| Service Description: |
Injection, aripiprazole, extended release, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0401 |
| Service Code Type: |
HCPCS |
| Effective Date: |
8/15/2013 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, aripiprazole, extended release, 1 mg |
| Comments: |
|
|
Abilify Maintena® (aripiprazole) |
Injection, aripiprazole, extended release, 1 mg |
J0401 |
| Service Description: |
Injection, paclitaxel protein-bound particles, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9264 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, paclitaxel protein-bound particles, 1 mg |
| Comments: |
|
|
Abraxane® (paclitaxel protein-bound particles) |
Injection, paclitaxel protein-bound particles, 1 mg |
J9264 |
| Service Description: |
Injection, tocilizumab, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J3262 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2010 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, tocilizumab, 1 mg |
| Comments: |
|
|
Actemra® (tocilizumab) |
Injection, tocilizumab, 1 mg |
J3262 |
| Service Description: |
Injection, crizanlizumab-tmca, 5 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0791 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, crizanlizumab-tmca, 5 mg |
| Comments: |
|
|
Adakveo (crizanlizumab-tmca) |
Injection, crizanlizumab-tmca, 5 mg |
J0791 |
| Service Description: |
Injection, brentuximab vedotin, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9042 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/15/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, brentuximab vedotin, 1 mg |
| Comments: |
|
|
Adcetris (brentuximab vedotin) |
Injection, brentuximab vedotin, 1 mg |
J9042 |
| Service Description: |
Skilled Nursing Facility |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0022 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Skilled Nursing Facility |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Skilled Nursing Facility |
0022 |
| Service Description: |
Room and Board, Subacute Pediatric (Private Hospital) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0190 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board, Subacute Pediatric (Private Hospital) |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Pediatric (Private Hospital) |
0190 |
| Service Description: |
Subacute Care - Level I |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0191 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Subacute Care - Level I |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level I |
0191 |
| Service Description: |
Subacute Care - Level II |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0192 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Subacute Care - Level II |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level II |
0192 |
| Service Description: |
Subacute Care - Level III |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0193 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Subacute Care - Level III |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level III |
0193 |
| Service Description: |
Subacute Care - Level IV |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0194 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Subacute Care - Level IV |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Subacute Care - Level IV |
0194 |
| Service Description: |
Room and Board, Subacute Adult (Private Hospital) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0199 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/1996 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board, Subacute Adult (Private Hospital) |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Adult (Private Hospital) |
0199 |
| Service Description: |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81479 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
| Comments: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
81479 |
| Service Description: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81599 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
| Comments: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
81599 |
| Service Description: |
Unlisted chemistry procedure |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
84999 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unlisted chemistry procedure |
| Comments: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted chemistry procedure |
84999 |
| Service Description: |
Unlisted miscellaneous pathology test |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
89240 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unlisted miscellaneous pathology test |
| Comments: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted miscellaneous pathology test |
89240 |
| Service Description: |
Injection, laronidase, 0.1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1931 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, laronidase, 0.1 mg |
| Comments: |
|
|
Aldurazyme® (laronidase) |
Injection, laronidase, 0.1 mg |
J1931 |
| Service Description: |
Injection, copanlisib, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9057 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, copanlisib, 1 mg |
| Comments: |
|
|
Aliqopa (copanlisib) |
Injection, copanlisib, 1 mg |
J9057 |
| Service Description: |
Injection, palonosetron hcl, 25 mcg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J2469 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, palonosetron hcl, 25 mcg |
| Comments: |
|
|
Aloxi (palonosetron) |
Injection, palonosetron hcl, 25 mcg |
J2469 |
| Service Description: |
Aminolevulinic acid, 10% gel |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7345 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Aminolevulinic acid, 10% gel |
| Comments: |
|
|
Ameluz (aminolevulinic acid) |
Aminolevulinic acid, 10% gel |
J7345 |
| Service Description: |
Injection, pemetrexed, 10 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9305 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, pemetrexed, 10 mg |
| Comments: |
|
|
Amilta (pemetrexed) |
Injection, pemetrexed, 10 mg |
J9305 |
| Service Description: |
Andexxa (adnexanet alfa) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9041 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Andexxa (adnexanet alfa) |
| Comments: |
|
|
Andexxa (adnexanet alfa) |
Andexxa (adnexanet alfa) |
C9041 |
| Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J0256 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
| Comments: |
|
|
Aralast™ (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
| Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0881 |
| Service Code Type: |
HCPCS |
| Effective Date: |
6/15/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
| Comments: |
|
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
| Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0882 |
| Service Code Type: |
HCPCS |
| Effective Date: |
6/15/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
| Comments: |
|
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
| Service Description: |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1943 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
| Comments: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
J1943 |
| Service Description: |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1944 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
| Comments: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
J1944 |
| Service Description: |
Injection, nelarabine, 50 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9261 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, nelarabine, 50 mg |
| Comments: |
|
|
Arranon® (nelarabine) |
Injection, nelarabine, 50 mg |
J9261 |
| Service Description: |
Injection, ofatumumab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9302 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2010 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, ofatumumab, 10 mg |
| Comments: |
|
|
Arzerra™ (ofatumumab) |
Injection, ofatumumab, 10 mg |
J9302 |
| Service Description: |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27412 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
| Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
27412 |
| Service Description: |
Autologous cultured chondrocytes, implant |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7330 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Autologous cultured chondrocytes, implant |
| Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
Autologous cultured chondrocytes, implant |
J7330 |
| Service Description: |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2112 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
| Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
S2112 |
| Service Description: |
Injection, testosterone undecanoate, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3145 |
| Service Code Type: |
HCPCS |
| Effective Date: |
12/1/2014 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, testosterone undecanoate, 1 mg |
| Comments: |
|
|
Aveed® (testosterone) |
Injection, testosterone undecanoate, 1 mg |
J3145 |
| Service Description: |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q5121 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
| Comments: |
|
|
Avsola (injection, infliximab-axxq, biosimilar) |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
Q5121 |
| Service Description: |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0714 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2016 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
| Comments: |
|
|
Avycaz® (ceftazidime/avibactam) |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
J0714 |
| Service Description: |
Azedra (iobenguane i 131) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9407 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Azedra (iobenguane i 131) |
| Comments: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9407 |
| Service Description: |
Azedra (iobenguane i 131) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9408 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Azedra (iobenguane i 131) |
| Comments: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9408 |
| Service Description: |
Injection, avelumab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9023 |
| Service Code Type: |
HCPCS |
| Effective Date: |
8/15/2017 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, avelumab, 10 mg |
| Comments: |
|
|
Bavencio (avelumab) |
Injection, avelumab, 10 mg |
J9023 |
| Service Description: |
Baxdela (delafloxacin) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9462 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Baxdela (delafloxacin) |
| Comments: |
|
|
Baxdela (delafloxacin) |
Baxdela (delafloxacin) |
C9462 |
| Service Description: |
ALCOHL&/RX SRVC; INTENSV OP; INTRVN |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0015 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ALCOHL&/RX SRVC; INTENSV OP; INTRVN |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHL&/RX SRVC; INTENSV OP; INTRVN |
H0015 |
| Service Description: |
ALCOHL&/RX SRVC;METHDONE ADMN&/SRVC |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0020 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ALCOHL&/RX SRVC;METHDONE ADMN&/SRVC |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHL&/RX SRVC;METHDONE ADMN&/SRVC |
H0020 |
| Service Description: |
MENTAL HEALTH PART HOSP TX < 24 HR |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0035 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MENTAL HEALTH PART HOSP TX < 24 HR |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
MENTAL HEALTH PART HOSP TX < 24 HR |
H0035 |
| Service Description: |
ALCOHOL &OR OTH DRUG ABS SRVC NOS |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0047 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ALCOHOL &OR OTH DRUG ABS SRVC NOS |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHOL &OR OTH DRUG ABS SRVC NOS |
H0047 |
| Service Description: |
ALCOHOL &OR OTH DRUG TX PROGM-DIEM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H2036 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ALCOHOL &OR OTH DRUG TX PROGM-DIEM |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHOL &OR OTH DRUG TX PROGM-DIEM |
H2036 |
| Service Description: |
PART HOSITALIZATN SRVC<24 HR-DIEM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S0201 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PART HOSITALIZATN SRVC<24 HR-DIEM |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
PART HOSITALIZATN SRVC<24 HR-DIEM |
S0201 |
| Service Description: |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S9475 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
S9475 |
| Service Description: |
INTENSIVE OP PSYC SERVICES PER DIEM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S9480 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
INTENSIVE OP PSYC SERVICES PER DIEM |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
INTENSIVE OP PSYC SERVICES PER DIEM |
S9480 |
| Service Description: |
Electroconvulsive therapy; includes necessary monitoring |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
90870 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Electroconvulsive therapy; includes necessary monitoring |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Outpatient electro-convulsive treatment |
Electroconvulsive therapy; includes necessary monitoring |
90870 |
| Service Description: |
Room and Board – Private, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0114 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board – Private, Psychiatric |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Private, Psychiatric |
0114 |
| Service Description: |
Detoxification Room and Board Private (one bed) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0116 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Detoxification Room and Board Private (one bed) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Private (one bed) |
0116 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0124 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 2 Bed, Psychiatric |
0124 |
| Service Description: |
Detoxification Room and Board Semiprivate (two beds) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0126 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Detoxification Room and Board Semiprivate (two beds) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Semiprivate (two beds) |
0126 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0134 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
0134 |
| Service Description: |
Detoxification Room and Board (3 and 4 beds) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0136 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Detoxification Room and Board (3 and 4 beds) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board (3 and 4 beds) |
0136 |
| Service Description: |
Psychiatric Room and Board Deluxe Private |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0144 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Psychiatric Room and Board Deluxe Private |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Psychiatric Room and Board Deluxe Private |
0144 |
| Service Description: |
Detoxification Room and Board Deluxe Private |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0146 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Detoxification Room and Board Deluxe Private |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Deluxe Private |
0146 |
| Service Description: |
Room and Board – Ward (Medical or General), Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0154 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Room and Board – Ward (Medical or General), Psychiatric |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Ward (Medical or General), Psychiatric |
0154 |
| Service Description: |
Detoxification Room and Board Ward |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0156 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Detoxification Room and Board Ward |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Ward |
0156 |
| Service Description: |
Intensive Care, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0204 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Intensive Care, Psychiatric |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Intensive Care, Psychiatric |
0204 |
| Service Description: |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0912 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
0912 |
| Service Description: |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0913 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
0913 |
| Service Description: |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0008 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/1900 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
H0008 |
| Service Description: |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0009 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/1900 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
H0009 |
| Service Description: |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0010 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/1900 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
H0010 |
| Service Description: |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0011 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/1900 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
H0011 |
| Service Description: |
BHVAL HEALTH; RES W/O ROOM&BD-DIEM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0017 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BHVAL HEALTH; RES W/O ROOM&BD-DIEM |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
BHVAL HEALTH; RES W/O ROOM&BD-DIEM |
H0017 |
| Service Description: |
BHVAL HLTH; SHRT-TERM RES PER DIEM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
H0018 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BHVAL HLTH; SHRT-TERM RES PER DIEM |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
BHVAL HLTH; SHRT-TERM RES PER DIEM |
H0018 |
| Service Description: |
Injection, belinostat, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9032 |
| Service Code Type: |
HCPCS |
| Effective Date: |
12/1/2014 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, belinostat, 10 mg |
| Comments: |
|
|
Beleodaq® (belinostat) |
Injection, belinostat, 10 mg |
J9032 |
| Service Description: |
Injection, belimumab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0490 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, belimumab, 10 mg |
| Comments: |
|
|
Benlysta® (belimumab) |
Injection, belimumab, 10 mg |
J0490 |
| Service Description: |
Injection, brolucizumab-dbll, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0179 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, brolucizumab-dbll, 1 mg |
| Comments: |
|
|
Beovu (brolucizumab-dbll) |
Injection, brolucizumab-dbll, 1 mg |
J0179 |
| Service Description: |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0597 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
| Comments: |
|
|
Berinert® (C1 esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
J0597 |
| Service Description: |
Injection, inotuzumab ozogamicin, 0.1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9229 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, inotuzumab ozogamicin, 0.1 mg |
| Comments: |
|
|
Besponsa |
Injection, inotuzumab ozogamicin, 0.1 mg |
J9229 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15271 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
Each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15272 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15273 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15274 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15275 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15276 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
each additional 25 sq. cm wound surface area, or part thereof) (List separately in addition to code for primary procedure |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15277 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15278 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9250 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
| Comments: |
|
|
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 |
| Service Description: |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9363 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
| Comments: |
|
|
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 |
| Service Description: |
Biobrane Biosynthetic Dressing |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4100 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Biobrane Biosynthetic Dressing |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Biobrane Biosynthetic Dressing |
Q4100 |
| Service Description: |
Epicel |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4100 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Epicel |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epicel |
Q4100 |
| Service Description: |
Skin substitute, not otherwise specified |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4100 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Skin substitute, not otherwise specified |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Skin substitute, not otherwise specified |
Q4100 |
| Service Description: |
Apligraf, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4101 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Apligraf, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Apligraf, per square centimeter |
Q4101 |
| Service Description: |
Oasis wound matrix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4102 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Oasis wound matrix, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Oasis wound matrix, per square centimeter |
Q4102 |
| Service Description: |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4104 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
| Comments: |
|
|
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 |
| Service Description: |
Integra dermal regeneration template (drt), per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4105 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Integra dermal regeneration template (drt), per square centimeter |
| Comments: |
|
|
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 |
| Service Description: |
Dermagraft, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4106 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Dermagraft, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermagraft, per square centimeter |
Q4106 |
| Service Description: |
Graftjacket, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4107 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Graftjacket, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket, per square centimeter |
Q4107 |
| Service Description: |
Integra matrix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4108 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Integra matrix, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra matrix, per square centimeter |
Q4108 |
| Service Description: |
Primatrix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4110 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Primatrix, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Primatrix, per square centimeter |
Q4110 |
| Service Description: |
Graftjacket xpress, injectable, 1cc |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4113 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Graftjacket xpress, injectable, 1cc |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket xpress, injectable, 1cc |
Q4113 |
| Service Description: |
Alloderm, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4116 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Alloderm, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Alloderm, per square centimeter |
Q4116 |
| Service Description: |
Matristem wound matrix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4119 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Matristem wound matrix, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Matristem wound matrix, per square centimeter |
Q4119 |
| Service Description: |
Theraskin, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4121 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Theraskin, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Theraskin, per square centimeter |
Q4121 |
| Service Description: |
Dermacell, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4122 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Dermacell, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermacell, per square centimeter |
Q4122 |
| Service Description: |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4128 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
| Comments: |
|
|
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 |
| Service Description: |
Strattice tm, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4130 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Strattice tm, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Strattice tm, per square centimeter |
Q4130 |
| Service Description: |
Grafix prime, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4133 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Grafix prime, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Grafix prime, per square centimeter |
Q4133 |
| Service Description: |
Epifix, injectable, 1 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4145 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Epifix, injectable, 1 mg |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, injectable, 1 mg |
Q4145 |
| Service Description: |
Transcyte, per sq centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4182 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Transcyte, per sq centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Transcyte, per sq centimeter |
Q4182 |
| Service Description: |
Epifix, per square centimeter |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4186 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Epifix, per square centimeter |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, per square centimeter |
Q4186 |
| Service Description: |
PURAPLY AM PER SQ CM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4196 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PURAPLY AM PER SQ CM |
| Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
PURAPLY AM PER SQ CM |
Q4196 |
| Service Description: |
BIOFEEDBACK TRAINING ANY MODALITY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
90901 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BIOFEEDBACK TRAINING ANY MODALITY |
| Comments: |
|
|
Biofeedback for Non Behavioral Health diagnoses |
BIOFEEDBACK TRAINING ANY MODALITY |
90901 |
| Service Description: |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
90911 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
| Comments: |
|
|
Biofeedback for Non Behavioral Health diagnoses |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
90911 |
| Service Description: |
BLEPHAROPLASTY LOWER EYELID |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15820 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BLEPHAROPLASTY LOWER EYELID |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID |
15820 |
| Service Description: |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15821 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
15821 |
| Service Description: |
BLEPHAROPLASTY UPPER EYELID |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15822 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BLEPHAROPLASTY UPPER EYELID |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID |
15822 |
| Service Description: |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15823 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
15823 |
| Service Description: |
REPAIR BROW PTOSIS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67900 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
REPAIR BROW PTOSIS |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
REPAIR BROW PTOSIS |
67900 |
| Service Description: |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67901 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
67901 |
| Service Description: |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67902 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
67902 |
| Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67903 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
67903 |
| Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67904 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
67904 |
| Service Description: |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67906 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
67906 |
| Service Description: |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67908 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
67908 |
| Service Description: |
REVISION OF EYELID |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67950 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
REVISION OF EYELID |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
REVISION OF EYELID |
67950 |
| Service Description: |
Injection, blinatumomab, 1 microgram |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9039 |
| Service Code Type: |
HCPCS |
| Effective Date: |
5/15/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, blinatumomab, 1 microgram |
| Comments: |
|
|
Blincyto® (blintatumomab) |
Injection, blinatumomab, 1 microgram |
J9039 |
| Service Description: |
Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7169 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg |
J7169 |
| Service Description: |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7180 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
J7180 |
| Service Description: |
Injection, factor xiii a-subunit, (recombinant), per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7181 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor xiii a-subunit, (recombinant), per iu |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii a-subunit, (recombinant), per iu |
J7181 |
| Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7182 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
J7182 |
| Service Description: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7183 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
J7183 |
| Service Description: |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7185 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
J7185 |
| Service Description: |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7186 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
| Comments: |
|
|
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 |
| Service Description: |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7187 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
J7187 |
| Service Description: |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7188 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
J7188 |
| Service Description: |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7189 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
J7189 |
| Service Description: |
Factor viii (antihemophilic factor, human) per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7190 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor viii (antihemophilic factor, human) per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, human) per i.u. |
J7190 |
| Service Description: |
Factor viii (antihemophilic factor (porcine)), per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7191 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor viii (antihemophilic factor (porcine)), per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor (porcine)), per i.u. |
J7191 |
| Service Description: |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7192 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
J7192 |
| Service Description: |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7193 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
J7193 |
| Service Description: |
Factor ix, complex, per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7194 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Factor ix, complex, per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix, complex, per i.u. |
J7194 |
| Service Description: |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7195 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
J7195 |
| Service Description: |
Injection, antithrombin recombinant, 50 i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7196 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, antithrombin recombinant, 50 i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, antithrombin recombinant, 50 i.u. |
J7196 |
| Service Description: |
Antithrombin iii (human), per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7197 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Antithrombin iii (human), per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Antithrombin iii (human), per i.u. |
J7197 |
| Service Description: |
Anti-inhibitor, per i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7198 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Anti-inhibitor, per i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Anti-inhibitor, per i.u. |
J7198 |
| Service Description: |
Hemophilia clotting factor, not otherwise classified |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7199 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Hemophilia clotting factor, not otherwise classified |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Hemophilia clotting factor, not otherwise classified |
J7199 |
| Service Description: |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7200 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
J7200 |
| Service Description: |
Injection, factor ix, fc fusion protein (recombinant), per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7201 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor ix, fc fusion protein (recombinant), per iu |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, fc fusion protein (recombinant), per iu |
J7201 |
| Service Description: |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7202 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
J7202 |
| Service Description: |
Injection, factor viii fc fusion protein (recombinant), per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7205 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii fc fusion protein (recombinant), per iu |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii fc fusion protein (recombinant), per iu |
J7205 |
| Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7207 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
J7207 |
| Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7209 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
| Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
J7209 |
| Service Description: |
Injection, cerliponase alfa, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0567 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, cerliponase alfa, 1 mg |
| Comments: |
|
|
Brineura (injection, cerliponase alfa) |
Injection, cerliponase alfa, 1 mg |
J0567 |
| Service Description: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31660 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
| Comments: |
|
|
Bronchial Thermoplasty |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
31660 |
| Service Description: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31661 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
| Comments: |
|
|
Bronchial Thermoplasty |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
31661 |
| Service Description: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1566 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
| Comments: |
|
|
Carimune (intraveneous immune globulin) |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
J1566 |
| Service Description: |
Injection, imiglucerase, 10 units |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1786 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2008 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, imiglucerase, 10 units |
| Comments: |
|
|
Cerezyme® (imiglucerase) |
Injection, imiglucerase, 10 units |
J1786 |
| Service Description: |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
46505 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
46505 |
| Service Description: |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
52287 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
52287 |
| Service Description: |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64611 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
64611 |
| Service Description: |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64612 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
64612 |
| Service Description: |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64615 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
64615 |
| Service Description: |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64616 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
64616 |
| Service Description: |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64617 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
64617 |
| Service Description: |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64642 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
64642 |
| Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64643 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
| Service Description: |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64644 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
64644 |
| Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64645 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
64645 |
| Service Description: |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64646 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
64646 |
| Service Description: |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64647 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
64647 |
| Service Description: |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64650 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
64650 |
| Service Description: |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64653 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
64653 |
| Service Description: |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
67345 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2000 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
67345 |
| Service Description: |
Injection, onabotulinumtoxina, 1 unit |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0585 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, onabotulinumtoxina, 1 unit |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
Injection, onabotulinumtoxina, 1 unit |
J0585 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0717 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
Injection, reslizumab, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J2786 |
| Service Code Type: |
HCPCS |
| Effective Date: |
12/15/2016 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, reslizumab, 1 mg |
| Comments: |
|
|
Cinqair (reslizumab) |
Injection, reslizumab, 1 mg |
J2786 |
| Service Description: |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0598 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
| Comments: |
|
|
Cinryze™ (C1-esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
J0598 |
| Service Description: |
Injection, clofarabine, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9027 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, clofarabine, 1 mg |
| Comments: |
|
|
Clolar® (clofarabine) |
Injection, clofarabine, 1 mg |
J9027 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81228 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81229 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities |
| Comments: |
|
|
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 |
| Service Description: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
S3870 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
| Comments: |
|
|
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 |
| Service Description: |
Unclassified drugs or biologicals |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9399 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs or biologicals |
| Comments: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs or biologicals |
C9399 |
| Service Description: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3490 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs |
| Comments: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs |
J3490 |
| Service Description: |
Cranial prosthesis |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
D5924 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Cranial prosthesis |
| Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial prosthesis |
D5924 |
| Service Description: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L0112 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
| Comments: |
|
|
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 |
| Service Description: |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L0113 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
| Comments: |
|
|
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 |
| Service Description: |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S1040 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
| Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
S1040 |
| Service Description: |
Injection, isavuconazonium, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1833 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2016 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, isavuconazonium, 1 mg |
| Comments: |
|
|
Cresemba® IV (isavuconazonium sulfate) |
Injection, isavuconazonium, 1 mg |
J1833 |
| Service Description: |
Injection, burosumab-twza 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0584 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, burosumab-twza 1 mg |
| Comments: |
|
|
Crysvita (burosumab-twza) |
Injection, burosumab-twza 1 mg |
J0584 |
| Service Description: |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70450 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
70450 |
| Service Description: |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70460 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
70460 |
| Service Description: |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70470 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
70470 |
| Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70480 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
70480 |
| Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70481 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
70481 |
| Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70482 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
70482 |
| Service Description: |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70486 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
70486 |
| Service Description: |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70487 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
70487 |
| Service Description: |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70488 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
70488 |
| Service Description: |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70490 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
70490 |
| Service Description: |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70491 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
70491 |
| Service Description: |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70492 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
70492 |
| Service Description: |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70496 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
70496 |
| Service Description: |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
70498 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
70498 |
| Service Description: |
CT THORAX W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
71250 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORAX W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O CONTRAST MATERIAL |
71250 |
| Service Description: |
CT THORAX W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
71260 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORAX W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/CONTRAST MATERIAL |
71260 |
| Service Description: |
CT THORAX W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
71270 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORAX W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O & W/CONTRAST MATERIAL |
71270 |
| Service Description: |
CTA chest (noncoronary) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
71275 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CTA chest (noncoronary) |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA chest (noncoronary) |
71275 |
| Service Description: |
CTA chest (noncoronary) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
71275 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CTA chest (noncoronary) |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA chest (noncoronary) |
71275 |
| Service Description: |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72125 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
72125 |
| Service Description: |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72126 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
72126 |
| Service Description: |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72127 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
72127 |
| Service Description: |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72128 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
72128 |
| Service Description: |
CT THORACIC SPINE W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72129 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORACIC SPINE W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/CONTRAST MATERIAL |
72129 |
| Service Description: |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72130 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
72130 |
| Service Description: |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72131 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
72131 |
| Service Description: |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72132 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
72132 |
| Service Description: |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72133 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
72133 |
| Service Description: |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72191 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
72191 |
| Service Description: |
CT PELVIS W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72192 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT PELVIS W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O CONTRAST MATERIAL |
72192 |
| Service Description: |
CT PELVIS W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72193 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT PELVIS W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/CONTRAST MATERIAL |
72193 |
| Service Description: |
CT PELVIS W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
72194 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT PELVIS W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O & W/CONTRAST MATERIAL |
72194 |
| Service Description: |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73200 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
73200 |
| Service Description: |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73201 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
73201 |
| Service Description: |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73202 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
73202 |
| Service Description: |
CT ANGIOGRAPHY UPPER EXTREMITY |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73206 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY UPPER EXTREMITY |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY UPPER EXTREMITY |
73206 |
| Service Description: |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73700 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
73700 |
| Service Description: |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73701 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
73701 |
| Service Description: |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73702 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
73702 |
| Service Description: |
CT ANGIOGRAPHY LOWER EXTREMITY |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
73706 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY LOWER EXTREMITY |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY LOWER EXTREMITY |
73706 |
| Service Description: |
CT ABDOMEN W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74150 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O CONTRAST MATERIAL |
74150 |
| Service Description: |
CT ABDOMEN W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74160 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/CONTRAST MATERIAL |
74160 |
| Service Description: |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74170 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
74170 |
| Service Description: |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74174 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
74174 |
| Service Description: |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74175 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
74175 |
| Service Description: |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74176 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
74176 |
| Service Description: |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74177 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
74177 |
| Service Description: |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
74178 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
74178 |
| Service Description: |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75571 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
75571 |
| Service Description: |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75572 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
75572 |
| Service Description: |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75573 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
75573 |
| Service Description: |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75574 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
75574 |
| Service Description: |
CONTRAST EXAM THORACIC AORTA |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75605 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CONTRAST EXAM THORACIC AORTA |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CONTRAST EXAM THORACIC AORTA |
75605 |
| Service Description: |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
75635 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
75635 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
76376 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
76377 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
76380 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
76380 |
| Service Description: |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
76497 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
76497 |
| Service Description: |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0042T |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2019 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
0042T |
| Service Description: |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S8092 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2019 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
| Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
S8092 |
| Service Description: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3490 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs |
| Comments: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified drugs |
J3490 |
| Service Description: |
Unclassified biologics |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3590 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified biologics |
| Comments: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified biologics |
J3590 |
| Service Description: |
Injection, immune globulin (cuvitru), 100 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1555 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, immune globulin (cuvitru), 100 mg |
| Comments: |
|
|
Cuvitru (Subcutaneous immune globulin) |
Injection, immune globulin (cuvitru), 100 mg |
J1555 |
| Service Description: |
Injection, ramucirumab, 5 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9308 |
| Service Code Type: |
HCPCS |
| Effective Date: |
12/1/2014 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, ramucirumab, 5 mg |
| Comments: |
|
|
Cyramza® (ramucirumab) |
Injection, ramucirumab, 5 mg |
J9308 |
| Service Description: |
Injection, decitabine, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0894 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, decitabine, 1 mg |
| Comments: |
|
|
Dacogen® (decitabine) |
Injection, decitabine, 1 mg |
J0894 |
| Service Description: |
Injection, dalbavancin, 5 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0875 |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, dalbavancin, 5 mg |
| Comments: |
|
|
Dalvance™ (dalbavancin) |
Injection, dalbavancin, 5 mg |
J0875 |
| Service Description: |
Injection, daratumumab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9145 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2016 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, daratumumab, 10 mg |
| Comments: |
|
|
Darzalex™ (daratumumab) |
Injection, daratumumab, 10 mg |
J9145 |
| Service Description: |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61850 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
| Comments: |
|
|
Deep Brain Stimulation |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
61850 |
| Service Description: |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61860 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
| Comments: |
|
|
Deep Brain Stimulation |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
61860 |
| Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61863 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
| Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
61863 |
| Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61864 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
| Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
61864 |
| Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61867 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
| Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
61867 |
| Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61868 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
| Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
61868 |
| Service Description: |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61870 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
| Comments: |
|
|
Deep Brain Stimulation |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
61870 |
| Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61885 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
| Comments: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
61885 |
| Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
61886 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
| Comments: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
61886 |
| Service Description: |
Dexametha opth insert 0.1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1096 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Dexametha opth insert 0.1 mg |
| Comments: |
|
|
Dextenza (dexamethasone ophthalmic insert) |
Dexametha opth insert 0.1 mg |
J1096 |
| Service Description: |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1095 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
| Comments: |
|
|
Dexycu (Dexamethasone) |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
J1095 |
| Service Description: |
Percutaneous implantation of neurostimulator electrode array, epidural |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
63650 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Percutaneous implantation of neurostimulator electrode array, epidural |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Percutaneous implantation of neurostimulator electrode array, epidural |
63650 |
| Service Description: |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
63655 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
63655 |
| Service Description: |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
63685 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
63685 |
| Service Description: |
Implantable neurostimulator, pulse generator, any type |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8679 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator, pulse generator, any type |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator, pulse generator, any type |
L8679 |
| Service Description: |
Implantable neurostimulator electrode, each |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8680 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator electrode, each |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator electrode, each |
L8680 |
| Service Description: |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8681 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
L8681 |
| Service Description: |
Implantable neurostimulator radiofrequency receiver |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8682 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator radiofrequency receiver |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator radiofrequency receiver |
L8682 |
| Service Description: |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8683 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
L8683 |
| Service Description: |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8685 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
L8685 |
| Service Description: |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8686 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
L8686 |
| Service Description: |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8687 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
L8687 |
| Service Description: |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
L8688 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
| Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
L8688 |
| Service Description: |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
N/A |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
Prior authorization is required for purchased or rented DME items when the allowed amount per individual item is
$500 or more |
| Frequency Restriction for Coverage: |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
| Comments: |
|
|
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
N/A |
| Service Description: |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7318 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
| Comments: |
|
|
Durolane (hyaluronic acid) |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
J7318 |
| Service Description: |
Injection, abobotulinumtoxina, 5 units |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0586 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2010 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, abobotulinumtoxina, 5 units |
| Comments: |
|
|
Dysport® (Botulinum toxin Type A) |
Injection, abobotulinumtoxina, 5 units |
J0586 |
| Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93320 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Comments: |
|
|
Echocardiogram: Stress |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
| Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93321 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Comments: |
|
|
Echocardiogram: Stress |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
| Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93325 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Comments: |
|
|
Echocardiogram: Stress |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
| Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93350 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
| Comments: |
|
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
93350 |
| Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93351 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
| Comments: |
|
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
93351 |
| Service Description: |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93352 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
| Comments: |
|
|
Echocardiogram: Stress |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
93352 |
| Service Description: |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93312 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
93312 |
| Service Description: |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93313 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
93313 |
| Service Description: |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93314 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
93314 |
| Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93315 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
93315 |
| Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93316 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
93316 |
| Service Description: |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93317 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
93317 |
| Service Description: |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93318 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
| Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
93318 |
| Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93320 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Comments: |
|
|
Echocardiogram: Transesophageal |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
| Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93321 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Comments: |
|
|
Echocardiogram: Transesophageal |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
| Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93325 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Comments: |
|
|
Echocardiogram: Transesophageal |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
| Service Description: |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93303 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
| Comments: |
|
|
Echocardiogram: Transthoracic |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
93303 |
| Service Description: |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93304 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
| Comments: |
|
|
Echocardiogram: Transthoracic |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
93304 |
| Service Description: |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93306 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
| Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
93306 |
| Service Description: |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93307 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
| Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
93307 |
| Service Description: |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93308 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
| Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
93308 |
| Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93320 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
| Comments: |
|
|
Echocardiogram: Transthoracic |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
| Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93321 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
| Comments: |
|
|
Echocardiogram: Transthoracic |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
| Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
93325 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
| Comments: |
|
|
Echocardiogram: Transthoracic |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
| Service Description: |
TTE CMPL SPC & COLR FLOW DPPLR ECHO |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C8929 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
TTE CMPL SPC & COLR FLOW DPPLR ECHO |
| Comments: |
|
|
Echocardiogram: Transthoracic |
TTE CMPL SPC & COLR FLOW DPPLR ECHO |
C8929 |
| Service Description: |
Injection, idursulfase, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1743 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, idursulfase, 1 mg |
| Comments: |
|
|
Elaprase® (idursulfase) |
Injection, idursulfase, 1 mg |
J1743 |
| Service Description: |
Injection, idursulfase, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1743 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, idursulfase, 1 mg |
| Comments: |
|
|
Elaprase® (idursulfase) |
Injection, idursulfase, 1 mg |
J1743 |
| Service Description: |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
E0761 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2001 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
| Comments: |
|
|
Electrical Stimulation to aid wound healing |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
E0761 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
G0281 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2001 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
G0329 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2001 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
Injection, taliglucerace alfa, 10 units |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3060 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2013 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, taliglucerace alfa, 10 units |
| Comments: |
|
|
Elelyso™ (taliglucerase alfa) |
Injection, taliglucerace alfa, 10 units |
J3060 |
| Service Description: |
Injection, rasburicase, 0.5 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J2783 |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2005 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, rasburicase, 0.5 mg |
| Comments: |
|
|
Elitek® (rasburicase) |
Injection, rasburicase, 0.5 mg |
J2783 |
| Service Description: |
Injection, oxaliplatin, 0.5 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9263 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, oxaliplatin, 0.5 mg |
| Comments: |
|
|
Eloxatin (oxaliplatin) |
Injection, oxaliplatin, 0.5 mg |
J9263 |
| Service Description: |
Injection, elotuzumab, 1mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9176 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/15/2016 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, elotuzumab, 1mg |
| Comments: |
|
|
Empliciti™ (elotuzumab) |
Injection, elotuzumab, 1mg |
J9176 |
| Service Description: |
Unclassified drugs or biologicals |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9399 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs or biologicals |
| Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Unclassified drugs or biologicals |
C9399 |
| Service Description: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3490 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs |
| Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Unclassified drugs |
J3490 |
| Service Description: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3590 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs |
| Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Unclassified drugs |
J3590 |
| Service Description: |
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9358 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
| Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
J9358 |
| Service Description: |
Not otherwise classified, antineoplastic drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9999 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Not otherwise classified, antineoplastic drugs |
| Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Not otherwise classified, antineoplastic drugs |
J9999 |
| Service Description: |
Injection, vedolizumab, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J3380 |
| Service Code Type: |
HCPCS |
| Effective Date: |
12/1/2014 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, vedolizumab, 1 mg |
| Comments: |
|
|
Entyvio® (vedolizumab) |
Injection, vedolizumab, 1 mg |
J3380 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62320 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62321 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62322 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62323 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64479 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
| Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
64479 |
| Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64480 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
| Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
64480 |
| Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64483 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
| Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
64483 |
| Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64484 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
| Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
64484 |
| Service Description: |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0228T |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2005 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
| Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
0228T |
| Service Description: |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0229T |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2005 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
| Comments: |
|
|
Epidural Injections |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
0229T |
| Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0230T |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2005 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
| Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
0230T |
| Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0231T |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2005 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
| Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
0231T |
| Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62263 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
| Comments: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
62263 |
| Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
62264 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
| Comments: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
62264 |
| Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0885 |
| Service Code Type: |
HCPCS |
| Effective Date: |
6/15/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
| Comments: |
|
|
Epogen® (epoetin alpha) |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
| Service Description: |
Injection, anidulafungin, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0348 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2008 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, anidulafungin, 1 mg |
| Comments: |
|
|
Eraxis™ (anidulafungin) |
Injection, anidulafungin, 1 mg |
J0348 |
| Service Description: |
Injection, cetuximab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9055 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, cetuximab, 10 mg |
| Comments: |
|
|
Erbitux (cetuximab) |
Injection, cetuximab, 10 mg |
J9055 |
| Service Description: |
Injection, asparaginase (erwinaze), 1,000 iu |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9019 |
| Service Code Type: |
HCPCS |
| Effective Date: |
7/1/2013 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, asparaginase (erwinaze), 1,000 iu |
| Comments: |
|
|
Erwinaze® (asparaginase) |
Injection, asparaginase (erwinaze), 1,000 iu |
J9019 |
| Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0881 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
| Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0882 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
| Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0885 |
| Service Code Type: |
HCPCS |
| Effective Date: |
6/15/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
| Service Description: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0887 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
J0887 |
| Service Description: |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0888 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
J0888 |
| Service Description: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q4081 |
| Service Code Type: |
HCPCS |
| Effective Date: |
6/15/2007 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Q4081 |
| Service Description: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q5106 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
| Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Q5106 |
| Service Description: |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7204 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
| Comments: |
|
|
Esperoct (Injection, factor viii, antihemophilic factor ,recombinant,glycopegylated-exei) |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
J7204 |
| Service Description: |
Injection, romosozumab-aqqg, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3111 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, romosozumab-aqqg, 1 mg |
| Comments: |
|
|
Evenity (romosozumab-aqqg) |
Injection, romosozumab-aqqg, 1 mg |
J3111 |
| Service Description: |
Injection, melphalan (evomela), 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9246 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, melphalan (evomela), 1 mg |
| Comments: |
|
|
Evomela |
Injection, melphalan (evomela), 1 mg |
J9246 |
| Service Description: |
Exondys 51 (eteplirsen) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
C9484 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/2017 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Exondys 51 (eteplirsen) |
| Comments: |
|
|
Exondys 51 (eteplirsen) |
Exondys 51 (eteplirsen) |
C9484 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28890 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0101T |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
| Comments: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
0101T |
| Service Description: |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0102T |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
| Comments: |
|
|
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 |
| Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0512T |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0513T |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
Injection, agalsidase beta, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J0180 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, agalsidase beta, 1 mg |
| Comments: |
|
|
Fabrazyme® (agalsidase beta) |
Injection, agalsidase beta, 1 mg |
J0180 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64490 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
64490 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64491 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
64491 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64492 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
64492 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64493 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
64493 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64494 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
| Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64495 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
64495 |
| Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0213T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
0213T |
| Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0214T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
0214T |
| Service Description: |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0215T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
| Comments: |
|
|
Facet Injections |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
0215T |
| Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0216T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
| Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
0216T |
| Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0217T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
| Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
0217T |
| Service Description: |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0218T |
| Service Code Type: |
HCPCS |
| Effective Date: |
3/1/2015 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
| Comments: |
|
|
Facet Injections |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
0218T |
| Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64633 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
64633 |
| Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64634 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
64634 |
| Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64635 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
64635 |
| Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64636 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
64636 |
| Service Description: |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64640 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
64640 |
| Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
64643 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
| Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
| Service Description: |
Injection, benralizumab, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J0517 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, benralizumab, 1 mg |
| Comments: |
|
|
Fasenra (benralizumab) |
Injection, benralizumab, 1 mg |
J0517 |
| Service Description: |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
59072 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
59072 |
| Service Description: |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
59074 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
59074 |
| Service Description: |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
59076 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
59076 |
| Service Description: |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2400 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
S2400 |
| Service Description: |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2401 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
S2401 |
| Service Description: |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2402 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
S2402 |
| Service Description: |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2403 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
S2403 |
| Service Description: |
Repair, myelomeningocele in the fetus, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2404 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, myelomeningocele in the fetus, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, myelomeningocele in the fetus, procedure performed in utero |
S2404 |
| Service Description: |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2405 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
S2405 |
| Service Description: |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2409 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
S2409 |
| Service Description: |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S2411 |
| Service Code Type: |
HCPCS |
| Effective Date: |
4/1/1999 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
| Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
S2411 |
| Service Description: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3490 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Unclassified drugs |
| Comments: |
|
|
Fetroja (cefiderocol) |
Unclassified drugs |
J3490 |
| Service Description: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1572 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
| Comments: |
|
|
Flebogamma (intravenous immune globulin) |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1572 |
| Service Description: |
Injection, epoprostenol, 0.5 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J1325 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, epoprostenol, 0.5 mg |
| Comments: |
|
|
Flolan® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
| Service Description: |
Sterile dilutant for epoprostenol, 50ml |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S0155 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Sterile dilutant for epoprostenol, 50ml |
| Comments: |
|
|
Flolan® (epoprostenol) |
Sterile dilutant for epoprostenol, 50ml |
S0155 |
| Service Description: |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
Q5108 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
| Comments: |
|
|
Fulphilia (pegfilgrastim-jmdb) |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
Q5108 |
| Service Description: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1557 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
| Comments: |
|
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1557 |
| Service Description: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
J1561 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2006 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
| Comments: |
|
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
J1561 |
| Service Description: |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43647 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
| Comments: |
|
|
Gastric Electrical Stimulation |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
43647 |
| Service Description: |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43648 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
| Comments: |
|
|
Gastric Electrical Stimulation |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
43648 |
| Service Description: |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43881 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
| Comments: |
|
|
Gastric Electrical Stimulation |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
43881 |
| Service Description: |
Injection, obinutuzumab, 10 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J9301 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/20/2018 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, obinutuzumab, 10 mg |
| Comments: |
|
|
Gazyva™ (obinutuzumab) |
Injection, obinutuzumab, 10 mg |
J9301 |
| Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7320 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
| Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
| Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7322 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
| Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
| Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
| Prior Authorization required: Preferred: |
No |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J7326 |
| Service Code Type: |
HCPCS |
| Effective Date: |
10/1/2009 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
| Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
| Service Description: |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
J3399 |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes |
| Comments: |
|
|
Gene Therapy |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes |
J3399 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81432 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81433 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81500 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
| Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
81500 |
| Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81503 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
| Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
81503 |
| Service Description: |
Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, al |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81519 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, al |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81521 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81410 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81410 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81411 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81413 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81414 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81439 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S3861 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
| Comments: |
|
|
Genetic Testing - Cardiac |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
S3861 |
| Service Description: |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S3865 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
| Comments: |
|
|
Genetic Testing - Cardiac |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
S3865 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
S3866 |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81201 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence |
81201 |
| Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81202 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
81202 |
| Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81203 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
81203 |
| Service Description: |
BRAF (V-RAF Murine Sarcoma Viral Oncogene Homolog B1) (e.g., colon cancer, gene analysis, V600E variant ) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Restricted to Preferred Only |
| Prior Authorization required: OON: |
Restricted to Preferred Only |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81210 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BRAF (V-RAF Murine Sarcoma Viral Oncogene Homolog B1) (e.g., colon cancer, gene analysis, V600E variant ) |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
BRAF (V-RAF Murine Sarcoma Viral Oncogene Homolog B1) (e.g., colon cancer, gene analysis, V600E variant ) |
81210 |
| Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81288 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81288 |
| Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81292 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81292 |
| Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81293 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81293 |
| Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81294 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81294 |
| Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81295 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81295 |
| Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81296 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81296 |
| Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81297 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81297 |
| Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81298 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis |
| Comments: |
|
|
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 |
| Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81299 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants |
| Comments: |
|
|
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 |
| Service Description: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion va |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81300 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion va |
| Comments: |
|
|
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 |
| Service Description: |
Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81301 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue |
81301 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81311 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81317 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81317 |
| Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81318 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81318 |
| Service Description: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81319 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysi |
81319 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81435 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81436 |
| Service Code Type: |
CPT |
| Effective Date: |
4/1/2011 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81525 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
| Comments: |
|
|
Genetic Testing - Colorectal Cancer |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
81525 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0069U |
| Service Code Type: |
HCPCS |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalinfixed paraffin-embedded tissue, algorithm reported as an expression score (miR31now™, GoPath Laboratories) |
| Comments: |
|
|
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 |
| Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81234 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
81234 |
| Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81239 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
81239 |
| Service Description: |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81251 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
81251 |
| Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81271 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81271 |
| Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81274 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
81274 |
| Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81302 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
81302 |
| Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81303 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
81303 |
| Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81304 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
| Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
81304 |
| Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81324 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
| Comments: |
|
|
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 |
| Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81325 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
| Comments: |
|
|
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 |
| Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81326 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81176 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81206 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
81206 |
| Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81207 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
81207 |
| Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81208 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
| Comments: |
|
|
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 |
| Service Description: |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81218 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
81218 |
| Service Description: |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81233 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
81233 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81245 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15) |
| Comments: |
|
|
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 |
| Service Description: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81246 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81272 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81305 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81315 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| 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 |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81316 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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 |
| Comments: |
|
|
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 |
| Service Description: |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81320 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
81320 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81334 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81340 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
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) |
| Comments: |
|
|
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 |
| 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) |
| Prior Authorization required: Pr | |