
|
Service Code: |
77427 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Management |
Radiation treatment management, 5 treatments |
77427 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation therapy management with complete course of therapy; 1-2 fractions |
Restricted to Preferred Facilities: |
|
Service Code: |
77431 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Management |
Radiation therapy management with complete course of therapy; 1-2 fractions |
77431 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) |
Restricted to Preferred Facilities: |
|
Service Code: |
77432 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) |
77432 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereotactic body radiation therapy, treatment management, per treatment course, to 1+ lesions, including image guidance, entire course not to exceed 5 fractions |
Restricted to Preferred Facilities: |
|
Service Code: |
77435 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Stereotactic body radiation therapy, treatment management, per treatment course, to 1+ lesions, including image guidance, entire course not to exceed 5 fractions |
77435 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intraoperative radiation treatment management |
Restricted to Preferred Facilities: |
|
Service Code: |
77469 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Management |
Intraoperative radiation treatment management |
77469 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) |
Restricted to Preferred Facilities: |
|
Service Code: |
77470 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Management |
Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) |
77470 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) |
Restricted to Preferred Facilities: |
|
Service Code: |
77600 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) |
77600 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 cm) |
Restricted to Preferred Facilities: |
|
Service Code: |
77605 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 cm) |
77605 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators |
Restricted to Preferred Facilities: |
|
Service Code: |
77610 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators |
77610 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators |
Restricted to Preferred Facilities: |
|
Service Code: |
77615 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators |
77615 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyperthermia generated by intracavitary probe(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
77620 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by intracavitary probe(s) |
77620 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Clinical Brachytherapy- Intracavitary radiation |
Restricted to Preferred Facilities: |
|
Service Code: |
77750 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Clinical Brachytherapy- Intracavitary radiation |
77750 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
Restricted to Preferred Facilities: |
|
Service Code: |
77761 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77761 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
intracavitary brachytherapy using 10 sources; intermediate |
Restricted to Preferred Facilities: |
|
Service Code: |
77762 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
intracavitary brachytherapy using 10 sources; intermediate |
77762 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
Restricted to Preferred Facilities: |
|
Service Code: |
77763 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77763 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel |
Restricted to Preferred Facilities: |
|
Service Code: |
77770 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel |
77770 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels |
Restricted to Preferred Facilities: |
|
Service Code: |
77771 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels |
77771 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels |
Restricted to Preferred Facilities: |
|
Service Code: |
77772 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels |
77772 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when performed |
Restricted to Preferred Facilities: |
|
Service Code: |
77778 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when performed |
77778 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
Restricted to Preferred Facilities: |
|
Service Code: |
77789 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77789 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
Restricted to Preferred Facilities: |
|
Service Code: |
77790 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77790 |
New / Changed in 2020: |
|
Service Description: |
LIVER IMAGING SPECT |
Restricted to Preferred Facilities: |
|
Service Code: |
78205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Liver |
LIVER IMAGING SPECT |
78205 |
New / Changed in 2020: |
|
Service Description: |
LIVER IMAGING SPECT W/VASCULAR FLOW |
Restricted to Preferred Facilities: |
|
Service Code: |
78206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Liver |
LIVER IMAGING SPECT W/VASCULAR FLOW |
78206 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone and/or Joint imaging; Limited area |
Restricted to Preferred Facilities: |
|
Service Code: |
78300 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Limited area |
78300 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone and/or Joint imaging; Multiple areas |
Restricted to Preferred Facilities: |
|
Service Code: |
78305 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Multiple areas |
78305 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone and/or Joint imaging; Whole Body |
Restricted to Preferred Facilities: |
|
Service Code: |
78306 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Whole Body |
78306 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Bone and/or Joint imaging; 3 phase study |
Restricted to Preferred Facilities: |
|
Service Code: |
78315 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; 3 phase study |
78315 |
New / Changed in 2020: |
|
Service Description: |
BONE &/JOINT IMAGING TOMOGRAPHIC SPECT |
Restricted to Preferred Facilities: |
|
Service Code: |
78320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Bone and Joint |
BONE &/JOINT IMAGING TOMOGRAPHIC SPECT |
78320 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
78451 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS |
78451 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL SPECT MULTIPLE STUDIES |
Restricted to Preferred Facilities: |
|
Service Code: |
78452 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL SPECT MULTIPLE STUDIES |
78452 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
78453 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS |
78453 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES |
Restricted to Preferred Facilities: |
|
Service Code: |
78454 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES |
78454 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL IMAGING PET METABOLIC EVALUATION |
Restricted to Preferred Facilities: |
|
Service Code: |
78459 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCARDIAL IMAGING PET METABOLIC EVALUATION |
78459 |
New / Changed in 2020: |
|
Service Description: |
MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN |
Restricted to Preferred Facilities: |
|
Service Code: |
78466 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN |
78466 |
New / Changed in 2020: |
|
Service Description: |
MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ |
Restricted to Preferred Facilities: |
|
Service Code: |
78468 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ |
78468 |
New / Changed in 2020: |
|
Service Description: |
MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ |
Restricted to Preferred Facilities: |
|
Service Code: |
78469 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ |
78469 |
New / Changed in 2020: |
|
Service Description: |
CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
78472 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS |
78472 |
New / Changed in 2020: |
|
Service Description: |
CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT |
Restricted to Preferred Facilities: |
|
Service Code: |
78473 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT |
78473 |
New / Changed in 2020: |
|
Service Description: |
CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT |
Restricted to Preferred Facilities: |
|
Service Code: |
78481 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT |
78481 |
New / Changed in 2020: |
|
Service Description: |
CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT |
Restricted to Preferred Facilities: |
|
Service Code: |
78483 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT |
78483 |
New / Changed in 2020: |
|
Service Description: |
MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
78491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS |
78491 |
New / Changed in 2020: |
|
Service Description: |
MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS |
Restricted to Preferred Facilities: |
|
Service Code: |
78492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 170 |
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS |
78492 |
New / Changed in 2020: |
|
Service Description: |
CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT |
Restricted to Preferred Facilities: |
|
Service Code: |
78494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 170 |
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT |
78494 |
New / Changed in 2020: |
|
Service Description: |
CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT |
Restricted to Preferred Facilities: |
|
Service Code: |
78496 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT |
78496 |
New / Changed in 2020: |
|
Service Description: |
UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE |
Restricted to Preferred Facilities: |
|
Service Code: |
78499 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nuclear Imaging (SPECT): Cardiac |
UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE |
78499 |
New / Changed in 2020: |
|
Service Description: |
BRAIN IMAGING TOMOGRAPHIC SPECT |
Restricted to Preferred Facilities: |
|
Service Code: |
78607 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 246 |
|
Nuclear Imaging (SPECT): Brain |
BRAIN IMAGING TOMOGRAPHIC SPECT |
78607 |
New / Changed in 2020: |
|
Service Description: |
BRAIN IMAGING PET METABOLIC EVALUATION |
Restricted to Preferred Facilities: |
|
Service Code: |
78608 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
BRAIN IMAGING PET METABOLIC EVALUATION |
78608 |
New / Changed in 2020: |
|
Service Description: |
BRAIN IMAGING PET PERFUSION EVALUATION |
Restricted to Preferred Facilities: |
|
Service Code: |
78609 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
BRAIN IMAGING PET PERFUSION EVALUATION |
78609 |
New / Changed in 2020: |
|
Service Description: |
CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT |
Restricted to Preferred Facilities: |
|
Service Code: |
78647 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nuclear Imaging (SPECT): Cerebrospinal Fluid Flow |
CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT |
78647 |
New / Changed in 2020: |
|
Service Description: |
KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC |
Restricted to Preferred Facilities: |
|
Service Code: |
78710 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nuclear Imaging (SPECT): Kidney |
KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC |
78710 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING LIMITED AREA CHEST HEAD/NECK |
Restricted to Preferred Facilities: |
|
Service Code: |
78811 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING LIMITED AREA CHEST HEAD/NECK |
78811 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING SKULL BASE TO MID-THIGH |
Restricted to Preferred Facilities: |
|
Service Code: |
78812 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING SKULL BASE TO MID-THIGH |
78812 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING WHOLE BODY |
Restricted to Preferred Facilities: |
|
Service Code: |
78813 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING WHOLE BODY |
78813 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING CT FOR ATTENUATION LIMITED AREA |
Restricted to Preferred Facilities: |
|
Service Code: |
78814 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING CT FOR ATTENUATION LIMITED AREA |
78814 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH |
Restricted to Preferred Facilities: |
|
Service Code: |
78815 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH |
78815 |
New / Changed in 2020: |
|
Service Description: |
PET IMAGING FOR CT ATTENUATION WHOLE BODY |
Restricted to Preferred Facilities: |
|
Service Code: |
78816 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING FOR CT ATTENUATION WHOLE BODY |
78816 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
Restricted to Preferred Facilities: |
|
Service Code: |
81107 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
81107 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
Restricted to Preferred Facilities: |
|
Service Code: |
81108 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
81108 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
Restricted to Preferred Facilities: |
|
Service Code: |
81109 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
81109 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
Restricted to Preferred Facilities: |
|
Service Code: |
81110 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
81110 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
Restricted to Preferred Facilities: |
|
Service Code: |
81111 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
81111 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
Restricted to Preferred Facilities: |
|
Service Code: |
81112 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
81112 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluable) (eg, glioma), common variants (eg, R132H, R132C) |
Restricted to Preferred Facilities: |
|
Service Code: |
81120 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluable) (eg, glioma), common variants (eg, R132H, R132C) |
81120 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IDH2 (isocitrate dehydrogenase 2 [NADP+], soluable) (eg, glioma), common variants (eg, R140W, R172M) |
Restricted to Preferred Facilities: |
|
Service Code: |
81121 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
IDH2 (isocitrate dehydrogenase 2 [NADP+], soluable) (eg, glioma), common variants (eg, R140W, R172M) |
81121 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed |
Restricted to Preferred Facilities: |
|
Service Code: |
81161 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed |
81161 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain |
Restricted to Preferred Facilities: |
|
Service Code: |
81170 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain |
81170 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81171 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81171 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
Restricted to Preferred Facilities: |
|
Service Code: |
81172 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
81172 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81173 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence |
81173 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81174 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
81174 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81175 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence |
81175 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) |
Restricted to Preferred Facilities: |
|
Service Code: |
81176 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) |
81176 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81177 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81177 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81178 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81178 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81179 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81179 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81180 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81180 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81181 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81181 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81182 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81182 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81183 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81183 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81184 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81184 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81185 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
81185 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81186 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant |
81186 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81187 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81187 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81188 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence |
81188 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81190 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) |
81190 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81190 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) |
81190 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASPA GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81200 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ASPA GENE ANALYSIS COMMON VARIANTS |
81200 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81201 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
81201 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
81202 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81203 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants |
81203 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) |
Restricted to Preferred Facilities: |
|
Service Code: |
81204 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) |
81204 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BCKDHB GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
BCKDHB GENE ANALYSIS COMMON VARIANTS |
81205 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81206 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
81206 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81207 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
81207 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81208 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
81208 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BLM GENE ANALYSIS 2281DEL6INS7 VARIANT |
Restricted to Preferred Facilities: |
|
Service Code: |
81209 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
BLM GENE ANALYSIS 2281DEL6INS7 VARIANT |
81209 |
New / Changed in 2020: |
Changed for 2020 |
Service Description: |
BRAF (V-RAF Murine Sarcoma Viral Oncogene Homolog B1) (e.g., colon cancer, gene analysis, V600E variant ) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81210 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
BRAF (V-RAF Murine Sarcoma Viral Oncogene Homolog B1) (e.g., colon cancer, gene analysis, V600E variant ) |
81210 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81218 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
81218 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 |
Restricted to Preferred Facilities: |
|
Service Code: |
81219 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 |
81219 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CFTR GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81220 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS COMMON VARIANTS |
81220 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81221 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
81221 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81222 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS |
81222 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CFTR GENE ANALYSIS FULL GENE SEQUENCE |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81223 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS FULL GENE SEQUENCE |
81223 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81224 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS |
81224 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81225 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) |
81225 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81226 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) |
81226 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81227 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) |
81227 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81228 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Comparative Genomic Hybridization (CGH) or Chromosomal Microarray Analysis (CMA) for Evaluation of Developmental Delay |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
81228 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81228 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
81228 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81229 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Comparative Genomic Hybridization (CGH) or Chromosomal Microarray Analysis (CMA) for Evaluation of Developmental Delay |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
81229 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81229 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
81229 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
Restricted to Preferred Facilities: |
|
Service Code: |
81233 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
81233 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81234 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
81234 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81236 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence |
81236 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large Bcell lymphoma) gene analysis, common variant(s) (eg, codon 646) 81238 F9(coagulation factor IX) (eg, hemophilia B) full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81237 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large Bcell lymphoma) gene analysis, common variant(s) (eg, codon 646) 81238 F9(coagulation factor IX) (eg, hemophilia B) full gene sequence |
81237 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
Restricted to Preferred Facilities: |
|
Service Code: |
81239 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
81239 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81240 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant |
81240 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
F5 (coagulation Factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81241 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
F5 (coagulation Factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant |
81241 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FANCC GENE ANALYSIS COMMON VARIANT |
Restricted to Preferred Facilities: |
|
Service Code: |
81242 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FANCC GENE ANALYSIS COMMON VARIANT |
81242 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles 81244 characterization of alleles (e.g., expanded size and promoter methylation status) |
Restricted to Preferred Facilities: |
|
Service Code: |
81243 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FMR1 (Fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles 81244 characterization of alleles (e.g., expanded size and promoter methylation status) |
81243 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL RETARDATION) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE AND PROMOTER METHYLATION STATUS) |
Restricted to Preferred Facilities: |
|
Service Code: |
81244 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL RETARDATION) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE AND PROMOTER METHYLATION STATUS) |
81244 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15) |
Restricted to Preferred Facilities: |
|
Service Code: |
81245 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15) |
81245 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
Restricted to Preferred Facilities: |
|
Service Code: |
81246 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
81246 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) |
Restricted to Preferred Facilities: |
|
Service Code: |
81247 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) |
81247 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81248 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) |
81248 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81249 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence |
81249 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
G6PC GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81250 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
G6PC GENE ANALYSIS COMMON VARIANTS |
81250 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81251 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
81251 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
GJB2 GENE ANALYSIS FULL GENE SEQUENCE |
Restricted to Preferred Facilities: |
|
Service Code: |
81252 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
GJB2 GENE ANALYSIS FULL GENE SEQUENCE |
81252 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81253 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
81253 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
GJB6 GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81254 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
GJB6 GENE ANALYSIS COMMON VARIANTS |
81254 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HEXA GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81255 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
HEXA GENE ANALYSIS COMMON VARIANTS |
81255 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D) |
Restricted to Preferred Facilities: |
|
Service Code: |
81256 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D) |
81256 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) |
Restricted to Preferred Facilities: |
|
Service Code: |
81257 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 255 |
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) |
81257 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81258 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; known familial variant |
81258 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81259 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; full gene sequence |
81259 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IKBKAP GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81260 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
IKBKAP GENE ANALYSIS COMMON VARIANTS |
81260 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (e.g., polymerase chain reaction) |
Restricted to Preferred Facilities: |
|
Service Code: |
81261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (e.g., polymerase chain reaction) |
81261 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot) |
Restricted to Preferred Facilities: |
|
Service Code: |
81262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot) |
81262 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis |
81263 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81264 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
81264 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC |
Restricted to Preferred Facilities: |
|
Service Code: |
81265 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC |
81265 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN |
Restricted to Preferred Facilities: |
|
Service Code: |
81266 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN |
81266 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION |
Restricted to Preferred Facilities: |
|
Service Code: |
81267 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION |
81267 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA |
Restricted to Preferred Facilities: |
|
Service Code: |
81268 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA |
81268 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; duplication/deletion variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81269 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; duplication/deletion variants |
81269 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81270 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant |
81270 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81271 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81271 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18) |
Restricted to Preferred Facilities: |
|
Service Code: |
81272 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18) |
81272 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18) |
Restricted to Preferred Facilities: |
|
Service Code: |
81272 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18) |
81272 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., mastocytosis), gene analysis, D816 variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81273 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., mastocytosis), gene analysis, D816 variant(s) |
81273 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
Restricted to Preferred Facilities: |
|
Service Code: |
81274 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
81274 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
KRAS(V-KI-RAS2 Kirsten Rat Sarcoma viral oncogene) gene analysis, variants in codons 12 and 13 |
Restricted to Preferred Facilities: |
|
Service Code: |
81275 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
KRAS(V-KI-RAS2 Kirsten Rat Sarcoma viral oncogene) gene analysis, variants in codons 12 and 13 |
81275 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene analysis; additional variant(s) (e.g., codon 61, codon 146) 81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81276 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene analysis; additional variant(s) (e.g., codon 61, codon 146) 81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant |
81276 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), promoter methylation analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81287 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), promoter methylation analysis |
81287 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81290 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 255 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS |
81290 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MTHFR GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81291 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
MTHFR GENE ANALYSIS COMMON VARIANTS |
81291 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81302 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
81302 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81303 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
81303 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81304 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
81304 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81305 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
81305 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
Restricted to Preferred Facilities: |
|
Service Code: |
81305 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
81305 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (e.g., colorectal carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and exon 3 (e.g., codon 61) |
Restricted to Preferred Facilities: |
|
Service Code: |
81311 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Colorectal Cancer |
NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (e.g., colorectal carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and exon 3 (e.g., codon 61) |
81311 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (e.g., gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12, 18) |
Restricted to Preferred Facilities: |
|
Service Code: |
81314 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (e.g., gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12, 18) |
81314 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81315 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative |
81315 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81316 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative |
81316 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
Restricted to Preferred Facilities: |
|
Service Code: |
81320 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
81320 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81321 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 255 |
|
Genetic Testing - Other |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis |
81321 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81322 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant |
81322 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81323 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant |
81323 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81324 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
81324 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81325 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
81325 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
Restricted to Preferred Facilities: |
|
Service Code: |
81326 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
81326 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed |
Restricted to Preferred Facilities: |
|
Service Code: |
81329 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed |
81329 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
SMPD1 GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81330 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
SMPD1 GENE ANALYSIS COMMON VARIANTS |
81330 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis |
Restricted to Preferred Facilities: |
|
Service Code: |
81331 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis |
81331 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, Member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z) |
Restricted to Preferred Facilities: |
|
Service Code: |
81332 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, Member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z) |
81332 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) |
Restricted to Preferred Facilities: |
|
Service Code: |
81333 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) |
81333 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) |
Restricted to Preferred Facilities: |
|
Service Code: |
81334 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) |
81334 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction) |
Restricted to Preferred Facilities: |
|
Service Code: |
81340 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction) |
81340 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot) |
Restricted to Preferred Facilities: |
|
Service Code: |
81341 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot) |
81341 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81342 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
81342 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81343 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81343 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Restricted to Preferred Facilities: |
|
Service Code: |
81344 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81344 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) |
Restricted to Preferred Facilities: |
|
Service Code: |
81345 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) |
81345 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
Restricted to Preferred Facilities: |
|
Service Code: |
81350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
81350 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
Restricted to Preferred Facilities: |
|
Service Code: |
81350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
81350 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
VKORC1 GENE ANALYSIS COMMON VARIANTS |
Restricted to Preferred Facilities: |
|
Service Code: |
81355 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
VKORC1 GENE ANALYSIS COMMON VARIANTS |
81355 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) |
Restricted to Preferred Facilities: |
|
Service Code: |
81361 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) |
81361 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); known familial variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81362 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); known familial variant(s) |
81362 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
81363 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) |
81363 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); full gene sequence |
Restricted to Preferred Facilities: |
|
Service Code: |
81364 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); full gene sequence |
81364 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, -C, DRB 1/3/4/5, and –DQB1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81370 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, -C, DRB 1/3/4/5, and –DQB1 |
81370 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, and – DRB1 (e.g. verification typing) |
Restricted to Preferred Facilities: |
|
Service Code: |
81371 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, and – DRB1 (e.g. verification typing) |
81371 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); complete (i.e., HLA-A, -B, and-C) |
Restricted to Preferred Facilities: |
|
Service Code: |
81372 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, low resolution (e.g., antigen equivalents); complete (i.e., HLA-A, -B, and-C) |
81372 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLA-A, -B, or –C), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81373 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLA-A, -B, or –C), each |
81373 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); one antigen equivalent (e.g. B*27), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81374 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, low resolution (e.g., antigen equivalents); one antigen equivalent (e.g. B*27), each |
81374 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); HLA-DRB1/3/4/5 and – DQB1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81375 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class II typing, low resolution (e.g., antigen equivalents); HLA-DRB1/3/4/5 and – DQB1 |
81375 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLADRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or –DPA1), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81376 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class II typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLADRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or –DPA1), each |
81376 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); one antigen equivalent , each |
Restricted to Preferred Facilities: |
|
Service Code: |
81377 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class II typing, low resolution (e.g., antigen equivalents); one antigen equivalent , each |
81377 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I and II typing, high resolution (i.e., alleles or allele groups), HLA-A, -B, -C, and -DRB1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81378 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I and II typing, high resolution (i.e., alleles or allele groups), HLA-A, -B, -C, and -DRB1 |
81378 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); complete (i.e., HLA-A, B, and -C) |
Restricted to Preferred Facilities: |
|
Service Code: |
81379 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); complete (i.e., HLA-A, B, and -C) |
81379 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 locus (e.g., HLA-A, B, or -C), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81380 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 locus (e.g., HLA-A, B, or -C), each |
81380 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., B*57:01P), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81381 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., B*57:01P), each |
81381 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLADRB1, - DRB3, 4/5, -DQB1, -DQA1, -DPB1, or -DP |
Restricted to Preferred Facilities: |
|
Service Code: |
81382 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLADRB1, - DRB3, 4/5, -DQB1, -DQA1, -DPB1, or -DP |
81382 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HLA Class II typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., HLA-DQB1*06:02P), each |
Restricted to Preferred Facilities: |
|
Service Code: |
81383 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA Class II typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., HLA-DQB1*06:02P), each |
81383 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MOLECULAR PATHOLOGY PROCEDURE, LEVEL 1 (EG, IDENTIFICATION OF SINGLE GERMLINE VARIANT [EG, SNP] BY TECHNIQUES SUCH AS RESTRICTION ENZYME DIGESTION OR MELT CURVE ANALYSIS) ACADM (ACYL-COA DEHYDROGENASE, C-4 TO C-12 STRAIGHT CHAIN, MCAD) (EG, MEDIUM CHAIN ACYL DEHYDROGENASE DEFICIENCY), K304E VARIANT |
Restricted to Preferred Facilities: |
|
Service Code: |
81400 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
MOLECULAR PATHOLOGY PROCEDURE, LEVEL 1 (EG, IDENTIFICATION OF SINGLE GERMLINE VARIANT [EG, SNP] BY TECHNIQUES SUCH AS RESTRICTION ENZYME DIGESTION OR MELT CURVE ANALYSIS) ACADM (ACYL-COA DEHYDROGENASE, C-4 TO C-12 STRAIGHT CHAIN, MCAD) (EG, MEDIUM CHAIN ACYL DEHYDROGENASE DEFICIENCY), K304E VARIANT |
81400 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
MOLECULAR PATHOLOGY PROCEDURE, LEVEL 2 (EG, 2-10 SNPS, 1 METHYLATED VARIANT, OR 1 SOMATIC VARIANT [TYPICALLY USING NONSEQUENCING TARGET VARIANT ANALYSIS], OR DETECTION OF A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT) ABCC8 (ATP-BINDING CASSETTE, SUB-FAMILY C [CFTR/MRP], MEMBER 8) (EG, FAMILIAL HYPERIN |
Restricted to Preferred Facilities: |
|
Service Code: |
81401 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
MOLECULAR PATHOLOGY PROCEDURE, LEVEL 2 (EG, 2-10 SNPS, 1 METHYLATED VARIANT, OR 1 SOMATIC VARIANT [TYPICALLY USING NONSEQUENCING TARGET VARIANT ANALYSIS], OR DETECTION OF A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT) ABCC8 (ATP-BINDING CASSETTE, SUB-FAMILY C [CFTR/MRP], MEMBER 8) (EG, FAMILIAL HYPERIN |
81401 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 3 (e.g., > 10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) |
Restricted to Preferred Facilities: |
|
Service Code: |
81402 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 3 (e.g., > 10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) |
81402 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 4 (e.g., analysis of single exon by DNA sequence analysis, analysis of > 10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) |
Restricted to Preferred Facilities: |
|
Service Code: |
81403 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 4 (e.g., analysis of single exon by DNA sequence analysis, analysis of > 10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) |
81403 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 5 (e.g., analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
81404 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 5 (e.g., analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) |
81404 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 6 (e.g., analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons) |
Restricted to Preferred Facilities: |
|
Service Code: |
81405 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 6 (e.g., analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons) |
81405 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 7 (e.g., analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia) |
Restricted to Preferred Facilities: |
|
Service Code: |
81406 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 7 (e.g., analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia) |
81406 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of > 50 exons, sequence analysis of multiple genes on 1 platform) |
Restricted to Preferred Facilities: |
|
Service Code: |
81407 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of > 50 exons, sequence analysis of multiple genes on 1 platform) |
81407 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Molecular pathology procedure, Level 9 (e.g., analysis of > 50 exons in a single gene by DNA sequence analysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
81408 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 9 (e.g., analysis of > 50 exons in a single gene by DNA sequence analysis) |
81408 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
Restricted to Preferred Facilities: |
|
Service Code: |
81410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Cardiac |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
81410 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81411 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Cardiac |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 |
81411 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASHKENAZI JEWISH ASSOCIATED DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 9 GENES, INCLUDING ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, AND SMPD1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81412 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ASHKENAZI JEWISH ASSOCIATED DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 9 GENES, INCLUDING ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, AND SMPD1 |
81412 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A |
Restricted to Preferred Facilities: |
|
Service Code: |
81413 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Cardiac |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A |
81413 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81414 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Cardiac |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 |
81414 |
New / Changed in 2020: |
|
Service Description: |
EXOME SEQUENCE ANALYSIS |
Restricted to Preferred Facilities: |
|
Service Code: |
81415 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 280 |
|
Whole Exome Sequencing |
EXOME SEQUENCE ANALYSIS |
81415 |
New / Changed in 2020: |
|
Service Description: |
EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME |
Restricted to Preferred Facilities: |
|
Service Code: |
81416 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 280 |
|
Whole Exome Sequencing |
EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME |
81416 |
New / Changed in 2020: |
|
Service Description: |
EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ |
Restricted to Preferred Facilities: |
|
Service Code: |
81417 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 280 |
|
Whole Exome Sequencing |
EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ |
81417 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS |
Restricted to Preferred Facilities: |
|
Service Code: |
81420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS |
81420 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CHROMOSOMAL MICRODELETION(S) GENOMIC SEQUENCE ANALYSIS (EG, DIGEORGE SYNDROME, CRI-DU-CHAT SYNDROME), CIRCULATING CELL-FREE FETAL DNA IN MATERNAL BLOOD |
Restricted to Preferred Facilities: |
|
Service Code: |
81422 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CHROMOSOMAL MICRODELETION(S) GENOMIC SEQUENCE ANALYSIS (EG, DIGEORGE SYNDROME, CRI-DU-CHAT SYNDROME), CIRCULATING CELL-FREE FETAL DNA IN MATERNAL BLOOD |
81422 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 |
Restricted to Preferred Facilities: |
|
Service Code: |
81432 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 |
81432 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 |
Restricted to Preferred Facilities: |
|
Service Code: |
81433 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 |
81433 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, conerod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A |
Restricted to Preferred Facilities: |
|
Service Code: |
81434 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, conerod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A |
81434 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL |
Restricted to Preferred Facilities: |
|
Service Code: |
81437 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL |
81437 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HEREDITARY NEUROENDOCRINE TUMOR DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR SDHB, SDHC, SDHD, AND VHL |
Restricted to Preferred Facilities: |
|
Service Code: |
81438 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other Cancer |
HEREDITARY NEUROENDOCRINE TUMOR DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR SDHB, SDHC, SDHD, AND VHL |
81438 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN 81479 Unlisted molecular pathology procedure |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81439 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Cardiac |
Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN 81479 Unlisted molecular pathology procedure |
81439 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
NOONAN SPECTRUM DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 12 GENES, INCLUDING BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, AND SOS1 |
Restricted to Preferred Facilities: |
|
Service Code: |
81442 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
NOONAN SPECTRUM DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 12 GENES, INCLUDING BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, AND SOS1 |
81442 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81450 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed |
81450 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81455 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed |
81455 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
Restricted to Preferred Facilities: |
|
Service Code: |
81479 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
81479 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
81500 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
81500 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
81503 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
81503 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL |
Restricted to Preferred Facilities: |
|
Service Code: |
81506 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL |
81506 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL ANEUPLOIDY 21 18 13 SEQ ANALY TRISOM RISK |
Restricted to Preferred Facilities: |
|
Service Code: |
81507 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL ANEUPLOIDY 21 18 13 SEQ ANALY TRISOM RISK |
81507 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
81508 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS |
81508 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS |
Restricted to Preferred Facilities: |
|
Service Code: |
81509 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS |
81509 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CONGENITAL ABNOR ASSAY THREE ANAL |
Restricted to Preferred Facilities: |
|
Service Code: |
81510 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CONGENITAL ABNOR ASSAY THREE ANAL |
81510 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL |
Restricted to Preferred Facilities: |
|
Service Code: |
81511 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL |
81511 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FETAL CONGENITAL ABNOR ASSAY FIVE ANAL |
Restricted to Preferred Facilities: |
|
Service Code: |
81512 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FETAL CONGENITAL ABNOR ASSAY FIVE ANAL |
81512 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (MammaPrint®, Agendia, Inc) |
Restricted to Preferred Facilities: |
|
Service Code: |
81521 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (MammaPrint®, Agendia, Inc) |
81521 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (Prolaris ®, Myriad Genetic Laboratories, Inc.) |
Restricted to Preferred Facilities: |
|
Service Code: |
81541 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (Prolaris ®, Myriad Genetic Laboratories, Inc.) |
81541 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious) (Afirma® Gene Expression Classifier, Veracyte, Inc.) 81599 Unlisted molecular pathology procedure 84999 Unlisted chemistry procedure 86386 Nuclear Matrix Protein 22 (NMP22), qualitative |
Restricted to Preferred Facilities: |
|
Service Code: |
81545 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious) (Afirma® Gene Expression Classifier, Veracyte, Inc.) 81599 Unlisted molecular pathology procedure 84999 Unlisted chemistry procedure 86386 Nuclear Matrix Protein 22 (NMP22), qualitative |
81545 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81599 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
81599 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
81599 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
81599 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unlisted chemistry procedure |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
84999 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted chemistry procedure |
84999 |
New / Changed in 2020: |
|
Service Description: |
STEM CELLS TOTAL COUNT |
Restricted to Preferred Facilities: |
|
Service Code: |
86367 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
STEM CELLS TOTAL COUNT |
86367 |
New / Changed in 2020: |
|
Service Description: |
SERUM SCREENING % REACTIVE ANTIBODY STANDRD METH |
Restricted to Preferred Facilities: |
|
Service Code: |
86807 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
SERUM SCREENING % REACTIVE ANTIBODY STANDRD METH |
86807 |
New / Changed in 2020: |
|
Service Description: |
SERUM SCREENING % REACTIVE ANTIBODY QUICK METH |
Restricted to Preferred Facilities: |
|
Service Code: |
86808 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
SERUM SCREENING % REACTIVE ANTIBODY QUICK METH |
86808 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING A/B/C SINGLE ANTIGEN |
Restricted to Preferred Facilities: |
|
Service Code: |
86812 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING A/B/C SINGLE ANTIGEN |
86812 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING A/B/C MULTIPLE ANTIGENS |
Restricted to Preferred Facilities: |
|
Service Code: |
86813 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING A/B/C MULTIPLE ANTIGENS |
86813 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING DR/DQ SINGLE ANTIGEN |
Restricted to Preferred Facilities: |
|
Service Code: |
86816 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING DR/DQ SINGLE ANTIGEN |
86816 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING DR/DQ MULTIPLE ANTIGENS |
Restricted to Preferred Facilities: |
|
Service Code: |
86817 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING DR/DQ MULTIPLE ANTIGENS |
86817 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING LYMPHOCYTE CULTURE MIXED |
Restricted to Preferred Facilities: |
|
Service Code: |
86821 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING LYMPHOCYTE CULTURE MIXED |
86821 |
New / Changed in 2020: |
|
Service Description: |
HLA TYPING LYMPHOCYTE CULTURE PRIMED |
Restricted to Preferred Facilities: |
|
Service Code: |
86822 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HLA TYPING LYMPHOCYTE CULTURE PRIMED |
86822 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPATIBILITY EACH UNIT IMMEDIATE SPIN TECHNIQUE |
Restricted to Preferred Facilities: |
|
Service Code: |
86920 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPATIBILITY EACH UNIT IMMEDIATE SPIN TECHNIQUE |
86920 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPATIBILITY EACH UNIT INCUBATION |
Restricted to Preferred Facilities: |
|
Service Code: |
86921 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPATIBILITY EACH UNIT INCUBATION |
86921 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPATIBILITY EACH UNIT ANTIGLOBULIN |
Restricted to Preferred Facilities: |
|
Service Code: |
86922 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPATIBILITY EACH UNIT ANTIGLOBULIN |
86922 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
COMPATIBILITY EACH UNIT ELECTRONIC |
Restricted to Preferred Facilities: |
|
Service Code: |
86923 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
COMPATIBILITY EACH UNIT ELECTRONIC |
86923 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Tissue culture for non-neoplastic disorders; lymphocyte |
Restricted to Preferred Facilities: |
|
Service Code: |
88230 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Tissue culture for non-neoplastic disorders; lymphocyte |
88230 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells |
Restricted to Preferred Facilities: |
|
Service Code: |
88235 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells |
88235 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Chromosome analysis; count 5 cells, 1 karyotype, with banding |
Restricted to Preferred Facilities: |
|
Service Code: |
88261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
Chromosome analysis; count 5 cells, 1 karyotype, with banding |
88261 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding |
Restricted to Preferred Facilities: |
|
Service Code: |
88262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding |
88262 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding |
Restricted to Preferred Facilities: |
|
Service Code: |
88263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding |
88263 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Chromosome analysis; count 20-25 cells |
Restricted to Preferred Facilities: |
|
Service Code: |
88264 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
Chromosome analysis; count 20-25 cells |
88264 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Chromosome analysis; additional high resolution study |
Restricted to Preferred Facilities: |
|
Service Code: |
88289 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
Chromosome analysis; additional high resolution study |
88289 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED CYTOGENETIC STUDY |
Restricted to Preferred Facilities: |
|
Service Code: |
88299 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
UNLISTED CYTOGENETIC STUDY |
88299 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IN SITU HYBRIDIZATION 1ST PROBE STAIN |
Restricted to Preferred Facilities: |
|
Service Code: |
88365 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
IN SITU HYBRIDIZATION 1ST PROBE STAIN |
88365 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN |
Restricted to Preferred Facilities: |
|
Service Code: |
88366 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN |
88366 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN |
Restricted to Preferred Facilities: |
|
Service Code: |
88367 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN |
88367 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL |
Restricted to Preferred Facilities: |
|
Service Code: |
88368 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Genetic Testing - Other |
M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL |
88368 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED IN VIVO LAB SERVICE |
Restricted to Preferred Facilities: |
|
Service Code: |
88749 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
UNLISTED IN VIVO LAB SERVICE |
88749 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unlisted miscellaneous pathology test |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
89240 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted miscellaneous pathology test |
89240 |
New / Changed in 2020: |
|
Service Description: |
RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E |
Restricted to Preferred Facilities: |
|
Service Code: |
90378 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 98 |
|
Synagis® (palivizumab) |
RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E |
90378 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Psychiatric diagnostic evaluation |
Restricted to Preferred Facilities: |
|
Service Code: |
90791 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychiatric diagnostic evaluation |
90791 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Psychiatric diagnostic evaluation with medical services |
Restricted to Preferred Facilities: |
|
Service Code: |
90792 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychiatric diagnostic evaluation with medical services |
90792 |
New / Changed in 2020: |
|
Service Description: |
BIOFEEDBACK TRAINING ANY MODALITY |
Restricted to Preferred Facilities: |
|
Service Code: |
90901 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
This is covered when medically necessary and with prior authorization from the plan. Does NOT require prior auth with behavioral health diagnosis. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
Biofeedback for Non Behavioral Health indications |
BIOFEEDBACK TRAINING ANY MODALITY |
90901 |
New / Changed in 2020: |
|
Service Description: |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
Restricted to Preferred Facilities: |
|
Service Code: |
90911 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
This is covered when medically necessary and with prior authorization from the plan. Does NOT require prior auth with behavioral health diagnosis. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 88.0 |
|
Biofeedback for Non Behavioral Health indications |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
90911 |
New / Changed in 2020: |
|
Service Description: |
TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC IND |
Restricted to Preferred Facilities: |
|
Service Code: |
92507 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
Not Applicable |
|
Gender Dysphoria and Gender Confirmation Treatment |
TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC IND |
92507 |
New / Changed in 2020: |
|
Service Description: |
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV |
Restricted to Preferred Facilities: |
|
Service Code: |
92508 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV |
92508 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid exam and selection, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92590 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid exam and selection, monaural |
92590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid exam and selection, binaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92591 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid exam and selection, binaural |
92591 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid check, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92592 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid check, monaural |
92592 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid check, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92592 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid check, monaural |
92592 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid check, binaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92593 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid check, binaural |
92593 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Electroacoustic evaluation for hearing aid, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92594 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Electroacoustic evaluation for hearing aid, monaural |
92594 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Electroacoustic evaluation for hearing aid, binaural |
Restricted to Preferred Facilities: |
|
Service Code: |
92595 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Electroacoustic evaluation for hearing aid, binaural |
92595 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ear protector evaluation |
Restricted to Preferred Facilities: |
|
Service Code: |
92596 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Ear protector evaluation |
92596 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cardioassist-hyphenmethod of circulatory assist; internal |
Restricted to Preferred Facilities: |
|
Service Code: |
92970 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Cardioassist-hyphenmethod of circulatory assist; internal |
92970 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Cardioassist-hyphenmethod of circulatory assist; external |
Restricted to Preferred Facilities: |
|
Service Code: |
92971 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Cardioassist-hyphenmethod of circulatory assist; external |
92971 |
New / Changed in 2020: |
|
Service Description: |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
Restricted to Preferred Facilities: |
|
Service Code: |
93303 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Transthoracic |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
93303 |
New / Changed in 2020: |
|
Service Description: |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
Restricted to Preferred Facilities: |
|
Service Code: |
93304 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 37 |
|
Echocardiogram: Transthoracic |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
93304 |
New / Changed in 2020: |
|
Service Description: |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
Restricted to Preferred Facilities: |
|
Service Code: |
93306 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 37 |
|
Echocardiogram: Transthoracic |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
93306 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
Restricted to Preferred Facilities: |
|
Service Code: |
93307 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 37 |
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
93307 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
Restricted to Preferred Facilities: |
|
Service Code: |
93308 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
93308 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
Restricted to Preferred Facilities: |
|
Service Code: |
93312 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
93312 |
New / Changed in 2020: |
|
Service Description: |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
Restricted to Preferred Facilities: |
|
Service Code: |
93313 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Transesophageal |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
93313 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
Restricted to Preferred Facilities: |
|
Service Code: |
93314 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
93314 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
Restricted to Preferred Facilities: |
|
Service Code: |
93315 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
93315 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
Restricted to Preferred Facilities: |
|
Service Code: |
93316 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
93316 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
Restricted to Preferred Facilities: |
|
Service Code: |
93317 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
93317 |
New / Changed in 2020: |
|
Service Description: |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
Restricted to Preferred Facilities: |
|
Service Code: |
93318 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
93318 |
New / Changed in 2020: |
|
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
Restricted to Preferred Facilities: |
|
Service Code: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Stress |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
New / Changed in 2020: |
|
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
Restricted to Preferred Facilities: |
|
Service Code: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transesophageal |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
New / Changed in 2020: |
|
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
Restricted to Preferred Facilities: |
|
Service Code: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transthoracic |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
Restricted to Preferred Facilities: |
|
Service Code: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Stress |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
Restricted to Preferred Facilities: |
|
Service Code: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Echocardiogram: Transesophageal |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
Restricted to Preferred Facilities: |
|
Service Code: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4.0 |
|
Echocardiogram: Transthoracic |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
Restricted to Preferred Facilities: |
|
Service Code: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 77.0 |
|
Echocardiogram: Stress |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
Restricted to Preferred Facilities: |
|
Service Code: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 129.0 |
|
Echocardiogram: Transesophageal |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
New / Changed in 2020: |
|
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
Restricted to Preferred Facilities: |
|
Service Code: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 156.0 |
|
Echocardiogram: Transthoracic |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
New / Changed in 2020: |
|
Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
Restricted to Preferred Facilities: |
|
Service Code: |
93350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 136.0 |
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
93350 |
New / Changed in 2020: |
|
Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
Restricted to Preferred Facilities: |
|
Service Code: |
93351 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
93351 |
New / Changed in 2020: |
|
Service Description: |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
Restricted to Preferred Facilities: |
|
Service Code: |
93352 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 5.0 |
|
Echocardiogram: Stress |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
93352 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow & volume status, recovery), with programming, if performed, & report |
Restricted to Preferred Facilities: |
|
Service Code: |
93750 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow & volume status, recovery), with programming, if performed, & report |
93750 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
Restricted to Preferred Facilities: |
|
Service Code: |
96130 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
96130 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
96131 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
96131 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
Restricted to Preferred Facilities: |
|
Service Code: |
96132 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
96132 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
96133 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
96133 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT NEW 10 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99201 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 10 MINUTES |
99201 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT NEW 20 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99202 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 20 MINUTES |
99202 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT NEW 30 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99203 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 30 MINUTES |
99203 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT NEW 45 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99204 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 45 MINUTES |
99204 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT NEW 60 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99205 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 60 MINUTES |
99205 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT VISIT 5 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99211 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 5 MINUTES |
99211 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT VISIT 10 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99212 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 10 MINUTES |
99212 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT VISIT 15 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99213 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 15 MINUTES |
99213 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT VISIT 25 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99214 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 25 MINUTES |
99214 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE OUTPATIENT VISIT 40 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99215 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 40 MINUTES |
99215 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99241 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN |
99241 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 30 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99242 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 30 MIN |
99242 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 40 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99243 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 40 MIN |
99243 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99244 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN |
99244 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 80 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99245 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 80 MIN |
99245 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99339 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN |
99339 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> |
Restricted to Preferred Facilities: |
|
Service Code: |
99340 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> |
99340 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99341 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES |
99341 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99342 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES |
99342 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99343 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES |
99343 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99344 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES |
99344 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99345 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN |
99345 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99347 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES |
99347 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99348 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES |
99348 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES |
Restricted to Preferred Facilities: |
|
Service Code: |
99349 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES |
99349 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS |
Restricted to Preferred Facilities: |
|
Service Code: |
99350 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS |
99350 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR |
Restricted to Preferred Facilities: |
|
Service Code: |
99354 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR |
99354 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 |
Restricted to Preferred Facilities: |
|
Service Code: |
99355 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 |
99355 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 30 M |
Restricted to Preferred Facilities: |
|
Service Code: |
99411 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 30 M |
99411 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 60 M |
Restricted to Preferred Facilities: |
|
Service Code: |
99412 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 60 M |
99412 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PROLNG CLINCL STAFF SVC DURING O/P E/M 1ST HR |
Restricted to Preferred Facilities: |
|
Service Code: |
99415 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG CLINCL STAFF SVC DURING O/P E/M 1ST HR |
99415 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
PROLNG CLINCL STAFF SVC DURING O/P E/M EA 30 MIN |
Restricted to Preferred Facilities: |
|
Service Code: |
99416 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG CLINCL STAFF SVC DURING O/P E/M EA 30 MIN |
99416 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ADMN & INTERPJ HEALTH RISK ASSESSMENT INSTRUMENT |
Restricted to Preferred Facilities: |
|
Service Code: |
99420 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
ADMN & INTERPJ HEALTH RISK ASSESSMENT INSTRUMENT |
99420 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review |
Restricted to Preferred Facilities: |
|
Service Code: |
99446 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review |
99446 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review |
Restricted to Preferred Facilities: |
|
Service Code: |
99447 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review |
99447 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review |
Restricted to Preferred Facilities: |
|
Service Code: |
99448 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review |
99448 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review |
Restricted to Preferred Facilities: |
|
Service Code: |
99449 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review |
99449 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient's treating/requesting physician or other qualified health care professional; 5 minutes or more of medical consultative time |
Restricted to Preferred Facilities: |
|
Service Code: |
99451 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient's treating/requesting physician or other qualified health care professional; 5 minutes or more of medical consultative time |
99451 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes |
Restricted to Preferred Facilities: |
|
Service Code: |
99452 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes |
99452 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
UNLISTED EVALUATION AND MANAGEMENT SERVICE |
Restricted to Preferred Facilities: |
|
Service Code: |
99499 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
UNLISTED EVALUATION AND MANAGEMENT SERVICE |
99499 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
Restricted to Preferred Facilities: |
|
Service Code: |
0016U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
0016U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected (JAK2 Mutation, University of Iowa,Department of Pathology) |
Restricted to Preferred Facilities: |
|
Service Code: |
0017U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Other Cancer |
Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected (JAK2 Mutation, University of Iowa,Department of Pathology) |
0017U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider (Oncomine™ Dx Target Test, Thermo Fisher Scientific ) |
Restricted to Preferred Facilities: |
|
Service Code: |
0022U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Other Cancer |
Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider (Oncomine™ Dx Target Test, Thermo Fisher Scientific ) |
0022U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
Restricted to Preferred Facilities: |
|
Service Code: |
0023U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
0023U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") (Thyroseq Genomic Classifier, CBLPath, Inc.) |
Restricted to Preferred Facilities: |
|
Service Code: |
0026U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Other Cancer |
Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") (Thyroseq Genomic Classifier, CBLPath, Inc.) |
0026U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 (JAK2 Exons 12 to 15 Sequencing, Mayo Clinic) |
Restricted to Preferred Facilities: |
|
Service Code: |
0027U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Other Cancer |
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 (JAK2 Exons 12 to 15 Sequencing, Mayo Clinic) |
0027U |
New / Changed in 2020: |
|
Service Description: |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
Restricted to Preferred Facilities: |
|
Service Code: |
0042T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2019 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
0042T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
Restricted to Preferred Facilities: |
|
Service Code: |
0046U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0046U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
Restricted to Preferred Facilities: |
|
Service Code: |
0049U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Leukemia and Lymphoma |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0049U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalinfixed paraffin-embedded tissue, algorithm reported as an expression score (miR31now™, GoPath Laboratories) |
Restricted to Preferred Facilities: |
|
Service Code: |
0069U |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 293 |
|
Genetic Testing - Colorectal Cancer |
Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalinfixed paraffin-embedded tissue, algorithm reported as an expression score (miR31now™, GoPath Laboratories) |
0069U |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
Restricted to Preferred Facilities: |
|
Service Code: |
0101T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
0101T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
Restricted to Preferred Facilities: |
|
Service Code: |
0102T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
0102T |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0213T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 42 |
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
0213T |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0214T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
0214T |
New / Changed in 2020: |
|
Service Description: |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0215T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
0215T |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0216T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
0216T |
New / Changed in 2020: |
|
Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
Restricted to Preferred Facilities: |
|
Service Code: |
0217T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
0217T |
New / Changed in 2020: |
|
Service Description: |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0218T |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Facet Injections |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
0218T |
New / Changed in 2020: |
|
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0228T |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
0228T |
New / Changed in 2020: |
|
Service Description: |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
Restricted to Preferred Facilities: |
|
Service Code: |
0229T |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Epidural Injections |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
0229T |
New / Changed in 2020: |
|
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
Restricted to Preferred Facilities: |
|
Service Code: |
0230T |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
0230T |
New / Changed in 2020: |
|
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
Restricted to Preferred Facilities: |
|
Service Code: |
0231T |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
0231T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HDR electronic skin surface brachytherapy treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
0394T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Radiation Oncology-Treatment Delivery |
HDR electronic skin surface brachytherapy treatment |
0394T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
HDR electronic brachytherapy for treating sites other than skin (interstitial or intracavitary) |
Restricted to Preferred Facilities: |
|
Service Code: |
0395T |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Radiation Oncology-Treatment Delivery |
HDR electronic brachytherapy for treating sites other than skin (interstitial or intracavitary) |
0395T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
Restricted to Preferred Facilities: |
|
Service Code: |
0512T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
0512T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
Restricted to Preferred Facilities: |
|
Service Code: |
0512T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
0512T |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) |
Restricted to Preferred Facilities: |
|
Service Code: |
0513T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) |
0513T |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interest |
Restricted to Preferred Facilities: |
|
Service Code: |
A0080 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interest |
A0080 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interest |
Restricted to Preferred Facilities: |
|
Service Code: |
A0090 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 82.0 |
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interest |
A0090 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation; taxi |
Restricted to Preferred Facilities: |
|
Service Code: |
A0100 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation; taxi |
A0100 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation and bus, intra or inter state carrier |
Restricted to Preferred Facilities: |
|
Service Code: |
A0110 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 108.0 |
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation and bus, intra or inter state carrier |
A0110 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems |
Restricted to Preferred Facilities: |
|
Service Code: |
A0120 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 86.0 |
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems |
A0120 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: wheel-chair van |
Restricted to Preferred Facilities: |
|
Service Code: |
A0130 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: wheel-chair van |
A0130 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation and air travel (private or commercial) intra or inter state |
Restricted to Preferred Facilities: |
|
Service Code: |
A0140 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 119.0 |
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation and air travel (private or commercial) intra or inter state |
A0140 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: per mile - case worker or social worker |
Restricted to Preferred Facilities: |
|
Service Code: |
A0160 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: per mile - case worker or social worker |
A0160 |
New / Changed in 2020: |
|
Service Description: |
Transportation ancillary: parking fees, tolls, other |
Restricted to Preferred Facilities: |
|
Service Code: |
A0170 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Transportation ancillary: parking fees, tolls, other |
A0170 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: ancillary: lodging-recipient |
Restricted to Preferred Facilities: |
|
Service Code: |
A0180 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: ancillary: lodging-recipient |
A0180 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: ancillary: meals-recipient |
Restricted to Preferred Facilities: |
|
Service Code: |
A0190 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: ancillary: meals-recipient |
A0190 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: ancillary: lodging escort |
Restricted to Preferred Facilities: |
|
Service Code: |
A0200 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: ancillary: lodging escort |
A0200 |
New / Changed in 2020: |
|
Service Description: |
Non-emergency transportation: ancillary: meals-escort |
Restricted to Preferred Facilities: |
|
Service Code: |
A0210 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 97.0 |
|
Ambulance Transport Service (Non-Emergent) |
Non-emergency transportation: ancillary: meals-escort |
A0210 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, neonatal transport, base rate, emergency transport, one way |
Restricted to Preferred Facilities: |
|
Service Code: |
A0225 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, neonatal transport, base rate, emergency transport, one way |
A0225 |
New / Changed in 2020: |
|
Service Description: |
Bls mileage (per mile) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0380 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Bls mileage (per mile) |
A0380 |
New / Changed in 2020: |
|
Service Description: |
Als mileage (per mile) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0390 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Als mileage (per mile) |
A0390 |
New / Changed in 2020: |
|
Service Description: |
Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation |
Restricted to Preferred Facilities: |
|
Service Code: |
A0422 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation |
A0422 |
New / Changed in 2020: |
|
Service Description: |
Extra ambulance attendant, ground (als or bls) or air (fixed or rotary winged); (requires medical review) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0424 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Extra ambulance attendant, ground (als or bls) or air (fixed or rotary winged); (requires medical review) |
A0424 |
New / Changed in 2020: |
|
Service Description: |
Ground mileage, per statute mile |
Restricted to Preferred Facilities: |
|
Service Code: |
A0425 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ground mileage, per statute mile |
A0425 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, advanced life support, non-emergency transport, level 1 (als 1) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0426 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, advanced life support, non-emergency transport, level 1 (als 1) |
A0426 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, advanced life support, emergency transport, level 1 (als1-emergency) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0427 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, advanced life support, emergency transport, level 1 (als1-emergency) |
A0427 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, basic life support, non-emergency transport, (bls) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0428 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, basic life support, non-emergency transport, (bls) |
A0428 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, basic life support, emergency transport (bls-emergency) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0429 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, basic life support, emergency transport (bls-emergency) |
A0429 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, conventional air services, transport, one way (fixed wing) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0430 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, conventional air services, transport, one way (fixed wing) |
A0430 |
New / Changed in 2020: |
|
Service Description: |
Ambulance service, conventional air services, transport, one way (rotary wing) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0431 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 268 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance service, conventional air services, transport, one way (rotary wing) |
A0431 |
New / Changed in 2020: |
|
Service Description: |
Paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers |
Restricted to Preferred Facilities: |
|
Service Code: |
A0432 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 147.0 |
|
Ambulance Transport Service (Non-Emergent) |
Paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers |
A0432 |
New / Changed in 2020: |
|
Service Description: |
Advanced life support, level 2 (als 2) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0433 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 147.0 |
|
Ambulance Transport Service (Non-Emergent) |
Advanced life support, level 2 (als 2) |
A0433 |
New / Changed in 2020: |
|
Service Description: |
Specialty care transport (sct) |
Restricted to Preferred Facilities: |
|
Service Code: |
A0434 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 125.0 |
|
Ambulance Transport Service (Non-Emergent) |
Specialty care transport (sct) |
A0434 |
New / Changed in 2020: |
|
Service Description: |
Fixed wing air mileage, per statute mile |
Restricted to Preferred Facilities: |
|
Service Code: |
A0435 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
Ambulance Transport Service (Non-Emergent) |
Fixed wing air mileage, per statute mile |
A0435 |
New / Changed in 2020: |
|
Service Description: |
Rotary wing air mileage, per statute mile |
Restricted to Preferred Facilities: |
|
Service Code: |
A0436 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ambulance Transport Service (Non-Emergent) |
Rotary wing air mileage, per statute mile |
A0436 |
New / Changed in 2020: |
|
Service Description: |
Ambulance response and treatment, no transport |
Restricted to Preferred Facilities: |
|
Service Code: |
A0998 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 83.0 |
|
Ambulance Transport Service (Non-Emergent) |
Ambulance response and treatment, no transport |
A0998 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi- density insert(s), per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5500 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 77.0 |
|
Orthoses |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi- density insert(s), per shoe |
A5500 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5501 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 60 |
|
Orthoses |
For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe |
A5501 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5503 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe |
A5503 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5504 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe |
A5504 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5505 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe |
A5505 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5506 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe |
A5506 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5507 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe |
A5507 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5508 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe |
A5508 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe |
Restricted to Preferred Facilities: |
|
Service Code: |
A5510 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe |
A5510 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer |
Restricted to Preferred Facilities: |
|
Service Code: |
A5512 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer |
A5512 |
New / Changed in 2020: |
|
Service Description: |
For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durom |
Restricted to Preferred Facilities: |
|
Service Code: |
A5513 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durom |
A5513 |
New / Changed in 2020: |
|
Service Description: |
Helmet, protective, soft, prefabricated, includes all components and accessories |
Restricted to Preferred Facilities: |
|
Service Code: |
A8000 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Helmet, protective, soft, prefabricated, includes all components and accessories |
A8000 |
New / Changed in 2020: |
|
Service Description: |
Helmet, protective, hard, prefabricated, includes all components and accessories |
Restricted to Preferred Facilities: |
|
Service Code: |
A8001 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Helmet, protective, hard, prefabricated, includes all components and accessories |
A8001 |
New / Changed in 2020: |
|
Service Description: |
Helmet, protective, soft, custom fabricated, includes all components and accessories |
Restricted to Preferred Facilities: |
|
Service Code: |
A8002 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Helmet, protective, soft, custom fabricated, includes all components and accessories |
A8002 |
New / Changed in 2020: |
|
Service Description: |
Helmet, protective, hard, custom fabricated, includes all components and accessories |
Restricted to Preferred Facilities: |
|
Service Code: |
A8003 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Helmet, protective, hard, custom fabricated, includes all components and accessories |
A8003 |
New / Changed in 2020: |
|
Service Description: |
Soft interface for helmet, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
A8004 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Soft interface for helmet, replacement only |
A8004 |
New / Changed in 2020: |
|
Service Description: |
Foot pressure off loading/supportive device, any type, each |
Restricted to Preferred Facilities: |
|
Service Code: |
A9283 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot pressure off loading/supportive device, any type, each |
A9283 |
New / Changed in 2020: |
|
Service Description: |
Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries |
Restricted to Preferred Facilities: |
|
Service Code: |
A9542 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 15 |
|
Zevalin® In-111 and Zevalin® Y-90 (ibritumomab) |
Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries |
A9542 |
New / Changed in 2020: |
|
Service Description: |
Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries |
Restricted to Preferred Facilities: |
|
Service Code: |
A9543 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 15 |
|
Zevalin® In-111 and Zevalin® Y-90 (ibritumomab) |
Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries |
A9543 |
New / Changed in 2020: |
|
Service Description: |
Radium ra-223 dichloride, therapeutic, per microcurie |
Restricted to Preferred Facilities: |
|
Service Code: |
A9606 |
Service Code Type: |
HCPCS |
Effective Date: |
9/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 110.0 |
|
Xofigo® (radium Ra 223 dichloride) |
Radium ra-223 dichloride, therapeutic, per microcurie |
A9606 |
New / Changed in 2020: |
|
Service Description: |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
Restricted to Preferred Facilities: |
|
Service Code: |
B4034 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4034 |
New / Changed in 2020: |
|
Service Description: |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
Restricted to Preferred Facilities: |
|
Service Code: |
B4035 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4035 |
New / Changed in 2020: |
|
Service Description: |
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
Restricted to Preferred Facilities: |
|
Service Code: |
B4036 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4036 |
New / Changed in 2020: |
|
Service Description: |
Nasogastric tubing with stylet |
Restricted to Preferred Facilities: |
|
Service Code: |
B4081 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Nasogastric tubing with stylet |
B4081 |
New / Changed in 2020: |
|
Service Description: |
Nasogastric tubing without stylet |
Restricted to Preferred Facilities: |
|
Service Code: |
B4082 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Nasogastric tubing without stylet |
B4082 |
New / Changed in 2020: |
|
Service Description: |
Stomach tube - levine type |
Restricted to Preferred Facilities: |
|
Service Code: |
B4083 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Stomach tube - levine type |
B4083 |
New / Changed in 2020: |
|
Service Description: |
Gastrostomy/jejunostomy tube, standard, any material, any type, each |
Restricted to Preferred Facilities: |
|
Service Code: |
B4087 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Gastrostomy/jejunostomy tube, standard, any material, any type, each |
B4087 |
New / Changed in 2020: |
|
Service Description: |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
Restricted to Preferred Facilities: |
|
Service Code: |
B4088 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
B4088 |
New / Changed in 2020: |
|
Service Description: |
Food thickener, administered orally, per ounce |
Restricted to Preferred Facilities: |
|
Service Code: |
B4100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Food thickener, administered orally, per ounce |
B4100 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
Restricted to Preferred Facilities: |
|
Service Code: |
B4102 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
B4102 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
Restricted to Preferred Facilities: |
|
Service Code: |
B4103 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
B4103 |
New / Changed in 2020: |
|
Service Description: |
Additive for enteral formula (e.g. fiber) |
Restricted to Preferred Facilities: |
|
Service Code: |
B4104 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Additive for enteral formula (e.g. fiber) |
B4104 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
Restricted to Preferred Facilities: |
|
Service Code: |
B4149 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
B4149 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calor |
Restricted to Preferred Facilities: |
|
Service Code: |
B4150 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calor |
B4150 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fibe |
Restricted to Preferred Facilities: |
|
Service Code: |
B4152 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fibe |
B4152 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral fe |
Restricted to Preferred Facilities: |
|
Service Code: |
B4153 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral fe |
B4153 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, |
Restricted to Preferred Facilities: |
|
Service Code: |
B4154 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, |
B4154 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain |
Restricted to Preferred Facilities: |
|
Service Code: |
B4155 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain |
B4155 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered |
Restricted to Preferred Facilities: |
|
Service Code: |
B4157 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered |
B4157 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an ent |
Restricted to Preferred Facilities: |
|
Service Code: |
B4158 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an ent |
B4158 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered thro |
Restricted to Preferred Facilities: |
|
Service Code: |
B4159 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered thro |
B4159 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, m |
Restricted to Preferred Facilities: |
|
Service Code: |
B4160 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, m |
B4160 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube |
Restricted to Preferred Facilities: |
|
Service Code: |
B4161 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube |
B4161 |
New / Changed in 2020: |
|
Service Description: |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an |
Restricted to Preferred Facilities: |
|
Service Code: |
B4162 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an |
B4162 |
New / Changed in 2020: |
|
Service Description: |
Enteral nutrition infusion pump - with alarm |
Restricted to Preferred Facilities: |
|
Service Code: |
B9002 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Enteral nutrition infusion pump - with alarm |
B9002 |
New / Changed in 2020: |
|
Service Description: |
Noc for enteral supplies |
Restricted to Preferred Facilities: |
|
Service Code: |
B9998 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nutritional Supplements |
Noc for enteral supplies |
B9998 |
New / Changed in 2020: |
|
Service Description: |
Prosthesis, penile, inflatable |
Restricted to Preferred Facilities: |
|
Service Code: |
C1813 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Prosthesis, penile, inflatable |
C1813 |
New / Changed in 2020: |
|
Service Description: |
Prosthesis, penile, non-inflatable |
Restricted to Preferred Facilities: |
|
Service Code: |
C2622 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Prosthesis, penile, non-inflatable |
C2622 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Perseris (risperidone) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9037 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Perseris (risperidone) |
Perseris (risperidone) |
C9037 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Poteligeo (mogamulizumab-kpkc) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9038 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Poteligeo (mogamulizumab-kpkc) |
Poteligeo (mogamulizumab-kpkc) |
C9038 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Andexxa (adnexanet alfa) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9041 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Andexxa (adnexanet alfa) |
Andexxa (adnexanet alfa) |
C9041 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Libtayo (cemiplimab-rwlc) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9044 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Libtayo (cemiplimab-rwlc) |
Libtayo (cemiplimab-rwlc) |
C9044 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, moxetumomab pasudotox-tdfk, 0.01 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
C9045 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Lumoxiti |
Injection, moxetumomab pasudotox-tdfk, 0.01 mg |
C9045 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
Restricted to Preferred Facilities: |
|
Service Code: |
C9250 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
C9250 |
New / Changed in 2020: |
|
Service Description: |
Injection, glucarpidase, 10 units |
Restricted to Preferred Facilities: |
|
Service Code: |
C9293 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 96.0 |
|
Voraxaze® (glucarpidase) |
Injection, glucarpidase, 10 units |
C9293 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
C9363 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
C9363 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs or biologicals |
Restricted to Preferred Facilities: |
|
Service Code: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zolgensma |
Unclassified drugs or biologicals |
C9399 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs or biologicals |
Restricted to Preferred Facilities: |
|
Service Code: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zulresso (brexanolone) |
Unclassified drugs or biologicals |
C9399 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Azedra (iobenguane i 131) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9407 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9407 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Azedra (iobenguane i 131) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9408 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9408 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Baxdela (delafloxacin) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9462 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Baxdela (delafloxacin) |
Baxdela (delafloxacin) |
C9462 |
New / Changed in 2020: |
|
Service Description: |
Exondys 51 (eteplirsen) |
Restricted to Preferred Facilities: |
|
Service Code: |
C9484 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Exondys 51 (eteplirsen) |
Exondys 51 (eteplirsen) |
C9484 |
New / Changed in 2020: |
|
Service Description: |
EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATI |
Restricted to Preferred Facilities: |
|
Service Code: |
D7140 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATI |
D7140 |
New / Changed in 2020: |
|
Service Description: |
SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP |
Restricted to Preferred Facilities: |
|
Service Code: |
D7210 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP |
D7210 |
New / Changed in 2020: |
|
Service Description: |
REMOVAL OF IMPACTED TOOTH, SOFT TISSUE |
Restricted to Preferred Facilities: |
|
Service Code: |
D7220 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
REMOVAL OF IMPACTED TOOTH, SOFT TISSUE |
D7220 |
New / Changed in 2020: |
|
Service Description: |
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING |
Restricted to Preferred Facilities: |
|
Service Code: |
D7250 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 127.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING |
D7250 |
New / Changed in 2020: |
|
Service Description: |
TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCID |
Restricted to Preferred Facilities: |
|
Service Code: |
D7270 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 111.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCID |
D7270 |
New / Changed in 2020: |
|
Service Description: |
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FRO |
Restricted to Preferred Facilities: |
|
Service Code: |
D7272 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FRO |
D7272 |
New / Changed in 2020: |
|
Service Description: |
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FRO |
Restricted to Preferred Facilities: |
|
Service Code: |
D7272 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION FRO |
D7272 |
New / Changed in 2020: |
|
Service Description: |
SURGICAL ACCESS OF AN UNERUPTED TOOTH |
Restricted to Preferred Facilities: |
|
Service Code: |
D7280 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
SURGICAL ACCESS OF AN UNERUPTED TOOTH |
D7280 |
New / Changed in 2020: |
|
Service Description: |
SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH T |
Restricted to Preferred Facilities: |
|
Service Code: |
D7281 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 130.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH T |
D7281 |
New / Changed in 2020: |
|
Service Description: |
MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO |
Restricted to Preferred Facilities: |
|
Service Code: |
D7282 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 130.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO |
D7282 |
New / Changed in 2020: |
|
Service Description: |
PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPA |
Restricted to Preferred Facilities: |
|
Service Code: |
D7283 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPA |
D7283 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Occlusal orthotic appliance |
Restricted to Preferred Facilities: |
|
Service Code: |
D7880 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Occlusal orthotic appliance |
D7880 |
New / Changed in 2020: |
|
Service Description: |
INHALATION OF NITROUS OXIDE/ANXIOLYSIS ANALGESIA |
Restricted to Preferred Facilities: |
|
Service Code: |
D9230 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
INHALATION OF NITROUS OXIDE/ANXIOLYSIS ANALGESIA |
D9230 |
New / Changed in 2020: |
|
Service Description: |
THERAPEUTIC DRUG INJECTION, BY REPORT |
Restricted to Preferred Facilities: |
|
Service Code: |
D9610 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 163.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
THERAPEUTIC DRUG INJECTION, BY REPORT |
D9610 |
New / Changed in 2020: |
|
Service Description: |
Thera par drugs 2 or > admin |
Restricted to Preferred Facilities: |
|
Service Code: |
D9612 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11.0 |
|
Extraction of teeth and Alveoloplasty (extractions that are required by traumatic injury, or prior to organ transplantation, cardiac or radiation procedures) |
Thera par drugs 2 or > admin |
D9612 |
New / Changed in 2020: |
|
Service Description: |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
E0485 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 55.0 |
|
Orthoses |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
E0485 |
New / Changed in 2020: |
|
Service Description: |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
E0486 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 39.0 |
|
Orthoses |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment |
E0486 |
New / Changed in 2020: |
|
Service Description: |
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less |
Restricted to Preferred Facilities: |
|
Service Code: |
E0691 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less |
E0691 |
New / Changed in 2020: |
|
Service Description: |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel |
Restricted to Preferred Facilities: |
|
Service Code: |
E0692 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel |
E0692 |
New / Changed in 2020: |
|
Service Description: |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel |
Restricted to Preferred Facilities: |
|
Service Code: |
E0693 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel |
E0693 |
New / Changed in 2020: |
|
Service Description: |
Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection |
Restricted to Preferred Facilities: |
|
Service Code: |
E0694 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 68.0 |
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection |
E0694 |
New / Changed in 2020: |
|
Service Description: |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
Restricted to Preferred Facilities: |
|
Service Code: |
E0761 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2001 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Electrical Stimulation to aid wound healing |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
E0761 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time |
Restricted to Preferred Facilities: |
|
Service Code: |
E2500 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 141.0 |
|
Speech Generating Devices |
Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time |
E2500 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time |
Restricted to Preferred Facilities: |
|
Service Code: |
E2502 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time |
E2502 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time |
Restricted to Preferred Facilities: |
|
Service Code: |
E2504 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time |
E2504 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time |
Restricted to Preferred Facilities: |
|
Service Code: |
E2506 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time |
E2506 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device |
Restricted to Preferred Facilities: |
|
Service Code: |
E2508 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device |
E2508 |
New / Changed in 2020: |
|
Service Description: |
Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access |
Restricted to Preferred Facilities: |
|
Service Code: |
E2510 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access |
E2510 |
New / Changed in 2020: |
|
Service Description: |
Speech generating software program, for personal computer or personal digital assistant |
Restricted to Preferred Facilities: |
|
Service Code: |
E2511 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Speech generating software program, for personal computer or personal digital assistant |
E2511 |
New / Changed in 2020: |
|
Service Description: |
Accessory for speech generating device, mounting system |
Restricted to Preferred Facilities: |
|
Service Code: |
E2512 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Accessory for speech generating device, mounting system |
E2512 |
New / Changed in 2020: |
|
Service Description: |
Accessory for speech generating device, not otherwise classified |
Restricted to Preferred Facilities: |
|
Service Code: |
E2599 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Speech Generating Devices |
Accessory for speech generating device, not otherwise classified |
E2599 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session |
Restricted to Preferred Facilities: |
|
Service Code: |
G0173 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session |
G0173 |
New / Changed in 2020: |
|
Service Description: |
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
Restricted to Preferred Facilities: |
|
Service Code: |
G0235 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2019 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
G0235 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
G0251 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment |
G0251 |
New / Changed in 2020: |
|
Service Description: |
Electrical stimulation, (unattended), to one or more areas, for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers not demonstrating measurable |
Restricted to Preferred Facilities: |
|
Service Code: |
G0281 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2001 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Electrical Stimulation to aid wound healing |
Electrical stimulation, (unattended), to one or more areas, for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers not demonstrating measurable |
G0281 |
New / Changed in 2020: |
|
Service Description: |
Electromagnetic therapy, to one or more areas for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healin |
Restricted to Preferred Facilities: |
|
Service Code: |
G0329 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2001 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Electrical Stimulation to aid wound healing |
Electromagnetic therapy, to one or more areas for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healin |
G0329 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
G0339 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment |
G0339 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
G0340 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 307 |
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment |
G0340 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ultrasonic guidance for placement of radiation therapy fields |
Restricted to Preferred Facilities: |
|
Service Code: |
G6001 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Ultrasonic guidance for placement of radiation therapy fields |
G6001 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy |
Restricted to Preferred Facilities: |
|
Service Code: |
G6002 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy |
G6002 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6003 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 MeV |
G6003 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6004 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 MeV |
G6004 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6005 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 MeV |
G6005 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater |
Restricted to Preferred Facilities: |
|
Service Code: |
G6006 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater |
G6006 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6007 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 MeV |
G6007 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6008 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 MeV |
G6008 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6009 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19 MeV |
G6009 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 MeV or greater |
Restricted to Preferred Facilities: |
|
Service Code: |
G6010 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 MeV or greater |
G6010 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6011 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
G6011 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6012 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 93.0 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV |
G6012 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV |
Restricted to Preferred Facilities: |
|
Service Code: |
G6013 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV |
G6013 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater |
Restricted to Preferred Facilities: |
|
Service Code: |
G6014 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater |
G6014 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intensity modulated Treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session |
Restricted to Preferred Facilities: |
|
Service Code: |
G6015 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Radiation Oncology-Treatment Delivery |
Intensity modulated Treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session |
G6015 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session |
Restricted to Preferred Facilities: |
|
Service Code: |
G6016 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Radiation Oncology-Treatment Delivery |
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session |
G6016 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment |
Restricted to Preferred Facilities: |
|
Service Code: |
G6017 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Radiation Oncology-Treatment Delivery |
Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment |
G6017 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Verification and documentation of sudden or rapidly progressive hearing loss |
Restricted to Preferred Facilities: |
|
Service Code: |
G8565 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Verification and documentation of sudden or rapidly progressive hearing loss |
G8565 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care |
Restricted to Preferred Facilities: |
|
Service Code: |
GCG0X |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 120.0 |
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care |
GCG0X |
New / Changed in 2020: |
|
Service Description: |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
Restricted to Preferred Facilities: |
|
Service Code: |
H0008 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
H0008 |
New / Changed in 2020: |
|
Service Description: |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
Restricted to Preferred Facilities: |
|
Service Code: |
H0009 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
H0009 |
New / Changed in 2020: |
|
Service Description: |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
Restricted to Preferred Facilities: |
|
Service Code: |
H0010 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
H0010 |
New / Changed in 2020: |
|
Service Description: |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
Restricted to Preferred Facilities: |
|
Service Code: |
H0011 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
H0011 |
New / Changed in 2020: |
|
Service Description: |
Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0129 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Orencia® (abatacept) |
Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
J0129 |
New / Changed in 2020: |
|
Service Description: |
Injection, agalsidase beta, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0180 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Fabrazyme® (agalsidase beta) |
Injection, agalsidase beta, 1 mg |
J0180 |
New / Changed in 2020: |
|
Service Description: |
Injection, alemtuzumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0202 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Lemtrada (alemtuzumab) |
Injection, alemtuzumab, 1 mg |
J0202 |
New / Changed in 2020: |
|
Service Description: |
Injection, alglucosidase alfa, (lumizyme), 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0221 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Lumizyme® (Alglucosidase alfa) |
Injection, alglucosidase alfa, (lumizyme), 10 mg |
J0221 |
New / Changed in 2020: |
|
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Aralast™ (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
New / Changed in 2020: |
|
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Prolastin® (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
New / Changed in 2020: |
|
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 43 |
|
Zemaira® (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
New / Changed in 2020: |
|
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0257 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2012 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Glassia (alpha1-proteinase inhibitor, human) |
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg |
J0257 |
New / Changed in 2020: |
|
Service Description: |
Injection, anidulafungin, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0348 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Eraxis™ (anidulafungin) |
Injection, anidulafungin, 1 mg |
J0348 |
New / Changed in 2020: |
|
Service Description: |
Injection, aripiprazole, extended release, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0401 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Abilify Maintena® (aripiprazole) |
Injection, aripiprazole, extended release, 1 mg |
J0401 |
New / Changed in 2020: |
|
Service Description: |
Injection, belatacept, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0485 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2012 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Nulojix® (belatacept) |
Injection, belatacept, 1 mg |
J0485 |
New / Changed in 2020: |
|
Service Description: |
Injection, belimumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0490 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Benlysta® (belimumab) |
Injection, belimumab, 10 mg |
J0490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, cerliponase alfa, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0567 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Brineura (injection, cerliponase alfa) |
Injection, cerliponase alfa, 1 mg |
J0567 |
New / Changed in 2020: |
|
Service Description: |
Buprenorphine implant, 74.2 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0570 |
Service Code Type: |
HCPCS |
Effective Date: |
10/31/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Probuphine (buprenorphine implant) |
Buprenorphine implant, 74.2 mg |
J0570 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, burosumab-twza 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0584 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Crysvita (burosumab-twza) |
Injection, burosumab-twza 1 mg |
J0584 |
New / Changed in 2020: |
|
Service Description: |
Injection, abobotulinumtoxina, 5 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0586 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2010 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Dysport® (Botulinum toxin Type A) |
Injection, abobotulinumtoxina, 5 units |
J0586 |
New / Changed in 2020: |
|
Service Description: |
Injection, rimabotulinumtoxinb, 100 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0587 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2001 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Myobloc® (botulinum toxin Type B) |
Injection, rimabotulinumtoxinb, 100 units |
J0587 |
New / Changed in 2020: |
|
Service Description: |
Injection, incobotulinumtoxin a, 1 unit |
Restricted to Preferred Facilities: |
|
Service Code: |
J0588 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2012 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 11.0 |
|
Xeomin® (Botulinum toxin Type A) |
Injection, incobotulinumtoxin a, 1 unit |
J0588 |
New / Changed in 2020: |
|
Service Description: |
Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0596 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 247 |
|
Ruconest® (C1 esterase inhibitor, recocmbinant) |
Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units |
J0596 |
New / Changed in 2020: |
|
Service Description: |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0597 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Berinert® (C1 esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
J0597 |
New / Changed in 2020: |
|
Service Description: |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0598 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Cinryze™ (C1-esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
J0598 |
New / Changed in 2020: |
|
Service Description: |
Injection, canakinumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0638 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2010 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Ilaris® (canakinumab) |
Injection, canakinumab, 1 mg |
J0638 |
New / Changed in 2020: |
|
Service Description: |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
Restricted to Preferred Facilities: |
|
Service Code: |
J0714 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Avycaz® (ceftazidime/avibactam) |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
J0714 |
New / Changed in 2020: |
|
Service Description: |
Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0717 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Cimzia® (certolizumab pegol) |
Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
J0717 |
New / Changed in 2020: |
|
Service Description: |
Injection, collagenase, clostridium histolyticum, 0.01 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0775 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 80.0 |
|
Xiaflex® (collagenase clostridium histolyticum) |
Injection, collagenase, clostridium histolyticum, 0.01 mg |
J0775 |
New / Changed in 2020: |
|
Service Description: |
Injection, dalbavancin, 5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0875 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Dalvance™ (dalbavancin) |
Injection, dalbavancin, 5 mg |
J0875 |
New / Changed in 2020: |
|
Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0881 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
New / Changed in 2020: |
|
Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0881 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
New / Changed in 2020: |
|
Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0882 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
New / Changed in 2020: |
|
Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0882 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Epogen® (epoetin alpha) |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Procrit® (epoetin alpha) |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0887 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Erythropoietin Stimulating Agents |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
J0887 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0887 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 65 |
|
Mircera® (epotin beta) |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
J0887 |
New / Changed in 2020: |
|
Service Description: |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0888 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 296 |
|
Erythropoietin Stimulating Agents |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
J0888 |
New / Changed in 2020: |
|
Service Description: |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
Restricted to Preferred Facilities: |
|
Service Code: |
J0888 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 155.0 |
|
Mircera® (epotin beta) |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
J0888 |
New / Changed in 2020: |
|
Service Description: |
Injection, decitabine, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0894 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Dacogen® (decitabine) |
Injection, decitabine, 1 mg |
J0894 |
New / Changed in 2020: |
|
Service Description: |
Injection, denosumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0897 |
Service Code Type: |
HCPCS |
Effective Date: |
3/29/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 92.0 |
|
Prolia™ (denosumab) |
Injection, denosumab, 1 mg |
J0897 |
New / Changed in 2020: |
|
Service Description: |
Injection, denosumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J0897 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 89.0 |
|
Xgeva™ (denosumab) |
Injection, denosumab, 1 mg |
J0897 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J1095 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 138.0 |
|
Dexycu (Dexamethasone) |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
J1095 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dexametha opth insert 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1096 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 28 |
|
Dextenza (dexamethasone ophthalmic insert) |
Dexametha opth insert 0.1 mg |
J1096 |
New / Changed in 2020: |
|
Service Description: |
Injection, ecallantide, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1290 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 126.0 |
|
Kalbitor® (ecallantide) |
Injection, ecallantide, 1 mg |
J1290 |
New / Changed in 2020: |
|
Service Description: |
Injection, eculizumab, 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1300 |
Service Code Type: |
HCPCS |
Effective Date: |
5/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 40.0 |
|
Soliris® (eculizumab) |
Injection, eculizumab, 10 mg |
J1300 |
New / Changed in 2020: |
|
Service Description: |
Injection, elosulfase alfa, 1mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1322 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 114.0 |
|
Vimizim® (elosulfase alfa) |
Injection, elosulfase alfa, 1mg |
J1322 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoprostenol, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Flolan® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoprostenol, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Flolan® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoprostenol, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1325 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2012 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 61.0 |
|
Veletri® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
New / Changed in 2020: |
|
Service Description: |
Injection, filgrastim (g-csf), 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J1442 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Neupogen® (filgrastim) |
Injection, filgrastim (g-csf), 1 microgram |
J1442 |
New / Changed in 2020: |
|
Service Description: |
Injection, filgrastim (g-csf), 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J1442 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, filgrastim (g-csf), 1 microgram |
J1442 |
New / Changed in 2020: |
|
Service Description: |
Injection, tbo-filgrastim, 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J1447 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Granix® (TBO-filgrastim) |
Injection, tbo-filgrastim, 1 microgram |
J1447 |
New / Changed in 2020: |
|
Service Description: |
Injection, tbo-filgrastim, 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J1447 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, tbo-filgrastim, 1 microgram |
J1447 |
New / Changed in 2020: |
|
Service Description: |
Injection, galsulfase, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1458 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Naglazyme® (galsulfase) |
Injection, galsulfase, 1 mg |
J1458 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1459 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1459 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1459 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Privigen (intravenous immune globulin) |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1459 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (cuvitru), 100 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1555 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Cuvitru (Subcutaneous immune globulin) |
Injection, immune globulin (cuvitru), 100 mg |
J1555 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (bivigam), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1556 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (bivigam), 500 mg |
J1556 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1557 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1557 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1557 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1557 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (hizentra), 100 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1559 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (hizentra), 100 mg |
J1559 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1561 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
J1561 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1561 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
J1561 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin (vivaglobin), 100 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1562 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (vivaglobin), 100 mg |
J1562 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1566 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Carimune (intraveneous immune globulin) |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
J1566 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1566 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
J1566 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1568 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1568 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1568 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Octagam (intravenous immune globulin) |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1568 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1569 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 38 |
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg |
J1569 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1572 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Flebogamma (intravenous immune globulin) |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1572 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1572 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1572 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
Restricted to Preferred Facilities: |
|
Service Code: |
J1575 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
HyQvia (immune globulin/hyaluronidase) |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
J1575 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1575 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
J1575 |
New / Changed in 2020: |
|
Service Description: |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1599 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
J1599 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1599 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Panzyga (immune globulin intravenous, human – ifas) |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
J1599 |
New / Changed in 2020: |
|
Service Description: |
Injection, golimumab, 1 mg, for intravenous use |
Restricted to Preferred Facilities: |
|
Service Code: |
J1602 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Simponi® Aria (golimumab) |
Injection, golimumab, 1 mg, for intravenous use |
J1602 |
New / Changed in 2020: |
|
Service Description: |
Injection, hydroxyprogesterone caproate, (makena), 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1726 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Makena® (hydroxyprogesterone caproate) |
Injection, hydroxyprogesterone caproate, (makena), 10 mg |
J1726 |
New / Changed in 2020: |
|
Service Description: |
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1729 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Makena® (hydroxyprogesterone caproate) |
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg |
J1729 |
New / Changed in 2020: |
|
Service Description: |
Injection, ibandronate sodium, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1740 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous (IV) Boniva® (ibandronate sodium) |
Injection, ibandronate sodium, 1 mg |
J1740 |
New / Changed in 2020: |
|
Service Description: |
Injection, idursulfase, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1743 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Elaprase® (idursulfase) |
Injection, idursulfase, 1 mg |
J1743 |
New / Changed in 2020: |
|
Service Description: |
Injection infliximab, 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1745 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2001 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Remicade® (infliximab) |
Injection infliximab, 10 mg |
J1745 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, ibalizumab-uiyk, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1746 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Trogarzo (ibalizumab-uiyk) |
Injection, ibalizumab-uiyk, 10 mg |
J1746 |
New / Changed in 2020: |
|
Service Description: |
Injection, imiglucerase, 10 units |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1786 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cerezyme® (imiglucerase) |
Injection, imiglucerase, 10 units |
J1786 |
New / Changed in 2020: |
|
Service Description: |
Injection, isavuconazonium, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1833 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cresemba® IV (isavuconazonium sulfate) |
Injection, isavuconazonium, 1 mg |
J1833 |
New / Changed in 2020: |
|
Service Description: |
Injection, laronidase, 0.1 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1931 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aldurazyme® (laronidase) |
Injection, laronidase, 0.1 mg |
J1931 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1943 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
J1943 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1944 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
J1944 |
New / Changed in 2020: |
|
Service Description: |
Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J1950 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
J1950 |
New / Changed in 2020: |
|
Service Description: |
Injection, mepolizumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2182 |
Service Code Type: |
HCPCS |
Effective Date: |
5/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nucala® (mepolizumab) |
Injection, mepolizumab, 1 mg |
J2182 |
New / Changed in 2020: |
|
Service Description: |
Injection, ziconotide, 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J2278 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prialt® (ziconotide intrathecal infusion) |
Injection, ziconotide, 1 microgram |
J2278 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, naltrexone, depot form, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2315 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Vivitrol (naltrexone microspheres) |
Injection, naltrexone, depot form, 1 mg |
J2315 |
New / Changed in 2020: |
|
Service Description: |
Injection, natalizumab, 1 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J2323 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 57.0 |
|
Tysabri® (natalizumab) |
Injection, natalizumab, 1 mg |
J2323 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, nusinersen, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2326 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Spinraza (nusinersen) |
Injection, nusinersen, 0.1 mg |
J2326 |
New / Changed in 2020: |
|
Service Description: |
Injection, octreotide, depot form for intramuscular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2353 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sandostatin LAR® (Octreotide acetate) |
Injection, octreotide, depot form for intramuscular injection, 1 mg |
J2353 |
New / Changed in 2020: |
|
Service Description: |
Injection, omalizumab, 5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2357 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2004 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 22 |
|
Xolair® (omalizumab) |
Injection, omalizumab, 5 mg |
J2357 |
New / Changed in 2020: |
|
Service Description: |
Injection, paliperidone palmitate extended release, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2426 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Invega Sustenna® (paliperidone palmitate extended release) |
Injection, paliperidone palmitate extended release, 1 mg |
J2426 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, palonosetron hcl, 25 mcg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2469 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aloxi (palonosetron) |
Injection, palonosetron hcl, 25 mcg |
J2469 |
New / Changed in 2020: |
|
Service Description: |
Injection, pasireotide long acting, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2502 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Signifor® LAR (pasireotide) |
Injection, pasireotide long acting, 1 mg |
J2502 |
New / Changed in 2020: |
|
Service Description: |
Injection, pegfilgrastim, 6 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2505 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Neulasta® (pegfilgrastim) |
Injection, pegfilgrastim, 6 mg |
J2505 |
New / Changed in 2020: |
|
Service Description: |
Injection, pegfilgrastim, 6 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2505 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, pegfilgrastim, 6 mg |
J2505 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, plerixafor, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2562 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Mozobil (plerixafor) |
Injection, plerixafor, 1 mg |
J2562 |
New / Changed in 2020: |
|
Service Description: |
Injection, rasburicase, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2783 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Elitek® (rasburicase) |
Injection, rasburicase, 0.5 mg |
J2783 |
New / Changed in 2020: |
|
Service Description: |
Injection, reslizumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2786 |
Service Code Type: |
HCPCS |
Effective Date: |
12/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cinqair (reslizumab) |
Injection, reslizumab, 1 mg |
J2786 |
New / Changed in 2020: |
|
Service Description: |
Injection, risperidone, long acting, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2794 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Risperdal Consta® (risperidone) |
Injection, risperidone, long acting, 0.5 mg |
J2794 |
New / Changed in 2020: |
|
Service Description: |
Injection, romiplostim, 10 micrograms |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J2796 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Nplate™ (romiplostim) |
Injection, romiplostim, 10 micrograms |
J2796 |
New / Changed in 2020: |
|
Service Description: |
Injection, sargramostim (gm-csf), 50 mcg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2820 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Leukine® (sargramostim) |
Injection, sargramostim (gm-csf), 50 mcg |
J2820 |
New / Changed in 2020: |
|
Service Description: |
Injection, sargramostim (gm-csf), 50 mcg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2820 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, sargramostim (gm-csf), 50 mcg |
J2820 |
New / Changed in 2020: |
|
Service Description: |
Inj sebelipase alfa 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2840 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Kanuma® (sebelipase alfa) |
Inj sebelipase alfa 1 mg |
J2840 |
New / Changed in 2020: |
|
Service Description: |
Injection, siltuximab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J2860 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sylvant™ (siltuximab) |
Injection, siltuximab, 10 mg |
J2860 |
New / Changed in 2020: |
|
Service Description: |
Injection, taliglucerace alfa, 10 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J3060 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Elelyso™ (taliglucerase alfa) |
Injection, taliglucerace alfa, 10 units |
J3060 |
New / Changed in 2020: |
|
Service Description: |
Injection, tedizolid phosphate, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3090 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2015 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Sivextro® (tedizolid phosphate) |
Injection, tedizolid phosphate, 1 mg |
J3090 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, romosozumab-aqqg, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3111 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Evenity (romosozumab-aqqg) |
Injection, romosozumab-aqqg, 1 mg |
J3111 |
New / Changed in 2020: |
|
Service Description: |
Injection, testosterone undecanoate, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3145 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aveed® (testosterone) |
Injection, testosterone undecanoate, 1 mg |
J3145 |
New / Changed in 2020: |
|
Service Description: |
Injection, tocilizumab, 1 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3262 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2010 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Actemra® (tocilizumab) |
Injection, tocilizumab, 1 mg |
J3262 |
New / Changed in 2020: |
|
Service Description: |
Injection, treprostinil, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3285 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Remodulin® (treprostinil) |
Injection, treprostinil, 1 mg |
J3285 |
New / Changed in 2020: |
|
Service Description: |
Ustekinumab, for subcutaneous injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J3357 |
Service Code Type: |
HCPCS |
Effective Date: |
5/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Stelara™ (ustekinumab) |
Ustekinumab, for subcutaneous injection, 1 mg |
J3357 |
New / Changed in 2020: |
|
Service Description: |
Injection, vedolizumab, 1 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3380 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Entyvio® (vedolizumab) |
Injection, vedolizumab, 1 mg |
J3380 |
New / Changed in 2020: |
|
Service Description: |
Injection, velaglucerase alfa, 100 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J3385 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 105.0 |
|
VPRIV® (velaglucerase alfa) |
Injection, velaglucerase alfa, 100 units |
J3385 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, hyaluronidase, up to 150 units |
Restricted to Preferred Facilities: |
|
Service Code: |
J3470 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, up to 150 units |
J3470 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) |
Restricted to Preferred Facilities: |
|
Service Code: |
J3471 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) |
J3471 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, hyaluronidase, ovine, preservative free, per 1000 usp units |
Restricted to Preferred Facilities: |
|
Service Code: |
J3472 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, ovine, preservative free, per 1000 usp units |
J3472 |
New / Changed in 2020: |
|
Service Description: |
Injection, hyaluronidase, recombinant, 1 usp unit |
Restricted to Preferred Facilities: |
|
Service Code: |
J3473 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, recombinant, 1 usp unit |
J3473 |
New / Changed in 2020: |
|
Service Description: |
Injection, hyaluronidase, recombinant, 1 usp unit |
Restricted to Preferred Facilities: |
|
Service Code: |
J3473 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Injection, hyaluronidase, recombinant, 1 usp unit |
J3473 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous Immune Globulin (IVIG) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Polivy (polatuzumab vedotin-piiq) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Revcovi (elapegademase-lvlr) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Xerava (eravacycline) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zolgensma |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Zulresso (brexanolone) |
Unclassified drugs |
J3490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Intravenous Immune Globulin (IVIG) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Polivy (polatuzumab vedotin-piiq) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
|
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 150.0 |
|
Praxbind (idarucizumab) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Revcovi (elapegademase-lvlr) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Unclassified biologics |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Xerava (eravacycline) |
Unclassified biologics |
J3590 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, emicizumab-kxwh, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7170 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hemlibra (emicizumab-kxwh) |
Injection, emicizumab-kxwh, 0.5 mg |
J7170 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7180 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
J7180 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor xiii a-subunit, (recombinant), per iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7181 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii a-subunit, (recombinant), per iu |
J7181 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7182 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
J7182 |
New / Changed in 2020: |
|
Service Description: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
Restricted to Preferred Facilities: |
|
Service Code: |
J7183 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
J7183 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7185 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
J7185 |
New / Changed in 2020: |
|
Service Description: |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7186 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
J7186 |
New / Changed in 2020: |
|
Service Description: |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
Restricted to Preferred Facilities: |
|
Service Code: |
J7187 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
J7187 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7188 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
J7188 |
New / Changed in 2020: |
|
Service Description: |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J7189 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
J7189 |
New / Changed in 2020: |
|
Service Description: |
Factor viii (antihemophilic factor, human) per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7190 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, human) per i.u. |
J7190 |
New / Changed in 2020: |
|
Service Description: |
Factor viii (antihemophilic factor (porcine)), per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7191 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor (porcine)), per i.u. |
J7191 |
New / Changed in 2020: |
|
Service Description: |
Factor viii (antihemophilic factor (porcine)), per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7191 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor (porcine)), per i.u. |
J7191 |
New / Changed in 2020: |
|
Service Description: |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
J7192 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
J7192 |
New / Changed in 2020: |
|
Service Description: |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7193 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
J7193 |
New / Changed in 2020: |
|
Service Description: |
Factor ix, complex, per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7194 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix, complex, per i.u. |
J7194 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
J7195 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
J7195 |
New / Changed in 2020: |
|
Service Description: |
Injection, antithrombin recombinant, 50 i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7196 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, antithrombin recombinant, 50 i.u. |
J7196 |
New / Changed in 2020: |
|
Service Description: |
Antithrombin iii (human), per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7197 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Antithrombin iii (human), per i.u. |
J7197 |
New / Changed in 2020: |
|
Service Description: |
Anti-inhibitor, per i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7198 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Anti-inhibitor, per i.u. |
J7198 |
New / Changed in 2020: |
|
Service Description: |
Hemophilia clotting factor, not otherwise classified |
Restricted to Preferred Facilities: |
|
Service Code: |
J7199 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Hemophilia clotting factor, not otherwise classified |
J7199 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7200 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
J7200 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor ix, fc fusion protein (recombinant), per iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7201 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, fc fusion protein (recombinant), per iu |
J7201 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7202 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
J7202 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7203 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Rebinyn (coagulation factor IX [recombinant], glycoPEGylated) |
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
J7203 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii fc fusion protein (recombinant), per iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J7205 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii fc fusion protein (recombinant), per iu |
J7205 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
Restricted to Preferred Facilities: |
|
Service Code: |
J7207 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
J7207 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u |
Restricted to Preferred Facilities: |
|
Service Code: |
J7208 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Jivi (antihemophilic factor VIII [recombinant]) |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u |
J7208 |
New / Changed in 2020: |
|
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
Restricted to Preferred Facilities: |
|
Service Code: |
J7209 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
J7209 |
New / Changed in 2020: |
|
Service Description: |
Ganciclovir, 4.5 mg, long-acting implant |
Restricted to Preferred Facilities: |
|
Service Code: |
J7310 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2005 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 34 |
|
Vitrasert® (ganciclovir intravitreal implant) |
Ganciclovir, 4.5 mg, long-acting implant |
J7310 |
New / Changed in 2020: |
|
Service Description: |
fluocinolone acetonide intravitreal implant |
Restricted to Preferred Facilities: |
|
Service Code: |
J7313 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2015 12:00:00 AM |
Comments: |
First treatment of Iluvien, for diabetic macular edema DOES NOT require prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Iluvien® (fluocinolone acetonide) |
fluocinolone acetonide intravitreal implant |
J7313 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Sodium hyaluronate per 20 to 25 mg dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7317 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Sodium hyaluronate per 20 to 25 mg dose |
J7317 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7318 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Durolane (hyaluronic acid) |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
J7318 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
GenVisc® 850 (hyaluronan or derivative) |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyalgan® (hyaluronate sodium) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Supartz™ (hyaluronate sodium) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hymovis ® (hyaluronan or derivative) |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthovisc® (hyaluronate sodium) |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Monovisc® (hyaluronan or derivative) |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
New / Changed in 2020: |
|
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
Restricted to Preferred Facilities: |
|
Service Code: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Autologous cultured chondrocytes, implant |
Restricted to Preferred Facilities: |
|
Service Code: |
J7330 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Autologous cultured chondrocyte (MACI) |
Autologous cultured chondrocytes, implant |
J7330 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Aminolevulinic acid, 10% gel |
Restricted to Preferred Facilities: |
|
Service Code: |
J7345 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ameluz (aminolevulinic acid) |
Aminolevulinic acid, 10% gel |
J7345 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J7686 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Remodulin® (treprostinil) |
Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg |
J7686 |
New / Changed in 2020: |
|
Service Description: |
Injection, asparaginase (erwinaze), 1,000 iu |
Restricted to Preferred Facilities: |
|
Service Code: |
J9019 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Erwinaze® (asparaginase) |
Injection, asparaginase (erwinaze), 1,000 iu |
J9019 |
New / Changed in 2020: |
|
Service Description: |
Injection, avelumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9023 |
Service Code Type: |
HCPCS |
Effective Date: |
8/15/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bavencio (avelumab) |
Injection, avelumab, 10 mg |
J9023 |
New / Changed in 2020: |
|
Service Description: |
Injection, clofarabine, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9027 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Clolar® (clofarabine) |
Injection, clofarabine, 1 mg |
J9027 |
New / Changed in 2020: |
|
Service Description: |
Injection, belinostat, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9032 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Beleodaq® (belinostat) |
Injection, belinostat, 10 mg |
J9032 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, bendamustine hcl, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9033 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Treanda (bendamustine) |
Injection, bendamustine hcl, 1 mg |
J9033 |
New / Changed in 2020: |
|
Service Description: |
Injection, blinatumomab, 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
J9039 |
Service Code Type: |
HCPCS |
Effective Date: |
5/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Blincyto® (blintatumomab) |
Injection, blinatumomab, 1 microgram |
J9039 |
New / Changed in 2020: |
|
Service Description: |
Injection, bortezomib, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9041 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2004 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 23 |
|
Velcade® (bortezomib) |
Injection, bortezomib, 0.1 mg |
J9041 |
New / Changed in 2020: |
|
Service Description: |
Injection, brentuximab vedotin, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9042 |
Service Code Type: |
HCPCS |
Effective Date: |
4/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Adcetris (brentuximab vedotin) |
Injection, brentuximab vedotin, 1 mg |
J9042 |
New / Changed in 2020: |
|
Service Description: |
Injection, cabazitaxel, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9043 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Jevtana® (cabazitaxel) |
Injection, cabazitaxel, 1 mg |
J9043 |
New / Changed in 2020: |
|
Service Description: |
Injection, carfilzomib, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9047 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Kyprolis® (carfilzomib) |
Injection, carfilzomib, 1 mg |
J9047 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, cetuximab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9055 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Erbitux (cetuximab) |
Injection, cetuximab, 10 mg |
J9055 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, copanlisib, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9057 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Aliqopa (copanlisib) |
Injection, copanlisib, 1 mg |
J9057 |
New / Changed in 2020: |
|
Service Description: |
Injection, daratumumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9145 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Darzalex™ (daratumumab) |
Injection, daratumumab, 10 mg |
J9145 |
New / Changed in 2020: |
|
Service Description: |
Injection, denileukin diftitox, 300 micrograms |
Restricted to Preferred Facilities: |
|
Service Code: |
J9160 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2004 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ontak® (denileukin diftitox) |
Injection, denileukin diftitox, 300 micrograms |
J9160 |
New / Changed in 2020: |
|
Service Description: |
Injection, elotuzumab, 1mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9176 |
Service Code Type: |
HCPCS |
Effective Date: |
4/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Empliciti™ (elotuzumab) |
Injection, elotuzumab, 1mg |
J9176 |
New / Changed in 2020: |
|
Service Description: |
Injection, eribulin mesylate, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9179 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Halaven - T™ (eribulin mesylate) |
Injection, eribulin mesylate, 0.1 mg |
J9179 |
New / Changed in 2020: |
|
Service Description: |
Injection, irinotecan liposome, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9205 |
Service Code Type: |
HCPCS |
Effective Date: |
4/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Onivyde™ (irinotecan liposome) |
Injection, irinotecan liposome, 1 mg |
J9205 |
New / Changed in 2020: |
|
Service Description: |
Injection, ixabepilone, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9207 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2008 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ixempra™ (ixabepilone) |
Injection, ixabepilone, 1 mg |
J9207 |
New / Changed in 2020: |
|
Service Description: |
Leuprolide acetate (for depot suspension), 7.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9217 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Leuprolide acetate (for depot suspension), 7.5 mg |
J9217 |
New / Changed in 2020: |
|
Service Description: |
Leuprolide acetate, per 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9218 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Leuprolide acetate, per 1 mg |
J9218 |
New / Changed in 2020: |
|
Service Description: |
Leuprolide acetate implant, 65 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9219 |
Service Code Type: |
HCPCS |
Effective Date: |
7/18/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gender Dysphoria and Gender Confirmation Treatment |
Leuprolide acetate implant, 65 mg |
J9219 |
New / Changed in 2020: |
|
Service Description: |
Histrelin implant (supprelin la), 50 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9226 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Supprelin® LA (histrelin acetate implant) |
Histrelin implant (supprelin la), 50 mg |
J9226 |
New / Changed in 2020: |
|
Service Description: |
Injection, ipilimumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9228 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 91.0 |
|
Yervoy™ (ipilimumab) |
Injection, ipilimumab, 1 mg |
J9228 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, inotuzumab ozogamicin, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9229 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Besponsa |
Injection, inotuzumab ozogamicin, 0.1 mg |
J9229 |
New / Changed in 2020: |
|
Service Description: |
Injection, nelarabine, 50 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9261 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Arranon® (nelarabine) |
Injection, nelarabine, 50 mg |
J9261 |
New / Changed in 2020: |
|
Service Description: |
Injection, omacetaxine mepesuccinate, 0.01 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9262 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Synribo™ (omacetaxine mepesuccinate) |
Injection, omacetaxine mepesuccinate, 0.01 mg |
J9262 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, oxaliplatin, 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9263 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Eloxatin (oxaliplatin) |
Injection, oxaliplatin, 0.5 mg |
J9263 |
New / Changed in 2020: |
|
Service Description: |
Injection, paclitaxel protein-bound particles, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9264 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2006 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Abraxane® (paclitaxel protein-bound particles) |
Injection, paclitaxel protein-bound particles, 1 mg |
J9264 |
New / Changed in 2020: |
|
Service Description: |
Injection, pembrolizumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9271 |
Service Code Type: |
HCPCS |
Effective Date: |
11/21/2017 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Keytruda® (pembrolizumab) |
Injection, pembrolizumab, 1 mg |
J9271 |
New / Changed in 2020: |
|
Service Description: |
Injection, necitumumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9295 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Portrazza™ (necitumumab) |
Injection, necitumumab, 1 mg |
J9295 |
New / Changed in 2020: |
|
Service Description: |
Injection, nivolumab, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9299 |
Service Code Type: |
HCPCS |
Effective Date: |
5/15/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Opdivo® (nivolumab) |
Injection, nivolumab, 1 mg |
J9299 |
New / Changed in 2020: |
|
Service Description: |
Injection, obinutuzumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9301 |
Service Code Type: |
HCPCS |
Effective Date: |
2/20/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Gazyva™ (obinutuzumab) |
Injection, obinutuzumab, 10 mg |
J9301 |
New / Changed in 2020: |
|
Service Description: |
Injection, ofatumumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9302 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2010 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Arzerra™ (ofatumumab) |
Injection, ofatumumab, 10 mg |
J9302 |
New / Changed in 2020: |
|
Service Description: |
Injection, panitumumab, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9303 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 50.0 |
|
Vectibix® (panitumumab) |
Injection, panitumumab, 10 mg |
J9303 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, pemetrexed, 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9305 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Amilta (pemetrexed) |
Injection, pemetrexed, 10 mg |
J9305 |
New / Changed in 2020: |
|
Service Description: |
Injection, ramucirumab, 5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9308 |
Service Code Type: |
HCPCS |
Effective Date: |
12/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Cyramza® (ramucirumab) |
Injection, ramucirumab, 5 mg |
J9308 |
New / Changed in 2020: |
|
Service Description: |
Injection, romidepsin, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9315 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2010 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Istodax® (romidepsin) |
Injection, romidepsin, 1 mg |
J9315 |
New / Changed in 2020: |
|
Service Description: |
Injection, talimogene laherparepvec, per 1 million plaque forming units |
Restricted to Preferred Facilities: |
|
Service Code: |
J9325 |
Service Code Type: |
HCPCS |
Effective Date: |
4/15/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Imlygic™ (talimogene laherparepvec) |
Injection, talimogene laherparepvec, per 1 million plaque forming units |
J9325 |
New / Changed in 2020: |
|
Service Description: |
Injection, temsirolimus, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9330 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Torisel™ (temsirolimus) |
Injection, temsirolimus, 1 mg |
J9330 |
New / Changed in 2020: |
|
Service Description: |
Injection, trabectedin, 0.1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9352 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 137.0 |
|
Yondelis® (trabectedin) |
Injection, trabectedin, 0.1 mg |
J9352 |
New / Changed in 2020: |
|
Service Description: |
Injection, ado-trastuzumab emtansine, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9354 |
Service Code Type: |
HCPCS |
Effective Date: |
9/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Kadcyla® (abo-trastuzumab emtansine) |
Injection, ado-trastuzumab emtansine, 1 mg |
J9354 |
New / Changed in 2020: |
|
Service Description: |
Injection, vincristine sulfate liposome, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9371 |
Service Code Type: |
HCPCS |
Effective Date: |
11/1/2014 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Marqibo® (vincristine sulfate liposome injection) |
Injection, vincristine sulfate liposome, 1 mg |
J9371 |
New / Changed in 2020: |
|
Service Description: |
Injection, ziv-aflibercept, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
J9400 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 101.0 |
|
Zaltrap® (ziv-aflibercept) |
Injection, ziv-aflibercept, 1 mg |
J9400 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Polivy (polatuzumab vedotin-piiq) |
Not otherwise classified, antineoplastic drugs |
J9999 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Revcovi (elapegademase-lvlr) |
Not otherwise classified, antineoplastic drugs |
J9999 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Xerava (eravacycline) |
Not otherwise classified, antineoplastic drugs |
J9999 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
K0672 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each |
K0672 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0813 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
K0813 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0814 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
K0814 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0815 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
K0815 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0816 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0816 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0820 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0820 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0821 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
K0821 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0822 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0822 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0823 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0823 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0824 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0824 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0825 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds |
K0825 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0826 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0826 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0826 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0826 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0827 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
K0827 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0828 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0828 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0829 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 pounds or more |
K0829 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0830 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0830 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0831 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds |
K0831 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0835 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0835 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0836 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
K0836 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0837 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0837 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0838 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds |
K0838 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0839 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0839 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0840 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0840 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0841 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0841 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0842 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds |
K0842 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0843 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0843 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0848 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0848 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0849 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0849 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0850 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0850 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0851 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds |
K0851 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0852 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0852 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0853 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
K0853 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0854 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0854 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0855 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more |
K0855 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0856 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0856 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0857 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
K0857 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0858 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds |
K0858 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0859 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds |
K0859 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0860 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0860 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0861 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0861 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0862 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0862 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0863 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0863 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
Restricted to Preferred Facilities: |
|
Service Code: |
K0864 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0864 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0868 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0868 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0869 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0869 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0870 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0870 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0871 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0871 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0877 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0877 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0878 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
K0878 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0879 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0879 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0880 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds |
K0880 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0884 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0884 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0885 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds |
K0885 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0886 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0886 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0890 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
K0890 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
Restricted to Preferred Facilities: |
|
Service Code: |
K0891 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
K0891 |
New / Changed in 2020: |
|
Service Description: |
Power wheelchair, not otherwise classified |
Restricted to Preferred Facilities: |
|
Service Code: |
K0898 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Power Wheelchair |
Power wheelchair, not otherwise classified |
K0898 |
New / Changed in 2020: |
|
Service Description: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L0112 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
L0112 |
New / Changed in 2020: |
|
Service Description: |
Thoracic, rib belt, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L0220 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Thoracic, rib belt, custom fabricated |
L0220 |
New / Changed in 2020: |
|
Service Description: |
Tlso, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and clo |
Restricted to Preferred Facilities: |
|
Service Code: |
L0452 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tlso, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and clo |
L0452 |
New / Changed in 2020: |
|
Service Description: |
Tlso, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapul |
Restricted to Preferred Facilities: |
|
Service Code: |
L0480 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tlso, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapul |
L0480 |
New / Changed in 2020: |
|
Service Description: |
Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine |
Restricted to Preferred Facilities: |
|
Service Code: |
L0482 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine |
L0482 |
New / Changed in 2020: |
|
Service Description: |
Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapul |
Restricted to Preferred Facilities: |
|
Service Code: |
L0484 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapul |
L0484 |
New / Changed in 2020: |
|
Service Description: |
Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine |
Restricted to Preferred Facilities: |
|
Service Code: |
L0486 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine |
L0486 |
New / Changed in 2020: |
|
Service Description: |
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L0622 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated |
L0622 |
New / Changed in 2020: |
|
Service Description: |
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may inclu |
Restricted to Preferred Facilities: |
|
Service Code: |
L0624 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may inclu |
L0624 |
New / Changed in 2020: |
|
Service Description: |
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral di |
Restricted to Preferred Facilities: |
|
Service Code: |
L0629 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral di |
L0629 |
New / Changed in 2020: |
|
Service Description: |
Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on th |
Restricted to Preferred Facilities: |
|
Service Code: |
L0632 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on th |
L0632 |
New / Changed in 2020: |
|
Service Description: |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/ |
Restricted to Preferred Facilities: |
|
Service Code: |
L0634 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/ |
L0634 |
New / Changed in 2020: |
|
Service Description: |
Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to |
Restricted to Preferred Facilities: |
|
Service Code: |
L0636 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to |
L0636 |
New / Changed in 2020: |
|
Service Description: |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lat |
Restricted to Preferred Facilities: |
|
Service Code: |
L0638 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lat |
L0638 |
New / Changed in 2020: |
|
Service Description: |
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces in |
Restricted to Preferred Facilities: |
|
Service Code: |
L0640 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces in |
L0640 |
New / Changed in 2020: |
|
Service Description: |
Cervical-thoracic-lumbar-sacral-orthoses (ctlso), anterior-posterior-lateral control, molded to patient model, (minerva type) |
Restricted to Preferred Facilities: |
|
Service Code: |
L0700 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Cervical-thoracic-lumbar-sacral-orthoses (ctlso), anterior-posterior-lateral control, molded to patient model, (minerva type) |
L0700 |
New / Changed in 2020: |
|
Service Description: |
Ctlso, anterior-posterior-lateral-control, molded to patient model, with interface material, (minerva type) |
Restricted to Preferred Facilities: |
|
Service Code: |
L0710 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ctlso, anterior-posterior-lateral-control, molded to patient model, with interface material, (minerva type) |
L0710 |
New / Changed in 2020: |
|
Service Description: |
Halo procedure, cervical halo incorporated into jacket vest |
Restricted to Preferred Facilities: |
|
Service Code: |
L0810 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Halo procedure, cervical halo incorporated into jacket vest |
L0810 |
New / Changed in 2020: |
|
Service Description: |
Halo procedure, cervical halo incorporated into plaster body jacket |
Restricted to Preferred Facilities: |
|
Service Code: |
L0820 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Halo procedure, cervical halo incorporated into plaster body jacket |
L0820 |
New / Changed in 2020: |
|
Service Description: |
Halo procedure, cervical halo incorporated into milwaukee type orthosis |
Restricted to Preferred Facilities: |
|
Service Code: |
L0830 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Halo procedure, cervical halo incorporated into milwaukee type orthosis |
L0830 |
New / Changed in 2020: |
|
Service Description: |
Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material |
Restricted to Preferred Facilities: |
|
Service Code: |
L0859 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material |
L0859 |
New / Changed in 2020: |
|
Service Description: |
Addition to halo procedure, replacement liner/interface material |
Restricted to Preferred Facilities: |
|
Service Code: |
L0861 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to halo procedure, replacement liner/interface material |
L0861 |
New / Changed in 2020: |
|
Service Description: |
Cervical-thoracic-lumbar-sacral orthosis (ctlso) (milwaukee), inclusive of furnishing initial orthosis, including model |
Restricted to Preferred Facilities: |
|
Service Code: |
L1000 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Cervical-thoracic-lumbar-sacral orthosis (ctlso) (milwaukee), inclusive of furnishing initial orthosis, including model |
L1000 |
New / Changed in 2020: |
|
Service Description: |
Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L1005 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment |
L1005 |
New / Changed in 2020: |
|
Service Description: |
Addition to cervical-thoracic-lumbar-sacral orthosis (ctlso) or scoliosis orthosis, axilla sling |
Restricted to Preferred Facilities: |
|
Service Code: |
L1010 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to cervical-thoracic-lumbar-sacral orthosis (ctlso) or scoliosis orthosis, axilla sling |
L1010 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, kyphosis pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1020 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, kyphosis pad |
L1020 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, kyphosis pad, floating |
Restricted to Preferred Facilities: |
|
Service Code: |
L1025 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, kyphosis pad, floating |
L1025 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, lumbar bolster pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1030 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, lumbar bolster pad |
L1030 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1040 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad |
L1040 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, sternal pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1050 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, sternal pad |
L1050 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, thoracic pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1060 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, thoracic pad |
L1060 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, trapezius sling |
Restricted to Preferred Facilities: |
|
Service Code: |
L1070 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, trapezius sling |
L1070 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, outrigger |
Restricted to Preferred Facilities: |
|
Service Code: |
L1080 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, outrigger |
L1080 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions |
Restricted to Preferred Facilities: |
|
Service Code: |
L1085 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions |
L1085 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, lumbar sling |
Restricted to Preferred Facilities: |
|
Service Code: |
L1090 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, lumbar sling |
L1090 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather |
Restricted to Preferred Facilities: |
|
Service Code: |
L1100 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather |
L1100 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L1110 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model |
L1110 |
New / Changed in 2020: |
|
Service Description: |
Addition to ctlso, scoliosis orthosis, cover for upright, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L1120 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to ctlso, scoliosis orthosis, cover for upright, each |
L1120 |
New / Changed in 2020: |
|
Service Description: |
Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only |
Restricted to Preferred Facilities: |
|
Service Code: |
L1200 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only |
L1200 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), lateral thoracic extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L1210 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), lateral thoracic extension |
L1210 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), anterior thoracic extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L1220 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), anterior thoracic extension |
L1220 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), milwaukee type superstructure |
Restricted to Preferred Facilities: |
|
Service Code: |
L1230 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), milwaukee type superstructure |
L1230 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), lumbar derotation pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1240 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), lumbar derotation pad |
L1240 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), anterior asis pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1250 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), anterior asis pad |
L1250 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), anterior thoracic derotation pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1260 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), anterior thoracic derotation pad |
L1260 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), abdominal pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1270 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), abdominal pad |
L1270 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), rib gusset (elastic), each |
Restricted to Preferred Facilities: |
|
Service Code: |
L1280 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), rib gusset (elastic), each |
L1280 |
New / Changed in 2020: |
|
Service Description: |
Addition to tlso, (low profile), lateral trochanteric pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L1290 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to tlso, (low profile), lateral trochanteric pad |
L1290 |
New / Changed in 2020: |
|
Service Description: |
Other scoliosis procedure, body jacket molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L1300 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Other scoliosis procedure, body jacket molded to patient model |
L1300 |
New / Changed in 2020: |
|
Service Description: |
Other scoliosis procedure, post-operative body jacket |
Restricted to Preferred Facilities: |
|
Service Code: |
L1310 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Other scoliosis procedure, post-operative body jacket |
L1310 |
New / Changed in 2020: |
|
Service Description: |
Spinal orthosis, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
L1499 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Spinal orthosis, not otherwise specified |
L1499 |
New / Changed in 2020: |
|
Service Description: |
Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1630 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom-fabricated |
L1630 |
New / Changed in 2020: |
|
Service Description: |
Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1640 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom-fabricated |
L1640 |
New / Changed in 2020: |
|
Service Description: |
Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1680 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated |
L1680 |
New / Changed in 2020: |
|
Service Description: |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1685 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
L1685 |
New / Changed in 2020: |
|
Service Description: |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1685 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated |
L1685 |
New / Changed in 2020: |
|
Service Description: |
Legg perthes orthosis, (toronto type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1700 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Legg perthes orthosis, (toronto type), custom-fabricated |
L1700 |
New / Changed in 2020: |
|
Service Description: |
Legg perthes orthosis, (newington type), custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1710 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Legg perthes orthosis, (newington type), custom fabricated |
L1710 |
New / Changed in 2020: |
|
Service Description: |
Legg perthes orthosis, trilateral, (tachdijan type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1720 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Legg perthes orthosis, trilateral, (tachdijan type), custom-fabricated |
L1720 |
New / Changed in 2020: |
|
Service Description: |
Legg perthes orthosis, (scottish rite type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1730 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Legg perthes orthosis, (scottish rite type), custom-fabricated |
L1730 |
New / Changed in 2020: |
|
Service Description: |
Legg perthes orthosis, (patten bottom type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1755 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Legg perthes orthosis, (patten bottom type), custom-fabricated |
L1755 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, without knee joint, rigid, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1834 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, without knee joint, rigid, custom-fabricated |
L1834 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1840 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
L1840 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1840 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
L1840 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, c |
Restricted to Preferred Facilities: |
|
Service Code: |
L1844 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, c |
L1844 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L1846 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment |
L1846 |
New / Changed in 2020: |
|
Service Description: |
Knee orthosis, modification of supracondylar prosthetic socket, custom-fabricated (sk) |
Restricted to Preferred Facilities: |
|
Service Code: |
L1860 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee orthosis, modification of supracondylar prosthetic socket, custom-fabricated (sk) |
L1860 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1900 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom-fabricated |
L1900 |
New / Changed in 2020: |
|
Service Description: |
Ankle orthosis, ankle gauntlet, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1904 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle orthosis, ankle gauntlet, custom-fabricated |
L1904 |
New / Changed in 2020: |
|
Service Description: |
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1907 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
L1907 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1920 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom-fabricated |
L1920 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1980 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom-fabricated |
L1980 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L1990 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom-fabricated |
L1990 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2000 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom-fabricated |
L2000 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2005 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated |
L2005 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), without knee joint, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2010 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), without knee joint, custom-fabricated |
L2010 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'ak' orthosis), custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2020 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'ak' orthosis), custom-fabricated |
L2020 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2030 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom fabricated |
L2030 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2034 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated |
L2034 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2036 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
L2036 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2037 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
L2037 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2038 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated |
L2038 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2040 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated |
L2040 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2050 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom-fabricated |
L2050 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2060 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom-fabricated |
L2060 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2070 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated |
L2070 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2080 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom-fabricated |
L2080 |
New / Changed in 2020: |
|
Service Description: |
Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2090 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom-fabricated |
L2090 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2106 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom-fabricated |
L2106 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2108 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom-fabricated |
L2108 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2126 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom-fabricated |
L2126 |
New / Changed in 2020: |
|
Service Description: |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L2128 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom-fabricated |
L2128 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables |
Restricted to Preferred Facilities: |
|
Service Code: |
L2627 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables |
L2627 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables |
Restricted to Preferred Facilities: |
|
Service Code: |
L2628 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables |
L2628 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert, removable, molded to patient model, spenco, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3001 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert, removable, molded to patient model, spenco, each |
L3001 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert, removable, molded to patient model, plastazote or equal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3002 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert, removable, molded to patient model, plastazote or equal, each |
L3002 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert, removable, molded to patient model, silicone gel, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3003 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert, removable, molded to patient model, silicone gel, each |
L3003 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3020 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each |
L3020 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert, removable, formed to patient foot, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3030 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert, removable, formed to patient foot, each |
L3030 |
New / Changed in 2020: |
|
Service Description: |
Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3031 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each |
L3031 |
New / Changed in 2020: |
|
Service Description: |
Foot, arch support, removable, premolded, longitudinal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3040 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, arch support, removable, premolded, longitudinal, each |
L3040 |
New / Changed in 2020: |
|
Service Description: |
Foot, arch support, removable, premolded, metatarsal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3050 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, arch support, removable, premolded, metatarsal, each |
L3050 |
New / Changed in 2020: |
|
Service Description: |
Foot, arch support, non-removable attached to shoe, longitudinal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3070 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, arch support, non-removable attached to shoe, longitudinal, each |
L3070 |
New / Changed in 2020: |
|
Service Description: |
Foot, arch support, non-removable attached to shoe, metatarsal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3080 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 259 |
|
Orthoses |
Foot, arch support, non-removable attached to shoe, metatarsal, each |
L3080 |
New / Changed in 2020: |
|
Service Description: |
Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3090 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 259 |
|
Orthoses |
Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each |
L3090 |
New / Changed in 2020: |
|
Service Description: |
Foot, abduction rotation bar, including shoes |
Restricted to Preferred Facilities: |
|
Service Code: |
L3140 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 259 |
|
Orthoses |
Foot, abduction rotation bar, including shoes |
L3140 |
New / Changed in 2020: |
|
Service Description: |
Foot, abduction rotatation bar, without shoes |
Restricted to Preferred Facilities: |
|
Service Code: |
L3150 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 259 |
|
Orthoses |
Foot, abduction rotatation bar, without shoes |
L3150 |
New / Changed in 2020: |
|
Service Description: |
Foot, adjustable shoe-styled positioning device |
Restricted to Preferred Facilities: |
|
Service Code: |
L3160 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, adjustable shoe-styled positioning device |
L3160 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, oxford with supinator or pronator, infant |
Restricted to Preferred Facilities: |
|
Service Code: |
L3201 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, oxford with supinator or pronator, infant |
L3201 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, oxford with supinator or pronator, child |
Restricted to Preferred Facilities: |
|
Service Code: |
L3202 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, oxford with supinator or pronator, child |
L3202 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, oxford with supinator or pronator, junior |
Restricted to Preferred Facilities: |
|
Service Code: |
L3203 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 142.0 |
|
Orthoses |
Orthopedic shoe, oxford with supinator or pronator, junior |
L3203 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, hightop with supinator or pronator, infant |
Restricted to Preferred Facilities: |
|
Service Code: |
L3204 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, hightop with supinator or pronator, infant |
L3204 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, hightop with supinator or pronator, child |
Restricted to Preferred Facilities: |
|
Service Code: |
L3206 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, hightop with supinator or pronator, child |
L3206 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, hightop with supinator or pronator, junior |
Restricted to Preferred Facilities: |
|
Service Code: |
L3207 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, hightop with supinator or pronator, junior |
L3207 |
New / Changed in 2020: |
|
Service Description: |
Surgical boot, each, infant |
Restricted to Preferred Facilities: |
|
Service Code: |
L3208 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Surgical boot, each, infant |
L3208 |
New / Changed in 2020: |
|
Service Description: |
Surgical boot, each, child |
Restricted to Preferred Facilities: |
|
Service Code: |
L3209 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Surgical boot, each, child |
L3209 |
New / Changed in 2020: |
|
Service Description: |
Surgical boot, each, junior |
Restricted to Preferred Facilities: |
|
Service Code: |
L3211 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Surgical boot, each, junior |
L3211 |
New / Changed in 2020: |
|
Service Description: |
Benesch boot, pair, infant |
Restricted to Preferred Facilities: |
|
Service Code: |
L3212 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Benesch boot, pair, infant |
L3212 |
New / Changed in 2020: |
|
Service Description: |
Benesch boot, pair, child |
Restricted to Preferred Facilities: |
|
Service Code: |
L3213 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Benesch boot, pair, child |
L3213 |
New / Changed in 2020: |
|
Service Description: |
Benesch boot, pair, junior |
Restricted to Preferred Facilities: |
|
Service Code: |
L3214 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Benesch boot, pair, junior |
L3214 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, ladies shoe, oxford, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3215 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, ladies shoe, oxford, each |
L3215 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, ladies shoe, depth inlay, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3216 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, ladies shoe, depth inlay, each |
L3216 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, ladies shoe, hightop, depth inlay, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3217 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, ladies shoe, hightop, depth inlay, each |
L3217 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, mens shoe, oxford, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3219 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, mens shoe, oxford, each |
L3219 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, mens shoe, depth inlay, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3221 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 143.0 |
|
Orthoses |
Orthopedic footwear, mens shoe, depth inlay, each |
L3221 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, mens shoe, hightop, depth inlay, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3222 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 58.0 |
|
Orthoses |
Orthopedic footwear, mens shoe, hightop, depth inlay, each |
L3222 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) |
Restricted to Preferred Facilities: |
|
Service Code: |
L3224 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) |
L3224 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) |
Restricted to Preferred Facilities: |
|
Service Code: |
L3225 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) |
L3225 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, custom shoe, depth inlay, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3230 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, custom shoe, depth inlay, each |
L3230 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3250 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each |
L3250 |
New / Changed in 2020: |
|
Service Description: |
Foot, shoe molded to patient model, silicone shoe, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3251 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, shoe molded to patient model, silicone shoe, each |
L3251 |
New / Changed in 2020: |
|
Service Description: |
Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3252 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each |
L3252 |
New / Changed in 2020: |
|
Service Description: |
Foot, molded shoe plastazote (or similar) custom fitted, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3253 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Foot, molded shoe plastazote (or similar) custom fitted, each |
L3253 |
New / Changed in 2020: |
|
Service Description: |
Non-standard size or width |
Restricted to Preferred Facilities: |
|
Service Code: |
L3254 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Non-standard size or width |
L3254 |
New / Changed in 2020: |
|
Service Description: |
Non-standard size or length |
Restricted to Preferred Facilities: |
|
Service Code: |
L3255 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 4 |
|
Orthoses |
Non-standard size or length |
L3255 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic footwear, additional charge for split size |
Restricted to Preferred Facilities: |
|
Service Code: |
L3257 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 146.0 |
|
Orthoses |
Orthopedic footwear, additional charge for split size |
L3257 |
New / Changed in 2020: |
|
Service Description: |
Surgical boot/shoe, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3260 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2018 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Orthoses |
Surgical boot/shoe, each |
L3260 |
New / Changed in 2020: |
|
Service Description: |
Plastazote sandal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3265 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 49.0 |
|
Orthoses |
Plastazote sandal, each |
L3265 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, heel, tapered to metatarsals, per inch |
Restricted to Preferred Facilities: |
|
Service Code: |
L3300 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 43 |
|
Orthoses |
Lift, elevation, heel, tapered to metatarsals, per inch |
L3300 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, heel and sole, neoprene, per inch |
Restricted to Preferred Facilities: |
|
Service Code: |
L3310 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 81.0 |
|
Orthoses |
Lift, elevation, heel and sole, neoprene, per inch |
L3310 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, heel and sole, cork, per inch |
Restricted to Preferred Facilities: |
|
Service Code: |
L3320 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lift, elevation, heel and sole, cork, per inch |
L3320 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, metal extension (skate) |
Restricted to Preferred Facilities: |
|
Service Code: |
L3330 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lift, elevation, metal extension (skate) |
L3330 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, inside shoe, tapered, up to one-half inch |
Restricted to Preferred Facilities: |
|
Service Code: |
L3332 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lift, elevation, inside shoe, tapered, up to one-half inch |
L3332 |
New / Changed in 2020: |
|
Service Description: |
Lift, elevation, heel, per inch |
Restricted to Preferred Facilities: |
|
Service Code: |
L3334 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Lift, elevation, heel, per inch |
L3334 |
New / Changed in 2020: |
|
Service Description: |
Heel wedge, sach |
Restricted to Preferred Facilities: |
|
Service Code: |
L3340 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel wedge, sach |
L3340 |
New / Changed in 2020: |
|
Service Description: |
Heel wedge |
Restricted to Preferred Facilities: |
|
Service Code: |
L3350 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel wedge |
L3350 |
New / Changed in 2020: |
|
Service Description: |
Sole wedge, outside sole |
Restricted to Preferred Facilities: |
|
Service Code: |
L3360 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Sole wedge, outside sole |
L3360 |
New / Changed in 2020: |
|
Service Description: |
Sole wedge, between sole |
Restricted to Preferred Facilities: |
|
Service Code: |
L3370 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Sole wedge, between sole |
L3370 |
New / Changed in 2020: |
|
Service Description: |
Clubfoot wedge |
Restricted to Preferred Facilities: |
|
Service Code: |
L3380 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Clubfoot wedge |
L3380 |
New / Changed in 2020: |
|
Service Description: |
Outflare wedge |
Restricted to Preferred Facilities: |
|
Service Code: |
L3390 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Outflare wedge |
L3390 |
New / Changed in 2020: |
|
Service Description: |
Metatarsal bar wedge, rocker |
Restricted to Preferred Facilities: |
|
Service Code: |
L3400 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Metatarsal bar wedge, rocker |
L3400 |
New / Changed in 2020: |
|
Service Description: |
Metatarsal bar wedge, between sole |
Restricted to Preferred Facilities: |
|
Service Code: |
L3410 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Metatarsal bar wedge, between sole |
L3410 |
New / Changed in 2020: |
|
Service Description: |
Full sole and heel wedge, between sole |
Restricted to Preferred Facilities: |
|
Service Code: |
L3420 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Full sole and heel wedge, between sole |
L3420 |
New / Changed in 2020: |
|
Service Description: |
Heel, counter, plastic reinforced |
Restricted to Preferred Facilities: |
|
Service Code: |
L3430 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, counter, plastic reinforced |
L3430 |
New / Changed in 2020: |
|
Service Description: |
Heel, counter, leather reinforced |
Restricted to Preferred Facilities: |
|
Service Code: |
L3440 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, counter, leather reinforced |
L3440 |
New / Changed in 2020: |
|
Service Description: |
Heel, sach cushion type |
Restricted to Preferred Facilities: |
|
Service Code: |
L3450 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, sach cushion type |
L3450 |
New / Changed in 2020: |
|
Service Description: |
Heel, sach cushion type |
Restricted to Preferred Facilities: |
|
Service Code: |
L3450 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, sach cushion type |
L3450 |
New / Changed in 2020: |
|
Service Description: |
Heel, new leather, standard |
Restricted to Preferred Facilities: |
|
Service Code: |
L3455 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, new leather, standard |
L3455 |
New / Changed in 2020: |
|
Service Description: |
Heel, new rubber, standard |
Restricted to Preferred Facilities: |
|
Service Code: |
L3460 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, new rubber, standard |
L3460 |
New / Changed in 2020: |
|
Service Description: |
Heel, thomas with wedge |
Restricted to Preferred Facilities: |
|
Service Code: |
L3465 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, thomas with wedge |
L3465 |
New / Changed in 2020: |
|
Service Description: |
Heel, thomas extended to ball |
Restricted to Preferred Facilities: |
|
Service Code: |
L3470 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, thomas extended to ball |
L3470 |
New / Changed in 2020: |
|
Service Description: |
Heel, pad and depression for spur |
Restricted to Preferred Facilities: |
|
Service Code: |
L3480 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, pad and depression for spur |
L3480 |
New / Changed in 2020: |
|
Service Description: |
Heel, pad, removable for spur |
Restricted to Preferred Facilities: |
|
Service Code: |
L3485 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Heel, pad, removable for spur |
L3485 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, insole, leather |
Restricted to Preferred Facilities: |
|
Service Code: |
L3500 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, insole, leather |
L3500 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, insole, rubber |
Restricted to Preferred Facilities: |
|
Service Code: |
L3510 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, insole, rubber |
L3510 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, insole, felt covered with leather |
Restricted to Preferred Facilities: |
|
Service Code: |
L3520 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, insole, felt covered with leather |
L3520 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, sole, half |
Restricted to Preferred Facilities: |
|
Service Code: |
L3530 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, sole, half |
L3530 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, sole, full |
Restricted to Preferred Facilities: |
|
Service Code: |
L3540 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, sole, full |
L3540 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, toe tap standard |
Restricted to Preferred Facilities: |
|
Service Code: |
L3550 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, toe tap standard |
L3550 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, toe tap, horseshoe |
Restricted to Preferred Facilities: |
|
Service Code: |
L3560 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, toe tap, horseshoe |
L3560 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, special extension to instep (leather with eyelets) |
Restricted to Preferred Facilities: |
|
Service Code: |
L3570 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, special extension to instep (leather with eyelets) |
L3570 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, convert instep to velcro closure |
Restricted to Preferred Facilities: |
|
Service Code: |
L3580 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, convert instep to velcro closure |
L3580 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, convert firm shoe counter to soft counter |
Restricted to Preferred Facilities: |
|
Service Code: |
L3590 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, convert firm shoe counter to soft counter |
L3590 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe addition, march bar |
Restricted to Preferred Facilities: |
|
Service Code: |
L3595 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe addition, march bar |
L3595 |
New / Changed in 2020: |
|
Service Description: |
Transfer of an orthosis from one shoe to another, caliper plate, existing |
Restricted to Preferred Facilities: |
|
Service Code: |
L3600 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Transfer of an orthosis from one shoe to another, caliper plate, existing |
L3600 |
New / Changed in 2020: |
|
Service Description: |
Transfer of an orthosis from one shoe to another, caliper plate, new |
Restricted to Preferred Facilities: |
|
Service Code: |
L3610 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Transfer of an orthosis from one shoe to another, caliper plate, new |
L3610 |
New / Changed in 2020: |
|
Service Description: |
Transfer of an orthosis from one shoe to another, solid stirrup, existing |
Restricted to Preferred Facilities: |
|
Service Code: |
L3620 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Transfer of an orthosis from one shoe to another, solid stirrup, existing |
L3620 |
New / Changed in 2020: |
|
Service Description: |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
Restricted to Preferred Facilities: |
|
Service Code: |
L3630 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
L3630 |
New / Changed in 2020: |
|
Service Description: |
Transfer of an orthosis from one shoe to another, dennis browne splint (riveton), both shoes |
Restricted to Preferred Facilities: |
|
Service Code: |
L3640 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Transfer of an orthosis from one shoe to another, dennis browne splint (riveton), both shoes |
L3640 |
New / Changed in 2020: |
|
Service Description: |
Orthopedic shoe, modification, addition or transfer, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
L3649 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Orthopedic shoe, modification, addition or transfer, not otherwise specified |
L3649 |
New / Changed in 2020: |
|
Service Description: |
Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3671 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3671 |
New / Changed in 2020: |
|
Service Description: |
Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, incl |
Restricted to Preferred Facilities: |
|
Service Code: |
L3674 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, incl |
L3674 |
New / Changed in 2020: |
|
Service Description: |
Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3702 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3702 |
New / Changed in 2020: |
|
Service Description: |
Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3720 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom-fabricated |
L3720 |
New / Changed in 2020: |
|
Service Description: |
Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3730 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom-fabricated |
L3730 |
New / Changed in 2020: |
|
Service Description: |
Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3740 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control, custom-fabricated |
L3740 |
New / Changed in 2020: |
|
Service Description: |
Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3763 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3763 |
New / Changed in 2020: |
|
Service Description: |
Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3764 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3764 |
New / Changed in 2020: |
|
Service Description: |
Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3765 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3765 |
New / Changed in 2020: |
|
Service Description: |
Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3766 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3766 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustmen |
Restricted to Preferred Facilities: |
|
Service Code: |
L3806 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustmen |
L3806 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3808 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment |
L3808 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3891 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each |
L3891 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3900 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom-fabricated |
L3900 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3901 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom-fabricated |
L3901 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand finger orthosis, external powered, electric, custom-fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L3904 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand finger orthosis, external powered, electric, custom-fabricated |
L3904 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3905 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3905 |
New / Changed in 2020: |
|
Service Description: |
Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3906 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3906 |
New / Changed in 2020: |
|
Service Description: |
Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3913 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3913 |
New / Changed in 2020: |
|
Service Description: |
Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3919 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3919 |
New / Changed in 2020: |
|
Service Description: |
Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3921 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3921 |
New / Changed in 2020: |
|
Service Description: |
Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3933 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment |
L3933 |
New / Changed in 2020: |
|
Service Description: |
Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3935 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment |
L3935 |
New / Changed in 2020: |
|
Service Description: |
Addition of joint to upper extremity orthosis, any material; per joint |
Restricted to Preferred Facilities: |
|
Service Code: |
L3956 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition of joint to upper extremity orthosis, any material; per joint |
L3956 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3961 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3961 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting |
Restricted to Preferred Facilities: |
|
Service Code: |
L3967 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting |
L3967 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and |
Restricted to Preferred Facilities: |
|
Service Code: |
L3971 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and |
L3971 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft in |
Restricted to Preferred Facilities: |
|
Service Code: |
L3973 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft in |
L3973 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L3975 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
L3975 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes |
Restricted to Preferred Facilities: |
|
Service Code: |
L3976 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes |
L3976 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitt |
Restricted to Preferred Facilities: |
|
Service Code: |
L3977 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitt |
L3977 |
New / Changed in 2020: |
|
Service Description: |
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include |
Restricted to Preferred Facilities: |
|
Service Code: |
L3978 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include |
L3978 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity orthosis, sock, fracture or equal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L3995 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Addition to upper extremity orthosis, sock, fracture or equal, each |
L3995 |
New / Changed in 2020: |
|
Service Description: |
Replace girdle for spinal orthosis (ctlso or so) |
Restricted to Preferred Facilities: |
|
Service Code: |
L4000 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Replace girdle for spinal orthosis (ctlso or so) |
L4000 |
New / Changed in 2020: |
|
Service Description: |
Replacement strap, any orthosis, includes all components, any length, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L4002 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Replacement strap, any orthosis, includes all components, any length, any type |
L4002 |
New / Changed in 2020: |
|
Service Description: |
Repair of orthotic device, labor component, per 15 minutes |
Restricted to Preferred Facilities: |
|
Service Code: |
L4205 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Repair of orthotic device, labor component, per 15 minutes |
L4205 |
New / Changed in 2020: |
|
Service Description: |
Repair of orthotic device, repair or replace minor parts |
Restricted to Preferred Facilities: |
|
Service Code: |
L4210 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Repair of orthotic device, repair or replace minor parts |
L4210 |
New / Changed in 2020: |
|
Service Description: |
Repair of orthotic device, repair or replace minor parts |
Restricted to Preferred Facilities: |
|
Service Code: |
L4210 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Repair of orthotic device, repair or replace minor parts |
L4210 |
New / Changed in 2020: |
|
Service Description: |
Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, cus |
Restricted to Preferred Facilities: |
|
Service Code: |
L4631 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Orthoses |
Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, cus |
L4631 |
New / Changed in 2020: |
|
Service Description: |
Partial foot, shoe insert with longitudinal arch, toe filler |
Restricted to Preferred Facilities: |
|
Service Code: |
L5000 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial foot, shoe insert with longitudinal arch, toe filler |
L5000 |
New / Changed in 2020: |
|
Service Description: |
Partial foot, molded socket, ankle height, with toe filler |
Restricted to Preferred Facilities: |
|
Service Code: |
L5010 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial foot, molded socket, ankle height, with toe filler |
L5010 |
New / Changed in 2020: |
|
Service Description: |
Partial foot, molded socket, tibial tubercle height, with toe filler |
Restricted to Preferred Facilities: |
|
Service Code: |
L5020 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial foot, molded socket, tibial tubercle height, with toe filler |
L5020 |
New / Changed in 2020: |
|
Service Description: |
Ankle, symes, molded socket, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5050 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Ankle, symes, molded socket, sach foot |
L5050 |
New / Changed in 2020: |
|
Service Description: |
Ankle, symes, metal frame, molded leather socket, articulated ankle/foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5060 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Ankle, symes, metal frame, molded leather socket, articulated ankle/foot |
L5060 |
New / Changed in 2020: |
|
Service Description: |
Below knee, molded socket, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5100 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below knee, molded socket, shin, sach foot |
L5100 |
New / Changed in 2020: |
|
Service Description: |
Below knee, plastic socket, joints and thigh lacer, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5105 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below knee, plastic socket, joints and thigh lacer, sach foot |
L5105 |
New / Changed in 2020: |
|
Service Description: |
Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5150 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot |
L5150 |
New / Changed in 2020: |
|
Service Description: |
Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5160 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot |
L5160 |
New / Changed in 2020: |
|
Service Description: |
Above knee, molded socket, single axis constant friction knee, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5200 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above knee, molded socket, single axis constant friction knee, shin, sach foot |
L5200 |
New / Changed in 2020: |
|
Service Description: |
Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no ankle joints, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L5210 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no ankle joints, each |
L5210 |
New / Changed in 2020: |
|
Service Description: |
Above knee, short prosthesis, no knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L5220 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above knee, short prosthesis, no knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each |
L5220 |
New / Changed in 2020: |
|
Service Description: |
Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5230 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot |
L5230 |
New / Changed in 2020: |
|
Service Description: |
Hip disarticulation, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5250 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hip disarticulation, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
L5250 |
New / Changed in 2020: |
|
Service Description: |
Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5270 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot |
L5270 |
New / Changed in 2020: |
|
Service Description: |
Hemipelvectomy, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5280 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hemipelvectomy, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot |
L5280 |
New / Changed in 2020: |
|
Service Description: |
Below knee, molded socket, shin, sach foot, endoskeletal system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5301 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below knee, molded socket, shin, sach foot, endoskeletal system |
L5301 |
New / Changed in 2020: |
|
Service Description: |
Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5312 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system |
L5312 |
New / Changed in 2020: |
|
Service Description: |
Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5321 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee |
L5321 |
New / Changed in 2020: |
|
Service Description: |
Hip disarticulation, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5331 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hip disarticulation, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
L5331 |
New / Changed in 2020: |
|
Service Description: |
Hemipelvectomy, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5341 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hemipelvectomy, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot |
L5341 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5400 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee |
L5400 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment |
Restricted to Preferred Facilities: |
|
Service Code: |
L5410 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment |
L5410 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change 'ak' or knee disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L5420 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change 'ak' or knee disarticulation |
L5420 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing, incl. fitting, alignment and supension, 'ak' or knee disarticulation, each additional cast change and realignment |
Restricted to Preferred Facilities: |
|
Service Code: |
L5430 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing, incl. fitting, alignment and supension, 'ak' or knee disarticulation, each additional cast change and realignment |
L5430 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, below knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5450 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, below knee |
L5450 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5460 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee |
L5460 |
New / Changed in 2020: |
|
Service Description: |
Initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed |
Restricted to Preferred Facilities: |
|
Service Code: |
L5500 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Initial, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed |
L5500 |
New / Changed in 2020: |
|
Service Description: |
Initial, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed |
Restricted to Preferred Facilities: |
|
Service Code: |
L5505 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Initial, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, direct formed |
L5505 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5510 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model |
L5510 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed |
Restricted to Preferred Facilities: |
|
Service Code: |
L5520 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed |
L5520 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5530 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model |
L5530 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, prefabricated, adjustable open end socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5535 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, prefabricated, adjustable open end socket |
L5535 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5540 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model |
L5540 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5560 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model |
L5560 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed |
Restricted to Preferred Facilities: |
|
Service Code: |
L5570 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed |
L5570 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5580 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model |
L5580 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5585 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket |
L5585 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5585 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket |
L5585 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5590 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model |
L5590 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5595 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model |
L5595 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5600 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model |
L5600 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, endoskeletal system, above knee, hydracadence system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5610 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, endoskeletal system, above knee, hydracadence system |
L5610 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5611 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control |
L5611 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5613 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control |
L5613 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5614 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control |
L5614 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5616 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control |
L5616 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L5617 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each |
L5617 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, symes |
Restricted to Preferred Facilities: |
|
Service Code: |
L5618 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, symes |
L5618 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, below knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5620 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, below knee |
L5620 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, knee disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L5622 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, knee disarticulation |
L5622 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, above knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5624 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, above knee |
L5624 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, hip disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L5626 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, hip disarticulation |
L5626 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, test socket, hemipelvectomy |
Restricted to Preferred Facilities: |
|
Service Code: |
L5628 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, test socket, hemipelvectomy |
L5628 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, acrylic socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5629 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, acrylic socket |
L5629 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, symes type, expandable wall socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5630 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, symes type, expandable wall socket |
L5630 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee or knee disarticulation, acrylic socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5631 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee or knee disarticulation, acrylic socket |
L5631 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, symes type, 'ptb' brim design socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5632 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, symes type, 'ptb' brim design socket |
L5632 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, symes type, posterior opening (canadian) socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5634 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, symes type, posterior opening (canadian) socket |
L5634 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, symes type, medial opening socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5636 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, symes type, medial opening socket |
L5636 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, total contact |
Restricted to Preferred Facilities: |
|
Service Code: |
L5637 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, total contact |
L5637 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, leather socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5638 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, leather socket |
L5638 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, wood socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5639 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, wood socket |
L5639 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, knee disarticulation, leather socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5640 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, knee disarticulation, leather socket |
L5640 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, leather socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5642 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, leather socket |
L5642 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, hip disarticulation, flexible inner socket, external frame |
Restricted to Preferred Facilities: |
|
Service Code: |
L5643 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, hip disarticulation, flexible inner socket, external frame |
L5643 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, wood socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5644 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, wood socket |
L5644 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, flexible inner socket, external frame |
Restricted to Preferred Facilities: |
|
Service Code: |
L5645 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, flexible inner socket, external frame |
L5645 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5646 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket |
L5646 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee suction socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5647 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee suction socket |
L5647 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5648 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket |
L5648 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, ischial containment/narrow m-l socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5649 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, ischial containment/narrow m-l socket |
L5649 |
New / Changed in 2020: |
|
Service Description: |
Additions to lower extremity, total contact, above knee or knee disarticulation socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5650 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Additions to lower extremity, total contact, above knee or knee disarticulation socket |
L5650 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, flexible inner socket, external frame |
Restricted to Preferred Facilities: |
|
Service Code: |
L5651 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, flexible inner socket, external frame |
L5651 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, suction suspension, above knee or knee disarticulation socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5652 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, suction suspension, above knee or knee disarticulation socket |
L5652 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, knee disarticulation, expandable wall socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L5653 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, knee disarticulation, expandable wall socket |
L5653 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5654 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal) |
L5654 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5655 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal) |
L5655 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5656 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal) |
L5656 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5658 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal) |
L5658 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, multi-durometer symes |
Restricted to Preferred Facilities: |
|
Service Code: |
L5661 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, multi-durometer symes |
L5661 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, socket insert, multi-durometer, below knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5665 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, socket insert, multi-durometer, below knee |
L5665 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, cuff suspension |
Restricted to Preferred Facilities: |
|
Service Code: |
L5666 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, cuff suspension |
L5666 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, molded distal cushion |
Restricted to Preferred Facilities: |
|
Service Code: |
L5668 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, molded distal cushion |
L5668 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5670 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar) |
L5670 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert |
Restricted to Preferred Facilities: |
|
Service Code: |
L5671 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert |
L5671 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, removable medial brim suspension |
Restricted to Preferred Facilities: |
|
Service Code: |
L5672 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, removable medial brim suspension |
L5672 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism |
Restricted to Preferred Facilities: |
|
Service Code: |
L5673 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism |
L5673 |
New / Changed in 2020: |
|
Service Description: |
Additions to lower extremity, below knee, knee joints, single axis, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L5676 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Additions to lower extremity, below knee, knee joints, single axis, pair |
L5676 |
New / Changed in 2020: |
|
Service Description: |
Additions to lower extremity, below knee, knee joints, polycentric, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L5677 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Additions to lower extremity, below knee, knee joints, polycentric, pair |
L5677 |
New / Changed in 2020: |
|
Service Description: |
Additions to lower extremity, below knee, joint covers, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L5678 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Additions to lower extremity, below knee, joint covers, pair |
L5678 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
Restricted to Preferred Facilities: |
|
Service Code: |
L5679 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism |
L5679 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, thigh lacer, nonmolded |
Restricted to Preferred Facilities: |
|
Service Code: |
L5680 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, thigh lacer, nonmolded |
L5680 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking me |
Restricted to Preferred Facilities: |
|
Service Code: |
L5681 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking me |
L5681 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded |
Restricted to Preferred Facilities: |
|
Service Code: |
L5682 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded |
L5682 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without |
Restricted to Preferred Facilities: |
|
Service Code: |
L5683 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without |
L5683 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, fork strap |
Restricted to Preferred Facilities: |
|
Service Code: |
L5684 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, fork strap |
L5684 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L5685 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each |
L5685 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, back check (extension control) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5686 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, back check (extension control) |
L5686 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, waist belt, webbing |
Restricted to Preferred Facilities: |
|
Service Code: |
L5688 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, waist belt, webbing |
L5688 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, below knee, waist belt, padded and lined |
Restricted to Preferred Facilities: |
|
Service Code: |
L5690 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, below knee, waist belt, padded and lined |
L5690 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, pelvic control belt, light |
Restricted to Preferred Facilities: |
|
Service Code: |
L5692 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, pelvic control belt, light |
L5692 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, pelvic control belt, padded and lined |
Restricted to Preferred Facilities: |
|
Service Code: |
L5694 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, pelvic control belt, padded and lined |
L5694 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L5695 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each |
L5695 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee or knee disarticulation, pelvic joint |
Restricted to Preferred Facilities: |
|
Service Code: |
L5696 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee or knee disarticulation, pelvic joint |
L5696 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee or knee disarticulation, pelvic band |
Restricted to Preferred Facilities: |
|
Service Code: |
L5697 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee or knee disarticulation, pelvic band |
L5697 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity, above knee or knee disarticulation, silesian bandage |
Restricted to Preferred Facilities: |
|
Service Code: |
L5698 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity, above knee or knee disarticulation, silesian bandage |
L5698 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, shoulder harness |
Restricted to Preferred Facilities: |
|
Service Code: |
L5699 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, shoulder harness |
L5699 |
New / Changed in 2020: |
|
Service Description: |
Replacement, socket, below knee, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5700 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement, socket, below knee, molded to patient model |
L5700 |
New / Changed in 2020: |
|
Service Description: |
Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5701 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model |
L5701 |
New / Changed in 2020: |
|
Service Description: |
Replacement, socket, hip disarticulation, including hip joint, molded to patient model |
Restricted to Preferred Facilities: |
|
Service Code: |
L5702 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement, socket, hip disarticulation, including hip joint, molded to patient model |
L5702 |
New / Changed in 2020: |
|
Service Description: |
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach) foot, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
L5703 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach) foot, replacement only |
L5703 |
New / Changed in 2020: |
|
Service Description: |
Custom shaped protective cover, below knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5704 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Custom shaped protective cover, below knee |
L5704 |
New / Changed in 2020: |
|
Service Description: |
Custom shaped protective cover, above knee |
Restricted to Preferred Facilities: |
|
Service Code: |
L5705 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Custom shaped protective cover, above knee |
L5705 |
New / Changed in 2020: |
|
Service Description: |
Custom shaped protective cover, knee disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L5706 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Custom shaped protective cover, knee disarticulation |
L5706 |
New / Changed in 2020: |
|
Service Description: |
Custom shaped protective cover, hip disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L5707 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Custom shaped protective cover, hip disarticulation |
L5707 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, manual lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5710 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, manual lock |
L5710 |
New / Changed in 2020: |
|
Service Description: |
Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material |
Restricted to Preferred Facilities: |
|
Service Code: |
L5711 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material |
L5711 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5712 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
L5712 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5714 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control |
L5714 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5716 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock |
L5716 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5718 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control |
L5718 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5722 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
L5722 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, fluid swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5724 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, fluid swing phase control |
L5724 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5726 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, external joints fluid swing phase control |
L5726 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5728 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control |
L5728 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5780 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control |
L5780 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5781 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system |
L5781 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty |
Restricted to Preferred Facilities: |
|
Service Code: |
L5782 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty |
L5782 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5785 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
L5785 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5790 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
L5790 |
New / Changed in 2020: |
|
Service Description: |
Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5795 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
L5795 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, manual lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5810 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, manual lock |
L5810 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material |
Restricted to Preferred Facilities: |
|
Service Code: |
L5811 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material |
L5811 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5812 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) |
L5812 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5814 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock |
L5814 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5816 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock |
L5816 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5818 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control |
L5818 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5822 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
L5822 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5822 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control |
L5822 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, fluid swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5824 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, fluid swing phase control |
L5824 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame |
Restricted to Preferred Facilities: |
|
Service Code: |
L5826 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame |
L5826 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5828 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control |
L5828 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee-shin system, single axis, pneumatic/ swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5830 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee-shin system, single axis, pneumatic/ swing phase control |
L5830 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5840 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control |
L5840 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable |
Restricted to Preferred Facilities: |
|
Service Code: |
L5845 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable |
L5845 |
New / Changed in 2020: |
|
Service Description: |
Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability |
Restricted to Preferred Facilities: |
|
Service Code: |
L5848 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability |
L5848 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist |
Restricted to Preferred Facilities: |
|
Service Code: |
L5850 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist |
L5850 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist |
Restricted to Preferred Facilities: |
|
Service Code: |
L5855 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist |
L5855 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L5856 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type |
L5856 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L5857 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type |
L5857 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L5858 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type |
L5858 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5859 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
L5859 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, below knee, alignable system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5910 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, below knee, alignable system |
L5910 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, above knee or hip disarticulation, alignable system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5920 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, above knee or hip disarticulation, alignable system |
L5920 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L5925 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock |
L5925 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, high activity knee control frame |
Restricted to Preferred Facilities: |
|
Service Code: |
L5930 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, high activity knee control frame |
L5930 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5940 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) |
L5940 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5950 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) |
L5950 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5960 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) |
L5960 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control |
Restricted to Preferred Facilities: |
|
Service Code: |
L5961 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control |
L5961 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, below knee, flexible protective outer surface covering system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5962 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, below knee, flexible protective outer surface covering system |
L5962 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, above knee, flexible protective outer surface covering system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5964 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, above knee, flexible protective outer surface covering system |
L5964 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5966 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system |
L5966 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature |
Restricted to Preferred Facilities: |
|
Service Code: |
L5968 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature |
L5968 |
New / Changed in 2020: |
|
Service Description: |
Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5969 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) |
L5969 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, foot, external keel, sach foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5970 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, foot, external keel, sach foot |
L5970 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
L5971 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only |
L5971 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, foot, flexible keel |
Restricted to Preferred Facilities: |
|
Service Code: |
L5972 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, foot, flexible keel |
L5972 |
New / Changed in 2020: |
|
Service Description: |
Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source |
Restricted to Preferred Facilities: |
|
Service Code: |
L5973 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source |
L5973 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, foot, single axis ankle/foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5974 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, foot, single axis ankle/foot |
L5974 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prosthesis, combination single axis ankle and flexible keel foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5975 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prosthesis, combination single axis ankle and flexible keel foot |
L5975 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, energy storing foot (seattle carbon copy ii or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5976 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, energy storing foot (seattle carbon copy ii or equal) |
L5976 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, foot, multiaxial ankle/foot |
Restricted to Preferred Facilities: |
|
Service Code: |
L5978 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, foot, multiaxial ankle/foot |
L5978 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5979 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one piece system |
L5979 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, flex foot system |
Restricted to Preferred Facilities: |
|
Service Code: |
L5980 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, flex foot system |
L5980 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, flex-walk system or equal |
Restricted to Preferred Facilities: |
|
Service Code: |
L5981 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, flex-walk system or equal |
L5981 |
New / Changed in 2020: |
|
Service Description: |
All exoskeletal lower extremity prostheses, axial rotation unit |
Restricted to Preferred Facilities: |
|
Service Code: |
L5982 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All exoskeletal lower extremity prostheses, axial rotation unit |
L5982 |
New / Changed in 2020: |
|
Service Description: |
All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability |
Restricted to Preferred Facilities: |
|
Service Code: |
L5984 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability |
L5984 |
New / Changed in 2020: |
|
Service Description: |
All endoskeletal lower extremity prostheses, dynamic prosthetic pylon |
Restricted to Preferred Facilities: |
|
Service Code: |
L5985 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All endoskeletal lower extremity prostheses, dynamic prosthetic pylon |
L5985 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L5986 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) |
L5986 |
New / Changed in 2020: |
|
Service Description: |
All lower extremity prosthesis, shank foot system with vertical loading pylon |
Restricted to Preferred Facilities: |
|
Service Code: |
L5987 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
All lower extremity prosthesis, shank foot system with vertical loading pylon |
L5987 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower limb prosthesis, vertical shock reducing pylon feature |
Restricted to Preferred Facilities: |
|
Service Code: |
L5988 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower limb prosthesis, vertical shock reducing pylon feature |
L5988 |
New / Changed in 2020: |
|
Service Description: |
Addition to lower extremity prosthesis, user adjustable heel height |
Restricted to Preferred Facilities: |
|
Service Code: |
L5990 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to lower extremity prosthesis, user adjustable heel height |
L5990 |
New / Changed in 2020: |
|
Service Description: |
Lower extremity prosthesis, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
L5999 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Lower extremity prosthesis, not otherwise specified |
L5999 |
New / Changed in 2020: |
|
Service Description: |
Partial hand, thumb remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6000 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial hand, thumb remaining |
L6000 |
New / Changed in 2020: |
|
Service Description: |
Partial hand, little and/or ring finger remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6010 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial hand, little and/or ring finger remaining |
L6010 |
New / Changed in 2020: |
|
Service Description: |
Partial hand, no finger remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6020 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial hand, no finger remaining |
L6020 |
New / Changed in 2020: |
|
Service Description: |
Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr |
Restricted to Preferred Facilities: |
|
Service Code: |
L6026 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr |
L6026 |
New / Changed in 2020: |
|
Service Description: |
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L6050 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad |
L6050 |
New / Changed in 2020: |
|
Service Description: |
Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L6055 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad |
L6055 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, molded socket, flexible elbow hinge, triceps pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L6100 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, molded socket, flexible elbow hinge, triceps pad |
L6100 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, molded socket, (muenster or northwestern suspension types) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6110 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, molded socket, (muenster or northwestern suspension types) |
L6110 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, molded double wall split socket, step-up hinges, half cuff |
Restricted to Preferred Facilities: |
|
Service Code: |
L6120 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, molded double wall split socket, step-up hinges, half cuff |
L6120 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, molded double wall split socket, stump activated locking hinge, half cuff |
Restricted to Preferred Facilities: |
|
Service Code: |
L6130 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, molded double wall split socket, stump activated locking hinge, half cuff |
L6130 |
New / Changed in 2020: |
|
Service Description: |
Elbow disarticulation, molded socket, outside locking hinge, forearm |
Restricted to Preferred Facilities: |
|
Service Code: |
L6200 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Elbow disarticulation, molded socket, outside locking hinge, forearm |
L6200 |
New / Changed in 2020: |
|
Service Description: |
Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm |
Restricted to Preferred Facilities: |
|
Service Code: |
L6205 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm |
L6205 |
New / Changed in 2020: |
|
Service Description: |
Above elbow, molded double wall socket, internal locking elbow, forearm |
Restricted to Preferred Facilities: |
|
Service Code: |
L6250 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above elbow, molded double wall socket, internal locking elbow, forearm |
L6250 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
Restricted to Preferred Facilities: |
|
Service Code: |
L6300 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
L6300 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, passive restoration (complete prosthesis) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6310 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, passive restoration (complete prosthesis) |
L6310 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, passive restoration (shoulder cap only) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6320 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, passive restoration (shoulder cap only) |
L6320 |
New / Changed in 2020: |
|
Service Description: |
Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
Restricted to Preferred Facilities: |
|
Service Code: |
L6350 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm |
L6350 |
New / Changed in 2020: |
|
Service Description: |
Interscapular thoracic, passive restoration (complete prosthesis) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6360 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular thoracic, passive restoration (complete prosthesis) |
L6360 |
New / Changed in 2020: |
|
Service Description: |
Interscapular thoracic, passive restoration (shoulder cap only) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6370 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular thoracic, passive restoration (shoulder cap only) |
L6370 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6380 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow |
L6380 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6382 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow |
L6382 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular |
Restricted to Preferred Facilities: |
|
Service Code: |
L6384 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular |
L6384 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, each additional cast change and realignment |
Restricted to Preferred Facilities: |
|
Service Code: |
L6386 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, each additional cast change and realignment |
L6386 |
New / Changed in 2020: |
|
Service Description: |
Immediate post surgical or early fitting, application of rigid dressing only |
Restricted to Preferred Facilities: |
|
Service Code: |
L6388 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Immediate post surgical or early fitting, application of rigid dressing only |
L6388 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Restricted to Preferred Facilities: |
|
Service Code: |
L6400 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
L6400 |
New / Changed in 2020: |
|
Service Description: |
Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Restricted to Preferred Facilities: |
|
Service Code: |
L6450 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
L6450 |
New / Changed in 2020: |
|
Service Description: |
Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Restricted to Preferred Facilities: |
|
Service Code: |
L6500 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
L6500 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Restricted to Preferred Facilities: |
|
Service Code: |
L6550 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
L6550 |
New / Changed in 2020: |
|
Service Description: |
Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
Restricted to Preferred Facilities: |
|
Service Code: |
L6570 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping |
L6570 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, |
Restricted to Preferred Facilities: |
|
Service Code: |
L6580 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, |
L6580 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover |
Restricted to Preferred Facilities: |
|
Service Code: |
L6582 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover |
L6582 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, molded to |
Restricted to Preferred Facilities: |
|
Service Code: |
L6584 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, molded to |
L6584 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, direct formed |
Restricted to Preferred Facilities: |
|
Service Code: |
L6586 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, direct formed |
L6586 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, n |
Restricted to Preferred Facilities: |
|
Service Code: |
L6588 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, n |
L6588 |
New / Changed in 2020: |
|
Service Description: |
Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, |
Restricted to Preferred Facilities: |
|
Service Code: |
L6590 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, |
L6590 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity additions, polycentric hinge, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L6600 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity additions, polycentric hinge, pair |
L6600 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity additions, single pivot hinge, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L6605 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity additions, single pivot hinge, pair |
L6605 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity additions, flexible metal hinge, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L6610 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity additions, flexible metal hinge, pair |
L6610 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, external powered, additional switch, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L6611 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, external powered, additional switch, any type |
L6611 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, disconnect locking wrist unit |
Restricted to Preferred Facilities: |
|
Service Code: |
L6615 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, disconnect locking wrist unit |
L6615 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, additional disconnect insert for locking wrist unit, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6616 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, additional disconnect insert for locking wrist unit, each |
L6616 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, flexion/extension wrist unit, with or without friction |
Restricted to Preferred Facilities: |
|
Service Code: |
L6620 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, flexion/extension wrist unit, with or without friction |
L6620 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6621 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device |
L6621 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, spring assisted rotational wrist unit with latch release |
Restricted to Preferred Facilities: |
|
Service Code: |
L6623 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, spring assisted rotational wrist unit with latch release |
L6623 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, flexion/extension and rotation wrist unit |
Restricted to Preferred Facilities: |
|
Service Code: |
L6624 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, flexion/extension and rotation wrist unit |
L6624 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, rotation wrist unit with cable lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L6625 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, rotation wrist unit with cable lock |
L6625 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, quick disconnect hook adapter, otto bock or equal |
Restricted to Preferred Facilities: |
|
Service Code: |
L6628 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, quick disconnect hook adapter, otto bock or equal |
L6628 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal |
Restricted to Preferred Facilities: |
|
Service Code: |
L6629 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal |
L6629 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, stainless steel, any wrist |
Restricted to Preferred Facilities: |
|
Service Code: |
L6630 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, stainless steel, any wrist |
L6630 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, latex suspension sleeve, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6632 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, latex suspension sleeve, each |
L6632 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, lift assist for elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6635 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, lift assist for elbow |
L6635 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, nudge control elbow lock |
Restricted to Preferred Facilities: |
|
Service Code: |
L6637 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, nudge control elbow lock |
L6637 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6638 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow |
L6638 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity additions, shoulder abduction joint, pair |
Restricted to Preferred Facilities: |
|
Service Code: |
L6640 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity additions, shoulder abduction joint, pair |
L6640 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, excursion amplifier, pulley type |
Restricted to Preferred Facilities: |
|
Service Code: |
L6641 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, excursion amplifier, pulley type |
L6641 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, excursion amplifier, pulley type |
Restricted to Preferred Facilities: |
|
Service Code: |
L6641 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, excursion amplifier, pulley type |
L6641 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, excursion amplifier, lever type |
Restricted to Preferred Facilities: |
|
Service Code: |
L6642 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, excursion amplifier, lever type |
L6642 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, shoulder flexion-abduction joint, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6645 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, shoulder flexion-abduction joint, each |
L6645 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system |
Restricted to Preferred Facilities: |
|
Service Code: |
L6646 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system |
L6646 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, shoulder lock mechanism, body powered actuator |
Restricted to Preferred Facilities: |
|
Service Code: |
L6647 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, shoulder lock mechanism, body powered actuator |
L6647 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, shoulder lock mechanism, external powered actuator |
Restricted to Preferred Facilities: |
|
Service Code: |
L6648 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, shoulder lock mechanism, external powered actuator |
L6648 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, shoulder universal joint, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6650 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, shoulder universal joint, each |
L6650 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, standard control cable, extra |
Restricted to Preferred Facilities: |
|
Service Code: |
L6655 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, standard control cable, extra |
L6655 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, heavy duty control cable |
Restricted to Preferred Facilities: |
|
Service Code: |
L6660 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, heavy duty control cable |
L6660 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, teflon, or equal, cable lining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6665 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, teflon, or equal, cable lining |
L6665 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, hook to hand, cable adapter |
Restricted to Preferred Facilities: |
|
Service Code: |
L6670 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, hook to hand, cable adapter |
L6670 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, harness, chest or shoulder, saddle type |
Restricted to Preferred Facilities: |
|
Service Code: |
L6672 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, harness, chest or shoulder, saddle type |
L6672 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, harness, (e.g. figure of eight type), single cable design |
Restricted to Preferred Facilities: |
|
Service Code: |
L6675 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, harness, (e.g. figure of eight type), single cable design |
L6675 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, harness, (e.g. figure of eight type), dual cable design |
Restricted to Preferred Facilities: |
|
Service Code: |
L6676 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, harness, (e.g. figure of eight type), dual cable design |
L6676 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6677 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow |
L6677 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, test socket, wrist disarticulation or below elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6680 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, test socket, wrist disarticulation or below elbow |
L6680 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, test socket, elbow disarticulation or above elbow |
Restricted to Preferred Facilities: |
|
Service Code: |
L6682 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, test socket, elbow disarticulation or above elbow |
L6682 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic |
Restricted to Preferred Facilities: |
|
Service Code: |
L6684 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic |
L6684 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, suction socket |
Restricted to Preferred Facilities: |
|
Service Code: |
L6686 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, suction socket |
L6686 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, frame type socket, below elbow or wrist disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L6687 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, frame type socket, below elbow or wrist disarticulation |
L6687 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, frame type socket, above elbow or elbow disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L6688 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, frame type socket, above elbow or elbow disarticulation |
L6688 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, frame type socket, shoulder disarticulation |
Restricted to Preferred Facilities: |
|
Service Code: |
L6689 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, frame type socket, shoulder disarticulation |
L6689 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, frame type socket, interscapular-thoracic |
Restricted to Preferred Facilities: |
|
Service Code: |
L6690 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, frame type socket, interscapular-thoracic |
L6690 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, removable insert, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6691 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, removable insert, each |
L6691 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, silicone gel insert or equal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L6692 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, silicone gel insert or equal, each |
L6692 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity addition, locking elbow, forearm counterbalance |
Restricted to Preferred Facilities: |
|
Service Code: |
L6693 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity addition, locking elbow, forearm counterbalance |
L6693 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanis |
Restricted to Preferred Facilities: |
|
Service Code: |
L6694 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanis |
L6694 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mech |
Restricted to Preferred Facilities: |
|
Service Code: |
L6695 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mech |
L6695 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or witho |
Restricted to Preferred Facilities: |
|
Service Code: |
L6696 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or witho |
L6696 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use wi |
Restricted to Preferred Facilities: |
|
Service Code: |
L6697 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use wi |
L6697 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert |
Restricted to Preferred Facilities: |
|
Service Code: |
L6698 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert |
L6698 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, passive hand/mitt, any material, any size |
Restricted to Preferred Facilities: |
|
Service Code: |
L6703 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, passive hand/mitt, any material, any size |
L6703 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, sport/recreational/work attachment, any material, any size |
Restricted to Preferred Facilities: |
|
Service Code: |
L6704 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, sport/recreational/work attachment, any material, any size |
L6704 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined |
Restricted to Preferred Facilities: |
|
Service Code: |
L6706 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined |
L6706 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined |
Restricted to Preferred Facilities: |
|
Service Code: |
L6707 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined |
L6707 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hand, mechanical, voluntary opening, any material, any size |
Restricted to Preferred Facilities: |
|
Service Code: |
L6708 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hand, mechanical, voluntary opening, any material, any size |
L6708 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hand, mechanical, voluntary closing, any material, any size |
Restricted to Preferred Facilities: |
|
Service Code: |
L6709 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hand, mechanical, voluntary closing, any material, any size |
L6709 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L6711 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric |
L6711 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L6712 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric |
L6712 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L6713 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric |
L6713 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L6714 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric |
L6714 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement |
Restricted to Preferred Facilities: |
|
Service Code: |
L6715 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement |
L6715 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined |
Restricted to Preferred Facilities: |
|
Service Code: |
L6721 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined |
L6721 |
New / Changed in 2020: |
|
Service Description: |
Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined |
Restricted to Preferred Facilities: |
|
Service Code: |
L6722 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined |
L6722 |
New / Changed in 2020: |
|
Service Description: |
Addition to terminal device, modifier wrist unit |
Restricted to Preferred Facilities: |
|
Service Code: |
L6805 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to terminal device, modifier wrist unit |
L6805 |
New / Changed in 2020: |
|
Service Description: |
Addition to terminal device, precision pinch device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6810 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to terminal device, precision pinch device |
L6810 |
New / Changed in 2020: |
|
Service Description: |
Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) |
Restricted to Preferred Facilities: |
|
Service Code: |
L6880 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) |
L6880 |
New / Changed in 2020: |
|
Service Description: |
Automatic grasp feature, addition to upper limb electric prosthetic terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6881 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Automatic grasp feature, addition to upper limb electric prosthetic terminal device |
L6881 |
New / Changed in 2020: |
|
Service Description: |
Microprocessor control feature, addition to upper limb prosthetic terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6882 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Microprocessor control feature, addition to upper limb prosthetic terminal device |
L6882 |
New / Changed in 2020: |
|
Service Description: |
Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power |
Restricted to Preferred Facilities: |
|
Service Code: |
L6883 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power |
L6883 |
New / Changed in 2020: |
|
Service Description: |
Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power |
Restricted to Preferred Facilities: |
|
Service Code: |
L6884 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power |
L6884 |
New / Changed in 2020: |
|
Service Description: |
Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power |
Restricted to Preferred Facilities: |
|
Service Code: |
L6885 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power |
L6885 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment |
Restricted to Preferred Facilities: |
|
Service Code: |
L6890 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment |
L6890 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated |
Restricted to Preferred Facilities: |
|
Service Code: |
L6895 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated |
L6895 |
New / Changed in 2020: |
|
Service Description: |
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6900 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining |
L6900 |
New / Changed in 2020: |
|
Service Description: |
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6905 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining |
L6905 |
New / Changed in 2020: |
|
Service Description: |
Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining |
Restricted to Preferred Facilities: |
|
Service Code: |
L6910 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining |
L6910 |
New / Changed in 2020: |
|
Service Description: |
Hand restoration (shading, and measurements included), replacement glove for above |
Restricted to Preferred Facilities: |
|
Service Code: |
L6915 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hand restoration (shading, and measurements included), replacement glove for above |
L6915 |
New / Changed in 2020: |
|
Service Description: |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6920 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device |
L6920 |
New / Changed in 2020: |
|
Service Description: |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal dev |
Restricted to Preferred Facilities: |
|
Service Code: |
L6925 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal dev |
L6925 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6930 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device |
L6930 |
New / Changed in 2020: |
|
Service Description: |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L6935 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device |
L6935 |
New / Changed in 2020: |
|
Service Description: |
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control o |
Restricted to Preferred Facilities: |
|
Service Code: |
L6940 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control o |
L6940 |
New / Changed in 2020: |
|
Service Description: |
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectroni |
Restricted to Preferred Facilities: |
|
Service Code: |
L6945 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectroni |
L6945 |
New / Changed in 2020: |
|
Service Description: |
Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal |
Restricted to Preferred Facilities: |
|
Service Code: |
L6950 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal |
L6950 |
New / Changed in 2020: |
|
Service Description: |
Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control |
Restricted to Preferred Facilities: |
|
Service Code: |
L6955 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control |
L6955 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries |
Restricted to Preferred Facilities: |
|
Service Code: |
L6960 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries |
L6960 |
New / Changed in 2020: |
|
Service Description: |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batte |
Restricted to Preferred Facilities: |
|
Service Code: |
L6965 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batte |
L6965 |
New / Changed in 2020: |
|
Service Description: |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries a |
Restricted to Preferred Facilities: |
|
Service Code: |
L6970 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries a |
L6970 |
New / Changed in 2020: |
|
Service Description: |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteri |
Restricted to Preferred Facilities: |
|
Service Code: |
L6975 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteri |
L6975 |
New / Changed in 2020: |
|
Service Description: |
Electric hand, switch or myoelectric controlled, adult |
Restricted to Preferred Facilities: |
|
Service Code: |
L7007 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electric hand, switch or myoelectric controlled, adult |
L7007 |
New / Changed in 2020: |
|
Service Description: |
Electric hand, switch or myoelectric, controlled, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L7008 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electric hand, switch or myoelectric, controlled, pediatric |
L7008 |
New / Changed in 2020: |
|
Service Description: |
Electric hook, switch or myoelectric controlled, adult |
Restricted to Preferred Facilities: |
|
Service Code: |
L7009 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electric hook, switch or myoelectric controlled, adult |
L7009 |
New / Changed in 2020: |
|
Service Description: |
Prehensile actuator, switch controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7040 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prehensile actuator, switch controlled |
L7040 |
New / Changed in 2020: |
|
Service Description: |
Electric hook, switch or myoelectric controlled, pediatric |
Restricted to Preferred Facilities: |
|
Service Code: |
L7045 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electric hook, switch or myoelectric controlled, pediatric |
L7045 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, hosmer or equal, switch controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7170 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, hosmer or equal, switch controlled |
L7170 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, microprocessor sequential control of elbow and terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L7180 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, microprocessor sequential control of elbow and terminal device |
L7180 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, microprocessor simultaneous control of elbow and terminal device |
Restricted to Preferred Facilities: |
|
Service Code: |
L7181 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, microprocessor simultaneous control of elbow and terminal device |
L7181 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, adolescent, variety village or equal, switch controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7185 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, adolescent, variety village or equal, switch controlled |
L7185 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, child, variety village or equal, switch controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7186 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 79.0 |
|
Prosthetics |
Electronic elbow, child, variety village or equal, switch controlled |
L7186 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, adolescent, variety village or equal, myoelectronically controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7190 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, adolescent, variety village or equal, myoelectronically controlled |
L7190 |
New / Changed in 2020: |
|
Service Description: |
Electronic elbow, child, variety village or equal, myoelectronically controlled |
Restricted to Preferred Facilities: |
|
Service Code: |
L7191 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic elbow, child, variety village or equal, myoelectronically controlled |
L7191 |
New / Changed in 2020: |
|
Service Description: |
Electronic wrist rotator, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L7259 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Electronic wrist rotator, any type |
L7259 |
New / Changed in 2020: |
|
Service Description: |
Six volt battery, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7360 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Six volt battery, each |
L7360 |
New / Changed in 2020: |
|
Service Description: |
Battery charger, six volt, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7362 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Battery charger, six volt, each |
L7362 |
New / Changed in 2020: |
|
Service Description: |
Twelve volt battery, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7364 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Twelve volt battery, each |
L7364 |
New / Changed in 2020: |
|
Service Description: |
Battery charger, twelve volt, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7366 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Battery charger, twelve volt, each |
L7366 |
New / Changed in 2020: |
|
Service Description: |
Lithium ion battery, rechargeable, replacement |
Restricted to Preferred Facilities: |
|
Service Code: |
L7367 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Lithium ion battery, rechargeable, replacement |
L7367 |
New / Changed in 2020: |
|
Service Description: |
Lithium ion battery charger, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
L7368 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Lithium ion battery charger, replacement only |
L7368 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L7400 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) |
L7400 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L7401 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) |
L7401 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) |
Restricted to Preferred Facilities: |
|
Service Code: |
L7402 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) |
L7402 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material |
Restricted to Preferred Facilities: |
|
Service Code: |
L7403 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material |
L7403 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material |
Restricted to Preferred Facilities: |
|
Service Code: |
L7404 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material |
L7404 |
New / Changed in 2020: |
|
Service Description: |
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material |
Restricted to Preferred Facilities: |
|
Service Code: |
L7405 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material |
L7405 |
New / Changed in 2020: |
|
Service Description: |
Upper extremity prosthesis, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
L7499 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper extremity prosthesis, not otherwise specified |
L7499 |
New / Changed in 2020: |
|
Service Description: |
Repair of prosthetic device, repair or replace minor parts |
Restricted to Preferred Facilities: |
|
Service Code: |
L7510 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Repair of prosthetic device, repair or replace minor parts |
L7510 |
New / Changed in 2020: |
|
Service Description: |
Repair prosthetic device, labor component, per 15 minutes |
Restricted to Preferred Facilities: |
|
Service Code: |
L7520 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Repair prosthetic device, labor component, per 15 minutes |
L7520 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic donning sleeve, any material, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7600 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic donning sleeve, any material, each |
L7600 |
New / Changed in 2020: |
|
Service Description: |
Male vacuum erection system |
Restricted to Preferred Facilities: |
|
Service Code: |
L7900 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Male vacuum erection system |
L7900 |
New / Changed in 2020: |
|
Service Description: |
Tension ring, for vacuum erection device, any type, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7902 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tension ring, for vacuum erection device, any type, replacement only, each |
L7902 |
New / Changed in 2020: |
|
Service Description: |
Tension ring, for vacuum erection device, any type, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L7902 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tension ring, for vacuum erection device, any type, replacement only, each |
L7902 |
New / Changed in 2020: |
|
Service Description: |
Nasal prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8040 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Nasal prosthesis, provided by a non-physician |
L8040 |
New / Changed in 2020: |
|
Service Description: |
Midfacial prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8041 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Midfacial prosthesis, provided by a non-physician |
L8041 |
New / Changed in 2020: |
|
Service Description: |
Orbital prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8042 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 306 |
|
Prosthetics |
Orbital prosthesis, provided by a non-physician |
L8042 |
New / Changed in 2020: |
|
Service Description: |
Upper facial prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8043 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Upper facial prosthesis, provided by a non-physician |
L8043 |
New / Changed in 2020: |
|
Service Description: |
Hemi-facial prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8044 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hemi-facial prosthesis, provided by a non-physician |
L8044 |
New / Changed in 2020: |
|
Service Description: |
Auricular prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8045 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Auricular prosthesis, provided by a non-physician |
L8045 |
New / Changed in 2020: |
|
Service Description: |
Partial facial prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8046 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Partial facial prosthesis, provided by a non-physician |
L8046 |
New / Changed in 2020: |
|
Service Description: |
Nasal septal prosthesis, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8047 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Nasal septal prosthesis, provided by a non-physician |
L8047 |
New / Changed in 2020: |
|
Service Description: |
Unspecified maxillofacial prosthesis, by report, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8048 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Unspecified maxillofacial prosthesis, by report, provided by a non-physician |
L8048 |
New / Changed in 2020: |
|
Service Description: |
Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a non-physician |
Restricted to Preferred Facilities: |
|
Service Code: |
L8049 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a non-physician |
L8049 |
New / Changed in 2020: |
|
Service Description: |
Truss, single with standard pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L8300 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Truss, single with standard pad |
L8300 |
New / Changed in 2020: |
|
Service Description: |
Truss, double with standard pads |
Restricted to Preferred Facilities: |
|
Service Code: |
L8310 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Truss, double with standard pads |
L8310 |
New / Changed in 2020: |
|
Service Description: |
Truss, addition to standard pad, water pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L8320 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Truss, addition to standard pad, water pad |
L8320 |
New / Changed in 2020: |
|
Service Description: |
Truss, addition to standard pad, scrotal pad |
Restricted to Preferred Facilities: |
|
Service Code: |
L8330 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Truss, addition to standard pad, scrotal pad |
L8330 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sheath, below knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8400 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sheath, below knee, each |
L8400 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sheath, above knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8410 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sheath, above knee, each |
L8410 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sheath, upper limb, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8415 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sheath, upper limb, each |
L8415 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8417 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each |
L8417 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, multiple ply, below knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8420 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sock, multiple ply, below knee, each |
L8420 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, multiple ply, above knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8430 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 226 |
|
Prosthetics |
Prosthetic sock, multiple ply, above knee, each |
L8430 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, multiple ply, upper limb, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8435 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sock, multiple ply, upper limb, each |
L8435 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic shrinker, below knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8440 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 226 |
|
Prosthetics |
Prosthetic shrinker, below knee, each |
L8440 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic shrinker, above knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8460 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 226 |
|
Prosthetics |
Prosthetic shrinker, above knee, each |
L8460 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic shrinker, upper limb, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8465 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic shrinker, upper limb, each |
L8465 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, single ply, fitting, below knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8470 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 226 |
|
Prosthetics |
Prosthetic sock, single ply, fitting, below knee, each |
L8470 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, single ply, fitting, above knee, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8480 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sock, single ply, fitting, above knee, each |
L8480 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic sock, single ply, fitting, upper limb, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8485 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic sock, single ply, fitting, upper limb, each |
L8485 |
New / Changed in 2020: |
|
Service Description: |
Unlisted procedure for miscellaneous prosthetic services |
Restricted to Preferred Facilities: |
|
Service Code: |
L8499 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Unlisted procedure for miscellaneous prosthetic services |
L8499 |
New / Changed in 2020: |
|
Service Description: |
Artificial larynx, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L8500 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Artificial larynx, any type |
L8500 |
New / Changed in 2020: |
|
Service Description: |
Tracheostomy speaking valve |
Restricted to Preferred Facilities: |
|
Service Code: |
L8501 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tracheostomy speaking valve |
L8501 |
New / Changed in 2020: |
|
Service Description: |
Artificial larynx replacement battery / accessory, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L8505 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Artificial larynx replacement battery / accessory, any type |
L8505 |
New / Changed in 2020: |
|
Service Description: |
Tracheo-esophageal voice prosthesis, patient inserted, any type, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8507 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tracheo-esophageal voice prosthesis, patient inserted, any type, each |
L8507 |
New / Changed in 2020: |
|
Service Description: |
Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L8509 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type |
L8509 |
New / Changed in 2020: |
|
Service Description: |
Voice amplifier |
Restricted to Preferred Facilities: |
|
Service Code: |
L8510 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Voice amplifier |
L8510 |
New / Changed in 2020: |
|
Service Description: |
Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8511 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each |
L8511 |
New / Changed in 2020: |
|
Service Description: |
Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10 |
Restricted to Preferred Facilities: |
|
Service Code: |
L8512 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10 |
L8512 |
New / Changed in 2020: |
|
Service Description: |
Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8513 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each |
L8513 |
New / Changed in 2020: |
|
Service Description: |
Tracheoesophageal puncture dilator, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8514 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Tracheoesophageal puncture dilator, replacement only, each |
L8514 |
New / Changed in 2020: |
|
Service Description: |
Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8515 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each |
L8515 |
New / Changed in 2020: |
|
Service Description: |
Artificial cornea |
Restricted to Preferred Facilities: |
|
Service Code: |
L8609 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Artificial cornea |
L8609 |
New / Changed in 2020: |
|
Service Description: |
Ocular implant |
Restricted to Preferred Facilities: |
|
Service Code: |
L8610 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Ocular implant |
L8610 |
New / Changed in 2020: |
|
Service Description: |
Aqueous shunt |
Restricted to Preferred Facilities: |
|
Service Code: |
L8612 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Aqueous shunt |
L8612 |
New / Changed in 2020: |
|
Service Description: |
Metacarpophalangeal joint implant |
Restricted to Preferred Facilities: |
|
Service Code: |
L8630 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Metacarpophalangeal joint implant |
L8630 |
New / Changed in 2020: |
|
Service Description: |
Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes en |
Restricted to Preferred Facilities: |
|
Service Code: |
L8631 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes en |
L8631 |
New / Changed in 2020: |
|
Service Description: |
Metatarsal joint implant |
Restricted to Preferred Facilities: |
|
Service Code: |
L8641 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Metatarsal joint implant |
L8641 |
New / Changed in 2020: |
|
Service Description: |
Hallux implant |
Restricted to Preferred Facilities: |
|
Service Code: |
L8642 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Hallux implant |
L8642 |
New / Changed in 2020: |
|
Service Description: |
Interphalangeal joint spacer, silicone or equal, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8658 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interphalangeal joint spacer, silicone or equal, each |
L8658 |
New / Changed in 2020: |
|
Service Description: |
Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size |
Restricted to Preferred Facilities: |
|
Service Code: |
L8659 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size |
L8659 |
New / Changed in 2020: |
|
Service Description: |
Vascular graft material, synthetic, implant |
Restricted to Preferred Facilities: |
|
Service Code: |
L8670 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Vascular graft material, synthetic, implant |
L8670 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator, pulse generator, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
L8679 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator, pulse generator, any type |
L8679 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator electrode, each |
Restricted to Preferred Facilities: |
|
Service Code: |
L8680 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator electrode, each |
L8680 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
Restricted to Preferred Facilities: |
|
Service Code: |
L8681 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
L8681 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator radiofrequency receiver |
Restricted to Preferred Facilities: |
|
Service Code: |
L8682 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator radiofrequency receiver |
L8682 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
Restricted to Preferred Facilities: |
|
Service Code: |
L8683 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
L8683 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L8685 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
L8685 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L8686 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
L8686 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L8687 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
L8687 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
Restricted to Preferred Facilities: |
|
Service Code: |
L8688 |
Service Code Type: |
CPT |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
Prior authorization is required prior to the trial implantation (the implantation before the device becomes permanent); Changes to a generator for a previously placed permanent device does not require prior auth. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
L8688 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Auditory osseointegrated device, includes all internal and external components |
Restricted to Preferred Facilities: |
|
Service Code: |
L8690 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Osseointegrated Hearing Device (BAHA Hearing Device) |
Auditory osseointegrated device, includes all internal and external components |
L8690 |
New / Changed in 2020: |
|
Service Description: |
Auditory osseointegrated device, includes all internal and external components |
Restricted to Preferred Facilities: |
|
Service Code: |
L8690 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 226 |
|
Prosthetics |
Auditory osseointegrated device, includes all internal and external components |
L8690 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Auditory osseointegrated device, external sound processor, replacement for osseointegrated sound processor) |
Restricted to Preferred Facilities: |
|
Service Code: |
L8691 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Osseointegrated Hearing Device (BAHA Hearing Device) |
Auditory osseointegrated device, external sound processor, replacement for osseointegrated sound processor) |
L8691 |
New / Changed in 2020: |
|
Service Description: |
Auditory osseointegrated device, external sound processor, replacement for osseointegrated sound processor) |
Restricted to Preferred Facilities: |
|
Service Code: |
L8691 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Auditory osseointegrated device, external sound processor, replacement for osseointegrated sound processor) |
L8691 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment |
Restricted to Preferred Facilities: |
|
Service Code: |
L8692 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Osseointegrated Hearing Device (BAHA Hearing Device) |
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment |
L8692 |
New / Changed in 2020: |
|
Service Description: |
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment |
Restricted to Preferred Facilities: |
|
Service Code: |
L8692 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment |
L8692 |
New / Changed in 2020: |
|
Service Description: |
Auditory osseointegrated device abutment, any length, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
L8693 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Auditory osseointegrated device abutment, any length, replacement only |
L8693 |
New / Changed in 2020: |
|
Service Description: |
External recharging system for battery (external) for use with implantable neurostimulator, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
L8695 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
External recharging system for battery (external) for use with implantable neurostimulator, replacement only |
L8695 |
New / Changed in 2020: |
|
Service Description: |
Prosthetic implant, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
L8699 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Prosthetic implant, not otherwise specified |
L8699 |
New / Changed in 2020: |
|
Service Description: |
Orthotic and prosthetic supply, accessory, and/or service component of another hcpcs "l" code |
Restricted to Preferred Facilities: |
|
Service Code: |
L9900 |
Service Code Type: |
HCPCS |
Effective Date: |
3/1/2013 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Prosthetics |
Orthotic and prosthetic supply, accessory, and/or service component of another hcpcs "l" code |
L9900 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Biobrane Biosynthetic Dressing |
Restricted to Preferred Facilities: |
|
Service Code: |
N/A |
Service Code Type: |
|
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Biobrane does not have a CPT code |
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Biobrane Biosynthetic Dressing |
N/A |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Epicel |
Restricted to Preferred Facilities: |
|
Service Code: |
N/A |
Service Code Type: |
|
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
Epicel does not have a CPT code |
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epicel |
N/A |
New / Changed in 2020: |
|
Service Description: |
|
Restricted to Preferred Facilities: |
|
Service Code: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2012 12:00:00 AM |
Comments: |
Any off-label drug or biologic used for an oncologic indication not included in the FDA approved labeling for the drug requires prior authorization. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Off Label Drug Use-Oncology Indications |
|
N/A |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0477 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0477 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0478 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type |
Q0478 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0479 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0479 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Driver for use with pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0480 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Driver for use with pneumatic ventricular assist device, replacement only |
Q0480 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Microprocessor control unit for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0481 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Microprocessor control unit for use with electric ventricular assist device, replacement only |
Q0481 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0482 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only |
Q0482 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Monitor/display module for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0483 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Monitor/display module for use with electric ventricular assist device, replacement only |
Q0483 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0484 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0484 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Monitor control cable for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0485 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Monitor control cable for use with electric ventricular assist device, replacement only |
Q0485 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0486 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only |
Q0486 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0487 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only |
Q0487 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power pack base for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0488 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power pack base for use with electric ventricular assist device, replacement only |
Q0488 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power pack base for use with electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0489 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power pack base for use with electric/pneumatic ventricular assist device, replacement only |
Q0489 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Emergency power source for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0490 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Emergency power source for use with electric ventricular assist device, replacement only |
Q0490 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Emergency power source for use with electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0491 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Emergency power source for use with electric/pneumatic ventricular assist device, replacement only |
Q0491 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Emergency power supply cable for use with electric ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0492 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Emergency power supply cable for use with electric ventricular assist device, replacement only |
Q0492 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0493 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only |
Q0493 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Emergency hand pump for use with electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0494 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Emergency hand pump for use with electric/pneumatic ventricular assist device, replacement only |
Q0494 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0495 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0495 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery, other than lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0496 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery, other than lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0496 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery clip for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0497 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery clip for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0497 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Holster for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0498 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Holster for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0498 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0499 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement |
Q0499 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Filters for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0500 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Filters for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0500 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0501 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0501 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Mobility cart for pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0502 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Mobility cart for pneumatic ventricular assist device, replacement only |
Q0502 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery for pneumatic ventricular assist device, replacement only, each |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0503 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery for pneumatic ventricular assist device, replacement only, each |
Q0503 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Power adapter for pneumatic ventricular assist device, replacement only, vehicle type |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0504 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Power adapter for pneumatic ventricular assist device, replacement only, vehicle type |
Q0504 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0506 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0506 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0506 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0506 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Miscellaneous supply or accessory for use with an external ventricular assist device |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0507 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with an external ventricular assist device |
Q0507 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Miscellaneous supply or accessory for use with an implanted ventricular assist device |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0508 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with an implanted ventricular assist device |
Q0508 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A |
Restricted to Preferred Facilities: |
|
Service Code: |
Q0509 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A |
Q0509 |
New / Changed in 2020: |
|
Service Description: |
Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion |
Restricted to Preferred Facilities: |
|
Service Code: |
Q2043 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Provenge® (sipuleucel-T) |
Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion |
Q2043 |
New / Changed in 2020: |
|
Service Description: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4081 |
Service Code Type: |
HCPCS |
Effective Date: |
6/15/2007 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Q4081 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4081 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Procrit® (epoetin alpha) |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Q4081 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Skin substitute, not otherwise specified |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4100 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 106.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Skin substitute, not otherwise specified |
Q4100 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Apligraf, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4101 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 48.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Apligraf, per square centimeter |
Q4101 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Oasis wound matrix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4102 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 48.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Oasis wound matrix, per square centimeter |
Q4102 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4104 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 48.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
Q4104 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Integra dermal regeneration template (drt), per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4105 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 124.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra dermal regeneration template (drt), per square centimeter |
Q4105 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dermagraft, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4106 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 91 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermagraft, per square centimeter |
Q4106 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Graftjacket, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4107 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 91 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket, per square centimeter |
Q4107 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Integra matrix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4108 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 91 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra matrix, per square centimeter |
Q4108 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Primatrix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4110 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 301 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Primatrix, per square centimeter |
Q4110 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Graftjacket xpress, injectable, 1cc |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4113 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 295 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket xpress, injectable, 1cc |
Q4113 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Alloderm, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4116 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 295 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Alloderm, per square centimeter |
Q4116 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Matristem wound matrix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4119 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 295 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Matristem wound matrix, per square centimeter |
Q4119 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Theraskin, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4121 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 295 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Theraskin, per square centimeter |
Q4121 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dermacell, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4122 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 99.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermacell, per square centimeter |
Q4122 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4128 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
Q4128 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Strattice tm, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4130 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 204 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Strattice tm, per square centimeter |
Q4130 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Grafix prime, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4133 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 133.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Grafix prime, per square centimeter |
Q4133 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Epifix, injectable, 1 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4145 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 112.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, injectable, 1 mg |
Q4145 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Transcyte, per sq centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4182 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 122.0 |
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Transcyte, per sq centimeter |
Q4182 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Epifix, per square centimeter |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4186 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, per square centimeter |
Q4186 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5101 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Q5101 |
New / Changed in 2020: |
|
Service Description: |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5101 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2016 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 59.0 |
|
Zarxio (filgrastim- sndz) |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Q5101 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
Q5104 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Renflexis (infliximab-abda) |
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg |
Q5104 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5106 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Q5106 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5106 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Retacrit (epoetin alfa-epbx) |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Q5106 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5108 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 54.0 |
|
Fulphilia (pegfilgrastim-jmdb) |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
Q5108 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5109 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Ixifi (infliximab-qbtx) |
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg |
Q5109 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram |
Restricted to Preferred Facilities: |
|
Service Code: |
Q5110 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Nivestym (filgrastim-aafi) |
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram |
Q5110 |
New / Changed in 2020: |
|
Service Description: |
Sterile dilutant for epoprostenol, 50ml |
Restricted to Preferred Facilities: |
|
Service Code: |
S0155 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2009 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Flolan® (epoprostenol) |
Sterile dilutant for epoprostenol, 50ml |
S0155 |
New / Changed in 2020: |
|
Service Description: |
Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by hcg, ultrasound to conf |
Restricted to Preferred Facilities: |
|
Service Code: |
S0199 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 275 |
|
Termination of Pregnancy (Abortion) |
Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by hcg, ultrasound to conf |
S0199 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss |
Restricted to Preferred Facilities: |
|
Service Code: |
S0618 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss |
S0618 |
New / Changed in 2020: |
|
Service Description: |
Transplantation of small intestine and liver allografts |
Restricted to Preferred Facilities: |
|
Service Code: |
S2053 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Transplantation of small intestine and liver allografts |
S2053 |
New / Changed in 2020: |
|
Service Description: |
Transplantation of multivisceral organs |
Restricted to Preferred Facilities: |
|
Service Code: |
S2054 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Transplantation of multivisceral organs |
S2054 |
New / Changed in 2020: |
|
Service Description: |
Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor |
Restricted to Preferred Facilities: |
|
Service Code: |
S2055 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor |
S2055 |
New / Changed in 2020: |
|
Service Description: |
Lobar lung transplantation |
Restricted to Preferred Facilities: |
|
Service Code: |
S2060 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Lobar lung transplantation |
S2060 |
New / Changed in 2020: |
|
Service Description: |
Donor lobectomy (lung) for transplantation, living donor |
Restricted to Preferred Facilities: |
|
Service Code: |
S2061 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Donor lobectomy (lung) for transplantation, living donor |
S2061 |
New / Changed in 2020: |
|
Service Description: |
Simultaneous pancreas kidney transplantation |
Restricted to Preferred Facilities: |
|
Service Code: |
S2065 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Simultaneous pancreas kidney transplantation |
S2065 |
New / Changed in 2020: |
|
Service Description: |
Islet cell tissue transplant from pancreas; allogeneic |
Restricted to Preferred Facilities: |
|
Service Code: |
S2102 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Islet cell tissue transplant from pancreas; allogeneic |
S2102 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
Restricted to Preferred Facilities: |
|
Service Code: |
S2112 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Autologous cultured chondrocyte (MACI) |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
S2112 |
New / Changed in 2020: |
|
Service Description: |
Cord blood harvesting for transplantation, allogeneic |
Restricted to Preferred Facilities: |
|
Service Code: |
S2140 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Cord blood harvesting for transplantation, allogeneic |
S2140 |
New / Changed in 2020: |
|
Service Description: |
Cord blood-derived stem-cell transplantation, allogeneic |
Restricted to Preferred Facilities: |
|
Service Code: |
S2142 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Cord blood-derived stem-cell transplantation, allogeneic |
S2142 |
New / Changed in 2020: |
|
Service Description: |
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m |
Restricted to Preferred Facilities: |
|
Service Code: |
S2150 |
Service Code Type: |
HCPCS |
Effective Date: |
8/1/2003 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 20 |
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m |
S2150 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear |
Restricted to Preferred Facilities: |
|
Service Code: |
S2230 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear |
S2230 |
New / Changed in 2020: |
|
Service Description: |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2400 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
S2400 |
New / Changed in 2020: |
|
Service Description: |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2401 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
S2401 |
New / Changed in 2020: |
|
Service Description: |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2402 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
S2402 |
New / Changed in 2020: |
|
Service Description: |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2403 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
S2403 |
New / Changed in 2020: |
|
Service Description: |
Repair, myelomeningocele in the fetus, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2404 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, myelomeningocele in the fetus, procedure performed in utero |
S2404 |
New / Changed in 2020: |
|
Service Description: |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
Restricted to Preferred Facilities: |
|
Service Code: |
S2405 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
S2405 |
New / Changed in 2020: |
|
Service Description: |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
Restricted to Preferred Facilities: |
|
Service Code: |
S2409 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
S2409 |
New / Changed in 2020: |
|
Service Description: |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
Restricted to Preferred Facilities: |
|
Service Code: |
S2411 |
Service Code Type: |
HCPCS |
Effective Date: |
4/1/1999 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Fetal Surgery (surgery on the unborn child) |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
S2411 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic Testing - Other Cancer |
Restricted to Preferred Facilities: |
|
Service Code: |
S3840 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3840 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic Testing - Other Cancer |
Restricted to Preferred Facilities: |
|
Service Code: |
S3841 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3841 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic Testing - Other Cancer |
Restricted to Preferred Facilities: |
|
Service Code: |
S3842 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3842 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic testing for alpha-thalassemia |
Restricted to Preferred Facilities: |
|
Service Code: |
S3845 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Genetic Testing - Severe Anemias |
Genetic testing for alpha-thalassemia |
S3845 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic testing for hemoglobin e beta-thalassemia |
Restricted to Preferred Facilities: |
|
Service Code: |
S3846 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MP 269 |
|
Genetic Testing - Severe Anemias |
Genetic testing for hemoglobin e beta-thalassemia |
S3846 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic testing for sickle cell anemia |
Restricted to Preferred Facilities: |
|
Service Code: |
S3850 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 151.0 |
|
Genetic Testing - Severe Anemias |
Genetic testing for sickle cell anemia |
S3850 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
Restricted to Preferred Facilities: |
|
Service Code: |
S3861 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 75.0 |
|
Genetic Testing - Cardiac |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
S3861 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
Restricted to Preferred Facilities: |
|
Service Code: |
S3865 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 75.0 |
|
Genetic Testing - Cardiac |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
S3865 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family (Effective 4/1/09) |
Restricted to Preferred Facilities: |
|
Service Code: |
S3866 |
Service Code Type: |
HCPCS |
Effective Date: |
2/1/2020 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 75.0 |
|
Genetic Testing - Cardiac |
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family (Effective 4/1/09) |
S3866 |
New / Changed in 2020: |
|
Service Description: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
S3870 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Comparative Genomic Hybridization (CGH) or Chromosomal Microarray Analysis (CMA) for Evaluation of Developmental Delay |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
S3870 |
New / Changed in 2020: |
|
Service Description: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
S3870 |
Service Code Type: |
HCPCS |
Effective Date: |
7/1/2011 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Genetic Testing - Other |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
S3870 |
New / Changed in 2020: |
|
Service Description: |
Magnetic resonance cholangiopancreatography (mrcp) |
Restricted to Preferred Facilities: |
|
Service Code: |
S8037 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2019 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance cholangiopancreatography (mrcp) |
S8037 |
New / Changed in 2020: |
|
Service Description: |
Magnetic resonance imaging (mri), low-field |
Restricted to Preferred Facilities: |
|
Service Code: |
S8042 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2019 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 13.0 |
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging (mri), low-field |
S8042 |
New / Changed in 2020: |
|
Service Description: |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
Restricted to Preferred Facilities: |
|
Service Code: |
S8092 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2019 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 67.0 |
|
CT (CAT) Scan (Outpatient/Nonemergency) |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
S8092 |
New / Changed in 2020: |
|
Service Description: |
Hospice inpatient respite care; per diem |
Restricted to Preferred Facilities: |
|
Service Code: |
T2044 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 150.0 |
|
Hospice |
Hospice inpatient respite care; per diem |
T2044 |
New / Changed in 2020: |
|
Service Description: |
Hospice general inpatient care; per diem |
Restricted to Preferred Facilities: |
|
Service Code: |
T2045 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/1996 12:00:00 AM |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
MBP 150.0 |
|
Hospice |
Hospice general inpatient care; per diem |
T2045 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ear protector evaluation |
Restricted to Preferred Facilities: |
|
Service Code: |
V5008 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Ear protector evaluation |
V5008 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Assessment for hearing aid |
Restricted to Preferred Facilities: |
|
Service Code: |
V5010 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Assessment for hearing aid |
V5010 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Fitting orientation/checking of hearing aid |
Restricted to Preferred Facilities: |
|
Service Code: |
V5011 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Fitting orientation/checking of hearing aid |
V5011 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Repair/modification of a hearing aid |
Restricted to Preferred Facilities: |
|
Service Code: |
V5014 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Repair/modification of a hearing aid |
V5014 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Conformity evaluation |
Restricted to Preferred Facilities: |
|
Service Code: |
V5020 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Conformity evaluation |
V5020 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, monaural, body worn, air conduction |
Restricted to Preferred Facilities: |
|
Service Code: |
V5030 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, monaural, body worn, air conduction |
V5030 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, monaural, body worn, bone conduction |
Restricted to Preferred Facilities: |
|
Service Code: |
V5040 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, monaural, body worn, bone conduction |
V5040 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid monaural, in the ear |
Restricted to Preferred Facilities: |
|
Service Code: |
V5050 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid monaural, in the ear |
V5050 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid monaural (BTE) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5060 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid monaural (BTE) |
V5060 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Glasses, air conduction |
Restricted to Preferred Facilities: |
|
Service Code: |
V5070 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Glasses, air conduction |
V5070 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Glasses, bone conduction |
Restricted to Preferred Facilities: |
|
Service Code: |
V5080 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Glasses, bone conduction |
V5080 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, unspecified hearing aid |
Restricted to Preferred Facilities: |
|
Service Code: |
V5090 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, unspecified hearing aid |
V5090 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Semi-implantable middle ear hearing prosthesis |
Restricted to Preferred Facilities: |
|
Service Code: |
V5095 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Semi-implantable middle ear hearing prosthesis |
V5095 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, bilateral, body worn |
Restricted to Preferred Facilities: |
|
Service Code: |
V5100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, bilateral, body worn |
V5100 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, bilateral, in the ear |
Restricted to Preferred Facilities: |
|
Service Code: |
V5110 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, bilateral, in the ear |
V5110 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Binaural, body |
Restricted to Preferred Facilities: |
|
Service Code: |
V5120 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Binaural, body |
V5120 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid binaural, in the ear |
Restricted to Preferred Facilities: |
|
Service Code: |
V5130 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid binaural, in the ear |
V5130 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid binaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5140 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid binaural, BTE |
V5140 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Binaural, glasses |
Restricted to Preferred Facilities: |
|
Service Code: |
V5150 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Binaural, glasses |
V5150 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, binaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5160 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, binaural, BTE |
V5160 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing device, monaural, in the ear (ite) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5171 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, in the ear (ite) |
V5171 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing device, monaural, in the canal (itc) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5172 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, in the canal (itc) |
V5172 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing device, monaural, behind the ear (bte) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5181 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, behind the ear (bte) |
V5181 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing, monaural, glasses |
Restricted to Preferred Facilities: |
|
Service Code: |
V5190 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing, monaural, glasses |
V5190 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, contralateral, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
V5200 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, contralateral, monaural |
V5200 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/ite |
Restricted to Preferred Facilities: |
|
Service Code: |
V5211 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/ite |
V5211 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5212 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/itc |
V5212 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5212 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/itc |
V5212 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/bte |
Restricted to Preferred Facilities: |
|
Service Code: |
V5213 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/bte |
V5213 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, itc/itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5214 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, itc/itc |
V5214 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, itc/bte |
Restricted to Preferred Facilities: |
|
Service Code: |
V5215 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, itc/bte |
V5215 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, bte/bte |
Restricted to Preferred Facilities: |
|
Service Code: |
V5221 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, bte/bte |
V5221 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, contralateral routing system, binaural, glasses |
Restricted to Preferred Facilities: |
|
Service Code: |
V5230 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, glasses |
V5230 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, contralateral routing system, binaural |
Restricted to Preferred Facilities: |
|
Service Code: |
V5240 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, contralateral routing system, binaural |
V5240 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Dispensing fee, monaural hearing aid, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
V5241 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Dispensing fee, monaural hearing aid, any type |
V5241 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, analog, monaural, cic (completely in the ear canal) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5242 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, monaural, cic (completely in the ear canal) |
V5242 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, analog, monaural, itc (in the canal) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5243 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, monaural, itc (in the canal) |
V5243 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, cic |
Restricted to Preferred Facilities: |
|
Service Code: |
V5244 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, cic |
V5244 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable, analog, monaural, itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5245 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, analog, monaural, itc |
V5245 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, ite (in the ear) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5246 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, ite (in the ear) |
V5246 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5247 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, BTE |
V5247 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, analog, binaural, cic |
Restricted to Preferred Facilities: |
|
Service Code: |
V5248 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, binaural, cic |
V5248 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, analog, binaural, itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5249 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, binaural, itc |
V5249 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable analog, binaural, cic |
Restricted to Preferred Facilities: |
|
Service Code: |
V5250 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, binaural, cic |
V5250 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable analog, binaural, itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5251 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, binaural, itc |
V5251 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable, binaural, ite |
Restricted to Preferred Facilities: |
|
Service Code: |
V5252 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, binaural, ite |
V5252 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digitally programmable, binaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5253 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, binaural, BTE |
V5253 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, monaural, cic |
Restricted to Preferred Facilities: |
|
Service Code: |
V5254 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, cic |
V5254 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, monaural, itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5255 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, itc |
V5255 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, monaural, ite |
Restricted to Preferred Facilities: |
|
Service Code: |
V5256 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, ite |
V5256 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, monaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5257 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, BTE |
V5257 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, binaural, cic |
Restricted to Preferred Facilities: |
|
Service Code: |
V5258 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, cic |
V5258 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, binaural, itc |
Restricted to Preferred Facilities: |
|
Service Code: |
V5259 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, itc |
V5259 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, binaural, ite |
Restricted to Preferred Facilities: |
|
Service Code: |
V5260 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, ite |
V5260 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, digital, binaural, BTE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5261 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, BTE |
V5261 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, disposable, any type, monaural |
Restricted to Preferred Facilities: |
|
Service Code: |
V5262 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, disposable, any type, monaural |
V5262 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, disposable, any type, binaural |
Restricted to Preferred Facilities: |
|
Service Code: |
V5263 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, disposable, any type, binaural |
V5263 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ear mold/insert, not disposable, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
V5264 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Ear mold/insert, not disposable, any type |
V5264 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ear mold/insert, disposable, any type |
Restricted to Preferred Facilities: |
|
Service Code: |
V5265 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Ear mold/insert, disposable, any type |
V5265 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Battery for use in hearing device |
Restricted to Preferred Facilities: |
|
Service Code: |
V5266 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Battery for use in hearing device |
V5266 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid supplies/accessories |
Restricted to Preferred Facilities: |
|
Service Code: |
V5267 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid supplies/accessories |
V5267 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Ear impression, each |
Restricted to Preferred Facilities: |
|
Service Code: |
V5275 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Ear impression, each |
V5275 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM SYS MONAURL ANY TYPE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5281 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM SYS MONAURL ANY TYPE |
V5281 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM SYS BINAURL ANY TYPE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5282 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM SYS BINAURL ANY TYPE |
V5282 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM NCK LOOP INDUCT RECV |
Restricted to Preferred Facilities: |
|
Service Code: |
V5283 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM NCK LOOP INDUCT RECV |
V5283 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVICE PERS FM/DM EAR LEVEL RECEIVER |
Restricted to Preferred Facilities: |
|
Service Code: |
V5284 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVICE PERS FM/DM EAR LEVEL RECEIVER |
V5284 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM DIR AUDIO INPUT RECV |
Restricted to Preferred Facilities: |
|
Service Code: |
V5285 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM DIR AUDIO INPUT RECV |
V5285 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LISTEN DEVC PERS BLUE TOOTH FM/DM RECEIVR |
Restricted to Preferred Facilities: |
|
Service Code: |
V5286 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC PERS BLUE TOOTH FM/DM RECEIVR |
V5286 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSISTIVE LISTENING DEVC PERS FM/DM RECEIVER NOS |
Restricted to Preferred Facilities: |
|
Service Code: |
V5287 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSISTIVE LISTENING DEVC PERS FM/DM RECEIVER NOS |
V5287 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LISTEN DEVC PERS FM/DM TRANSMITTER ALD |
Restricted to Preferred Facilities: |
|
Service Code: |
V5288 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC PERS FM/DM TRANSMITTER ALD |
V5288 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM ADPTR/BOOT CPLG RECV |
Restricted to Preferred Facilities: |
|
Service Code: |
V5289 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM ADPTR/BOOT CPLG RECV |
V5289 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
ASSIST LISTEN DEVC TRANSMITT MICROPHONE ANY TYPE |
Restricted to Preferred Facilities: |
|
Service Code: |
V5290 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC TRANSMITT MICROPHONE ANY TYPE |
V5290 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing aid, not otherwise classified |
Restricted to Preferred Facilities: |
|
Service Code: |
V5298 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing aid, not otherwise classified |
V5298 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Hearing service miscellaneous |
Restricted to Preferred Facilities: |
|
Service Code: |
V5299 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Hearing service miscellaneous |
V5299 |
New / Changed in 2020: |
New for 2020 |
Service Description: |
Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) |
Restricted to Preferred Facilities: |
|
Service Code: |
V5336 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2020 12:00:00 AM |
Comments: |
Age 0-18, Coverage limit is $3,000 per ear, every 36 months |
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
Pediatric Hearing Aids |
Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) |
V5336 |
New / Changed in 2020: |
|
Service Description: |
|
Restricted to Preferred Facilities: |
|
Service Code: |
|
Service Code Type: |
|
Effective Date: |
1/1/1900 12:00:00 AM |
Comments: |
|
Most recent communication to Providers: |
|
Geisinger Medical Policy # from Former Plan: |
|
|
|
|
|