Northern Light Health's Employee Health Plan

The following list identifies services requiring prior authorization. To request prior authorization, unless otherwise noted, please contact the Medical Management Department at (855) 429-1024, fax (877) 403-7162, www.employeehealthplan.northernlighthealth.org, Monday through Friday, 8 AM to 5 PM. Effective 1/1/2020. Urgent care services do not require prior authorization except high end imaging (CT/MRI/PET scans). All emergent services are excluded from requiring prior authorization.

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Procedure or Service:

Service Description:

Service Code:

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Skilled Nursing Facility

0022

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Room and Board, Subacute Pediatric (Private Hospital)

0190

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Subacute Care - Level I

0191

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Subacute Care - Level II

0192

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Subacute Care - Level III

0193

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Subacute Care - Level IV

0194

Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF)

Room and Board, Subacute Adult (Private Hospital)

0199

Behavioral Health (Mental Health) and Substance Abuse: Outpatient electro-convulsive treatment

Electroshock Behavioral Health Treatments/Services

0901

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION INTERNAL ANAL SPHINCTER

46505

Chemodenervation-Botox® (Botulinum toxin Type A)

CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER

52287

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS

64611

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL

64612

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE

64615

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA

64616

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG

64617

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE

64642

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE

64643

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES

64644

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES

64645

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES

64646

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES

64647

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE

64650

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY

64653

Chemodenervation-Botox® (Botulinum toxin Type A)

CHEMODENERVATION EXTRAOCULAR MUSCLE

67345

Radiation Oncology- Prep for Treatment

Unlisted procedure, therapeutic radiology clinical treatment planning

77299

Genetic Testing - Colorectal Cancer

APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence

81201

Genetic Testing - Colorectal Cancer

APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants

81202

Genetic Testing - Colorectal Cancer

APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian

81203

Genetic Testing - Colorectal Cancer

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81288

Genetic Testing - Colorectal Cancer

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81292

Genetic Testing - Colorectal Cancer

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81293

Genetic Testing - Colorectal Cancer

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81294

Genetic Testing - Colorectal Cancer

MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81295

Genetic Testing - Colorectal Cancer

MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81296

Genetic Testing - Colorectal Cancer

MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis;

81297

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

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

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

Genetic Testing - Colorectal Cancer

Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue

81301

Genetic Testing - Colorectal Cancer

PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi

81317

Genetic Testing - Colorectal Cancer

PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi

81318

Genetic Testing - Colorectal Cancer

PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi

81319

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

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

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

Genetic Testing - Colorectal Cancer

ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES

81525

Behavioral Health (Mental Health) and Substance Abuse: Outpatient electro-convulsive treatment

Electroconvulsive therapy; includes necessary monitoring

90870

Kymriah (tisagenleclencel)

Kymriah or Yescarta

0537T

Yescarta (axicabtagene ciloleucel)

Kymriah or Yescarta

0537T

Kymriah (tisagenleclencel)

Kymriah or Yescarta

0538T

Yescarta (axicabtagene ciloleucel)

Kymriah or Yescarta

0538T

Kymriah (tisagenleclencel)

Kymriah or Yescarta

0539T

Yescarta (axicabtagene ciloleucel)

Kymriah or Yescarta

0539T

Kymriah (tisagenleclencel)

Kymriah or Yescarta

0540T

Yescarta (axicabtagene ciloleucel)

Kymriah or Yescarta

0540T

Radiation Oncology-Tumor Treatment Fields

Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only

A4555

Lutathera (luteum Lu 177 dotate)

Lutetium lu 177, dotatate, therapeutic, 1 millicurie

A9513

Cosentyx® (secukinumab) vials

Unclassified drugs or biologicals

C9399

Cranial Orthotics – helmets/remolding bands for Infants

Cranial prosthesis

D5924

Radiation Oncology-Tumor Treatment Fields

Electrical stimulation device used for cancer treatment, includes all accessories, any type

E0766

Fasenra (benralizumab)

Injection, benralizumab, 1 mg

J0517

Zinplava (bezlotoxumab)

Injection, bezlotoxumab, 10 mg

J0565

Chemodenervation-Botox® (Botulinum toxin Type A)

Injection, onabotulinumtoxina, 1 unit

J0585

Parsabiv (etelcalcetide)

Injection, etelcalcetide, 0.1 mg

J0606

Radicava (edaravone)

Injection, edaravone, 1 mg

J1301

Sustol (granisetron extended release)

Inj, granisetron, xr, 0.1 mg

J1627

Vabomere (meropenem/vaborbactam)

Injection, meropenem and vaborbactam, 10mg/10mg (20mg)

J2186

Ocrevus (ocrelizumab)

Injection, ocrelizumab, 1 mg

J2350

Zyprexa Relprevv® (olanzapine)

Injection, olanzapine, long-acting, 1 mg

J2358

Zilretta (triamcinolone acetonide ER injection)

Injection, Durvalumab, 10 mg

J3304

Stelara™ (ustekinumab)

Ustekinumab, for intravenous injection, 1 mg

J3358

Mepsevii (vestronidase alfa-vjbk)

Inj., vestronidase alfa-vjbk

J3397

Luxturna (voretigeneneparvovec-rzyl)

Inj luxturna 1 billion vec g

J3398

Cosentyx® (secukinumab) vials

Unclassified drugs

J3490

Unituxin (dinutuximab)

Unclassified drugs

J3490

Unituxin (dinutuximab)

Unclassified biologics

J3590

Tecentriq™ (atezolizumab)

Injection, atezolizumab, 10 mg

J9022

Vyxeos (daunorubicin/cytarabine liposomal)

Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine

J9153

Imfinzi (durvalumab)

Injection, durvalumab, 10 mg

J9173

Mylotarg (gemfuzumab ozogamicin)

Gemtuzumab ozogamicin 0.1 mg

J9203

Lartruvo (olaratumab)

Inj, olaratumab, 10 mg

J9285

Rituxin Hycela (rituximab/hyaluronidase)

Injection, rituximab 10 mg and hyaluronidase

J9311

Rituxan® (rituximab) Rituxan for Non-Hodgkin’s Lymphoma does not require prior authorization.

Injection, rituximab, 10 mg

J9312

Tepadina (thiotepa)

Injection, thiotepa, 15 mg

J9340

Unituxin (dinutuximab)

Not otherwise classified, antineoplastic drugs

J9999

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

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

Durable Medical Equipment (Outpatient - see Comments)

N/A

Health Care Services associated with Non-covered Services (including but not limited to deep sedation and general anesthesia)

N/A

Yescarta (axicabtagene ciloleucel)

Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco

Q2041

Kymriah (tisagenleclencel)

Injection, hydroxyprogesterone caproate, 1 mg

Q2042

Inflectra (infliximab-dyyb)

Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg

Q5103

Sublocade (buprenorphine ER injection for subcutaneous use )

Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg

Q9991

Sublocade (buprenorphine ER injection for subcutaneous use )

Injection, buprenorphine extended-release (sublocade), greater than 100 mg

Q9992

Cranial Orthotics – helmets/remolding bands for Infants

Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

S1040

Behavioral Health (Mental Health) and Substance Abuse: Outpatient treatment of Opioid dependence

Ambulatory setting substance abuse treatment or detoxification services, per diem

S9475

Hospice

Private duty/independent nursing service(s), licensed, up to 15 minutes

T1000

Inpatient Facility Admission - Planned

Room and Board – Private, Medical/Surgical/Gynecological

0111

Inpatient Facility Admission - Planned

Room and Board – Private, OB

0112

Inpatient Facility Admission - Planned

Room and Board – Private, Pediatric

0113

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Room and Board – Private, Psychiatric

0114

Inpatient Facility Admission - Planned

Room and Board – Private, Psychiatric

0114

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Detoxification Room and Board Private (one bed)

0116

Inpatient Facility Admission - Planned

Room and Board – Private, Oncology

0117

Inpatient Facility Admission - Planned

Room and Board – Private, Rehabilitation

0118

Inpatient Facility Admission - Planned

Room and Board – Private, Other

0119

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Medical/Surgical/Gynecological

0121

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Obstetric

0122

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Pediatric

0123

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Room and Board – Semiprivate 2 Bed, Psychiatric

0124

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Psychiatric

0124

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Detoxification Room and Board Semiprivate (two beds)

0126

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Oncology

0127

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 2 Bed, Rehabilitation

0128

Inpatient Facility Admission - Planned

Room and Board – Semiprivate, 2 Beds, Other

0129

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Medical/Surgical/Gynecological

0131

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Obstetric

0132

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Pediatric

0133

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Room and Board – Semiprivate 3 or 4 Bed, Psychiatric

0134

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Psychiatric

0134

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Detoxification Room and Board (3 and 4 beds)

0136

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Oncology

0137

Inpatient Facility Admission - Planned

Room and Board – Semiprivate 3 or 4 Bed, Rehabilitation

0138

Inpatient Facility Admission - Planned

Room and Board – Semiprivate, 3 and 4 Beds, Other

0139

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Psychiatric Room and Board Deluxe Private

0144

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Detoxification Room and Board Deluxe Private

0146

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Medical/Surgical/Gynecological

0151

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Obstetric

0152

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Pediatric

0153

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Room and Board – Ward (Medical or General), Psychiatric

0154

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Psychiatric

0154

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Detoxification Room and Board Ward

0156

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Oncology

0157

Inpatient Facility Admission - Planned

Room and Board – Ward (Medical or General), Rehabilitation

0158

Inpatient Facility Admission - Planned

Room and Board – Ward, Other

0159

Inpatient Facility Admission - Planned

Room and Board, Other

0169

Inpatient Facility Admission - Planned

Nursery, General Classification

0170

Inpatient Facility Admission - Planned

Nursery, Newborn, Level I

0171

Inpatient Facility Admission - Planned

Nursery, Newborn, Level II

0172

Inpatient Facility Admission - Planned

Nursery, Newborn, Level III

0173

Inpatient Facility Admission - Planned

Nursery, Newborn, Level IV

0174

Inpatient Facility Admission - Planned

Room and Board, Subacute Pediatric (Private Hospital)

0190

Inpatient Facility Admission - Planned

Room and Board, Subacute Adult (Private Hospital)

0199

Inpatient Facility Admission - Planned

Intensive Care, General Classification

0200

Inpatient Facility Admission - Planned

Intensive Care, Surgical

0201

Inpatient Facility Admission - Planned

Intensive Care, Medical

0202

Inpatient Facility Admission - Planned

Intensive Care, Pediatric

0203

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Intensive Care, Psychiatric

0204

Inpatient Facility Admission - Planned

Intensive Care, Psychiatric

0204

Inpatient Facility Admission - Planned

Intensive Care, Intermediate ICU

0206

Inpatient Facility Admission - Planned

Intensive Care, Burn Care

0207

Inpatient Facility Admission - Planned

Intensive Care, Trauma

0208

Inpatient Facility Admission - Planned

Intensive Care, Other

0209

Inpatient Facility Admission - Planned

Coronary Care, General Classification

0210

Inpatient Facility Admission - Planned

Coronary Care, Myocardial Infarction

0211

Inpatient Facility Admission - Planned

Coronary Care, Pulmonary Care

0212

Inpatient Facility Admission - Planned

Coronary Care, Intermediate CCU

0214

Inpatient Facility Admission - Planned

Coronary Care, Other

0219

Hospice

Inpatient respite care

0655

Hospice

General inpatient care (nonrespite)

0656

Inpatient Facility Admission - Planned

Lithotripsy, General Classification

0790

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Behavioral Health Treatments/Services Partial hospitalization - less intensive

0912

Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services

Behavioral Health Treatments/Services Partial hospitalization - intensive

0913

Gender Dysphoria and Gender Confirmation Treatment

SUBCUTANEOUS HORMONE PELLET IMPLANTATION

11980

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

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

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

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

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

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

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

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

Blepharoplasty (plastic surgery of the eyelids)

BLEPHAROPLASTY LOWER EYELID

15820

Blepharoplasty (plastic surgery of the eyelids)

BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD

15821

Blepharoplasty (plastic surgery of the eyelids)

BLEPHAROPLASTY UPPER EYELID

15822

Blepharoplasty (plastic surgery of the eyelids)

BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN

15823

Gender Dysphoria and Gender Confirmation Treatment

MASTECTOMY PARTIAL

19301

Gender Dysphoria and Gender Confirmation Treatment

MASTECTOMY SIMPLE COMPLETE

19303

Gender Dysphoria and Gender Confirmation Treatment

MASTECTOMY SUBCUTANEOUS

19304

Breast Reduction or Reconstructive Surgery

MASTOPEXY

19316

Breast Reduction or Reconstructive Surgery

REDUCTION MAMMAPLASTY

19318

Breast Reduction or Reconstructive Surgery

MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT

19324

Gender Dysphoria and Gender Confirmation Treatment

MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT

19324

Breast Reduction or Reconstructive Surgery

MAMMAPLASTY, AUGMENTATION; W/PROSTHETIC IMPLANT

19325

Gender Dysphoria and Gender Confirmation Treatment

MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT

19325

Breast Reduction or Reconstructive Surgery

REMOVAL, INTACT MAMMARY IMPLANT

19328

Breast Reduction or Reconstructive Surgery

REMOVAL, MAMMARY IMPLANT MATL

19330

Breast Reduction or Reconstructive Surgery

IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19340

Breast Reduction or Reconstructive Surgery

DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19342

Gender Dysphoria and Gender Confirmation Treatment

NIPPLE/AREOLA RECONSTRUCTION

19350

Breast Reduction or Reconstructive Surgery

CORRECTION OF INVERTED NIPPLES

19355

Gender Dysphoria and Gender Confirmation Treatment

BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ

19357

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Breast reconstruction with latissimus dorsi flap, without prosthetic implant

19361

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Breast reconstruction with free flap

19364

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Breast reconstruction with other technique

19366

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

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

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

Breast Reduction or Reconstructive Surgery

OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST

19370

Breast Reduction or Reconstructive Surgery

PERIPROSTHETIC CAPSULECTOMY, BREAST

19371

Breast Reduction or Reconstructive Surgery

REVISION OF RECONSTRUCTED BREAST

19380

Breast Reduction or Reconstructive Surgery

REVISION OF RECONSTRUCTED BREAST

19380

Breast Reduction or Reconstructive Surgery

PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT

19396

Xiaflex® (collagenase clostridium histolyticum)

INJECTION ENZYME PALMAR FASCIAL CORD

20527

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Bone graft, any donor area; minor or small (e.g., dowel or button)

20900

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Bone graft, any donor area; major or large

20902

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

GENIOPLASTY AUGMENTATION

21120

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE

21121

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

GENIOPLASTY 2/> SLIDING OSTEOTOMIES

21122

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS

21123

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL

21125

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL

21127

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT

21141

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT

21142

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT

21143

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS

21145

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS

21146

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS

21147

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF

21193

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT

21194

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD

21195

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI

21196

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

OSTEOTOMY MANDIBLE SEGMENTAL

21198

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT

21199

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

OSTEOTOMY MAXILLA SEGMENTAL

21206

Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies)

HYOID MYOTOMY & SUSPENSION

21685

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Reconstructive repair of pectus excavatum or carinatum; open

21740

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy

21742

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy

21743

Spinal Fusion (Elective)

ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR

22533

Spinal Fusion (Elective)

ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR

22534

Spinal Fusion (Elective)

ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2

22551

Spinal Fusion (Elective)

ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC

22552

Spinal Fusion (Elective)

ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2

22554

Spinal Fusion (Elective)

ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC

22556

Spinal Fusion (Elective)

ARTHRODESIS ANTERIOR INTERBODY LUMBAR

22558

Spinal Fusion (Elective)

ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC

22585

Spinal Fusion (Elective)

ARTHRODESIS POSTERIOR/ POSTEROLATERAL LUMBAR

22612

Spinal Fusion (Elective)

ARTHRODESIS POSTERIOR/ POSTEROLATERAL EA ADDL

22614

Spinal Fusion (Elective)

ARTHRODESIS POSTERIOR INTERBODY LUMBAR

22630

Spinal Fusion (Elective)

ARTHRODESIS POSTERIOR INTERBODY EA ADDL

22632

Spinal Fusion (Elective)

ARTHDSIS POST/ POSTEROLATRL/ POSTINTERBODY LUMBAR

22633

Spinal Fusion (Elective)

ARTHDSIS POST/ POSTEROLATRL/ POSTINTRBDYADL SPC/ SEG

22634

Sacroiliac Joint Injection

INJECT SI JOINT ARTHRGRPHY&/ ANES/ STEROID W/ IMA

27096

Sacroiliac Joint Fusion

ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS

27279

Autologous cultured chondrocyte (MACI)

AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE

27412

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

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

Rhinoplasty including major septal repair

RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI

30400

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

Rhinoplasty including major septal repair

RHINP PRIM COMPLETE XTRNL PARTS

30410

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

Rhinoplasty including major septal repair

RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR

30420

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

Rhinoplasty including major septal repair

RHINOPLASTY SECONDARY MINOR REVISION

30430

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

Rhinoplasty including major septal repair

RHINOPLASTY SECONDARY INTERMEDIATE REVISION

30435

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

Rhinoplasty including major septal repair

RHINOPLASTY SECONDARY MAJOR REVISION

30450

Rhinoplasty including major septal repair

SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF

30520

Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries

SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF

30520

Rhinoplasty including major septal repair

SEPTAL/OTHER INTRANASAL DERMATOPLASTY

30620

Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries

SEPTAL/OTHER INTRANASAL DERMATOPLASTY

30620

Gender Dysphoria and Gender Confirmation Treatment

LARYNGOPLASTY CRICOID SPLIT

31587

Bronchial Thermoplasty

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe

31660

Bronchial Thermoplasty

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

31661

Gender Dysphoria and Gender Confirmation Treatment

TRACHEOPLASTY CERVICAL

31750

Lung Volume Reduction Surgery

RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG

32491

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR PNEUMONECTOMY FROM CADAVER DONOR

32850

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

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

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

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

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

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR CARDIECTOMY-PNEUMONECTOMY

33930

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR CARDIECTOMY

33940

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

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

Ventricular Assist Device (VAD)

Insertion of ventricular assist device; extracorporeal, single ventricle

33975

Ventricular Assist Device (VAD)

Insertion of ventricular assist device; extracorporeal, biventricular

33976

Ventricular Assist Device (VAD)

Removal of ventricular assist device; extracorporeal, single ventricle

33977

Ventricular Assist Device (VAD)

Removal of ventricular assist device; extracorporeal, biventricular

33978

Ventricular Assist Device (VAD)

Insertion of ventricular assist device, implantable intracorporeal, single ventricle

33979

Ventricular Assist Device (VAD)

Removal of ventricular assist device, implantable intracorporeal, single ventricular

33980

Ventricular Assist Device (VAD)

Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump

33981

Ventricular Assist Device (VAD)

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass

33982

Ventricular Assist Device (VAD)

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass

33983

Ventricular Assist Device (VAD)

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only

33990

Ventricular Assist Device (VAD)

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture

33991

Ventricular Assist Device (VAD)

Removal of percutaneous ventricular assist device at separate and distinct session from insertion

33992

Ventricular Assist Device (VAD)

Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion

33993

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

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

Varicose Vein Treatments

1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK

36468

Varicose Vein Treatments

NJX SCLEROSING SOLUTION SINGLE VEIN

36470

Varicose Vein Treatments

NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG

36471

Varicose Vein Treatments

NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG

36471

Varicose Vein Treatments

ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED

36473

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

Varicose Vein Treatments

ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN

36475

Varicose Vein Treatments

ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS

36476

Varicose Vein Treatments

ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN

36478

Varicose Vein Treatments

ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS

36479

Varicose Vein Treatments

36482

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

Intrathecal Infusion Pump

Insertion of tunneled centrally inserted central venous access device with subcutaneous pump

36563

Varicose Vein Treatments

VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX

37500

Varicose Vein Treatments

LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ

37700

Varicose Vein Treatments

LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN

37718

Varicose Vein Treatments

LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW

37722

Varicose Vein Treatments

LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS

37735

Varicose Vein Treatments

LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG

37760

Varicose Vein Treatments

LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG

37761

Varicose Vein Treatments

STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS

37765

Varicose Vein Treatments

STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS

37766

Varicose Vein Treatments

LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX

37780

Varicose Vein Treatments

LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG

37785

Varicose Vein Treatments

UNLISTED PROCEDURE VASCULAR SURGERY

37799

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

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

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

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

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

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

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

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

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

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC

38230

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS

38232

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

ALLOGENEIC LYMPHOCYTE INFUSIONS

38242

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

TRNSPLJ HEMATOPOIETIC CELL BOOST

38243

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

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

Magnetic Esophageal Sphincter Augmentation (LINX)

Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed

43284

Magnetic Esophageal Sphincter Augmentation (LINX)

Removal of esophageal sphincter augmentation device

43285

Obesity Surgery

LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM

43644

Obesity Surgery

LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ

43645

Gastric Electrical Stimulation

LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM

43647

Gastric Electrical Stimulation

LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM

43648

Obesity Surgery

LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE

43770

Obesity Surgery

LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE

43771

Obesity Surgery

LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE

43772

Obesity Surgery

LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE

43773

Obesity Surgery

LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT

43774

Obesity Surgery

LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY

43775

Obesity Surgery

GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY

43842

Obesity Surgery

GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP

43843

Obesity Surgery

GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM

43845

Obesity Surgery

GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<

43846

Obesity Surgery

GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ

43847

Obesity Surgery

REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE

43848

Gastric Electrical Stimulation

IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN

43881

Obesity Surgery

GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY

43886

Obesity Surgery

GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY

43887

Obesity Surgery

GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT

43888

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR

44135

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

INTESTINAL ALLOTRANSPLANTATION LIVING DONOR

44136

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR HEPATECTOMY CADAVER DONOR

47133

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

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

BKBENCH PREP CADAVER DONOR

47143

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

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

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT

48550

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

TRANSPLANTATION PANCREATIC ALLOGRAFT

48554

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

RMVL TRANSPLANTED PANCREATIC ALLOGRAFT

48556

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

DONOR NEPHRECTOMY OPEN LIVING DONOR

50320

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

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

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

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE

50340

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

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

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

RMVL TRNSPLED RENAL ALLOGRAFT

50370

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY

50380

Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ)

LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR

50547

Gender Dysphoria and Gender Confirmation Treatment

URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT

53415

Gender Dysphoria and Gender Confirmation Treatment

URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE

53420

Gender Dysphoria and Gender Confirmation Treatment

URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE

53425

Gender Dysphoria and Gender Confirmation Treatment

URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE

53425

Gender Dysphoria and Gender Confirmation Treatment

URETHROPLASTY RCNSTJ FEMALE URETHRA

53430

Gender Dysphoria and Gender Confirmation Treatment

AMPUTATION PENIS PARTIAL

54120

Gender Dysphoria and Gender Confirmation Treatment

AMPUTATION PENIS COMPLETE

54125

Gender Dysphoria and Gender Confirmation Treatment

INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID

54400

Gender Dysphoria and Gender Confirmation Treatment

INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED

54401

Gender Dysphoria and Gender Confirmation Treatment

INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH

54405

Gender Dysphoria and Gender Confirmation Treatment

RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH

54406

Gender Dysphoria and Gender Confirmation Treatment

RPR COMPONENT INFLATABLE PENILE PROSTHESIS

54408

Gender Dysphoria and Gender Confirmation Treatment

RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS

54410

Gender Dysphoria and Gender Confirmation Treatment

RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL

54411

Gender Dysphoria and Gender Confirmation Treatment

RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT

54415

Gender Dysphoria and Gender Confirmation Treatment

RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI

54416

Gender Dysphoria and Gender Confirmation Treatment

RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD

54417

Gender Dysphoria and Gender Confirmation Treatment

ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH

54520

Gender Dysphoria and Gender Confirmation Treatment

INSJ TESTICULAR PROSTH SEPARATE PROCEDURE

54660

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY SURGICAL ORCHIECTOMY

54690

Gender Dysphoria and Gender Confirmation Treatment

SCROTOPLASTY SIMPLE

55175

Gender Dysphoria and Gender Confirmation Treatment

SCROTOPLASTY COMPLICATED

55180

Gender Dysphoria and Gender Confirmation Treatment

UNLISTED PROCEDURE MALE GENITAL SYSTEM

55899

Gender Dysphoria and Gender Confirmation Treatment

INTERSEX SURG MALE FEMALE

55970

Gender Dysphoria and Gender Confirmation Treatment

INTERSEX SURG FEMALE MALE

55980

Gender Dysphoria and Gender Confirmation Treatment

VULVECTOMY SIMPLE COMPLETE

56625

Gender Dysphoria and Gender Confirmation Treatment

PLASTIC REPAIR INTROITUS

56800

Gender Dysphoria and Gender Confirmation Treatment

CLITOROPLASTY INTERSEX STATE

56805

Gender Dysphoria and Gender Confirmation Treatment

PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX

56810

Gender Dysphoria and Gender Confirmation Treatment

VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL

57106

Gender Dysphoria and Gender Confirmation Treatment

VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T

57107

Gender Dysphoria and Gender Confirmation Treatment

VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL

57110

Gender Dysphoria and Gender Confirmation Treatment

VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS

57111

Gender Dysphoria and Gender Confirmation Treatment

CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT

57291

Gender Dysphoria and Gender Confirmation Treatment

CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT

57292

Gender Dysphoria and Gender Confirmation Treatment

REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP

57295

Gender Dysphoria and Gender Confirmation Treatment

REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR

57296

Gender Dysphoria and Gender Confirmation Treatment

VAGINOPLASTY INTERSEX STATE

57335

Gender Dysphoria and Gender Confirmation Treatment

TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY

58150

Gender Dysphoria and Gender Confirmation Treatment

SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY

58180

Gender Dysphoria and Gender Confirmation Treatment

VAGINAL HYSTERECTOMY UTERUS 250 GM/<

58260

Gender Dysphoria and Gender Confirmation Treatment

VAG HYST 250 GM/< W/RMVL TUBE&/OVARY

58262

Gender Dysphoria and Gender Confirmation Treatment

VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY

58275

Gender Dysphoria and Gender Confirmation Treatment

VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE

58280

Gender Dysphoria and Gender Confirmation Treatment

VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION

58285

Gender Dysphoria and Gender Confirmation Treatment

VAGINAL HYSTERECTOMY UTERUS > 250 GM

58290

Gender Dysphoria and Gender Confirmation Treatment

VAG HYST > 250 GM RMVL TUBE&/OVARY

58291

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/<

58541

Gender Dysphoria and Gender Confirmation Treatment

LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR

58542

Gender Dysphoria and Gender Confirmation Treatment

LAPS SUPRACERVICAL HYSTERECTOMY >250

58543

Gender Dysphoria and Gender Confirmation Treatment

LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY

58544

Gender Dysphoria and Gender Confirmation Treatment

LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/<

58550

Gender Dysphoria and Gender Confirmation Treatment

LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES

58552

Gender Dysphoria and Gender Confirmation Treatment

LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS

58553

Gender Dysphoria and Gender Confirmation Treatment

LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR

58554

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/<

58570

Gender Dysphoria and Gender Confirmation Treatment

LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY

58571

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM

58572

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR

58573

Gender Dysphoria and Gender Confirmation Treatment

LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES

58661

Gender Dysphoria and Gender Confirmation Treatment

SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX

58720

Gender Dysphoria and Gender Confirmation Treatment

OOPHORECTOMY PARTIAL/TOTAL UNI/BI

58940

Fetal Surgery (surgery on the unborn child)

FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE

59072

Fetal Surgery (surgery on the unborn child)

FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE

59074

Fetal Surgery (surgery on the unborn child)

FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE

59076

Termination of Pregnancy (Abortion)

INDUCED ABORTION DILATION AND CURETTAGE

59840

Termination of Pregnancy (Abortion)

INDUCED ABORTION DILATION & EVACUATION

59841

Termination of Pregnancy (Abortion)

INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ

59850

Termination of Pregnancy (Abortion)

INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C

59851

Termination of Pregnancy (Abortion)

INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM

59852

Termination of Pregnancy (Abortion)

INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS

59855

Termination of Pregnancy (Abortion)

INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC

59856

Termination of Pregnancy (Abortion)

INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT

59857

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

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

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

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

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

Deep Brain Stimulation

TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL

61850

Deep Brain Stimulation

CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL

61860

Deep Brain Stimulation

STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY

61863

Deep Brain Stimulation

STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY

61864

Deep Brain Stimulation

STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY

61867

Deep Brain Stimulation

STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY

61868

Deep Brain Stimulation

CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL

61870

Deep Brain Stimulation

INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR

61885

Vagal Nerve Stimulation

INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR

61885

Deep Brain Stimulation

INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS

61886

Vagal Nerve Stimulation

INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS

61886

Epidural Lysis of Adhesions

PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS

62263

Epidural Lysis of Adhesions

PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY

62264

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

Epidural Injections

62321

Epidural Injections

62322

Epidural Injections

62323

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

Intrathecal Infusion Pump

62325

Intrathecal Infusion Pump

62326

Intrathecal Infusion Pump

62327

Intrathecal Infusion Pump

IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM

62350

Intrathecal Infusion Pump

IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM

62351

Intrathecal Infusion Pump

IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR

62360

Intrathecal Infusion Pump

IMPLTJ/RPLCMT FS NON-PRGRBL PUMP

62361

Intrathecal Infusion Pump

IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP

2020 Prior Auth List