| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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, 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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 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: |
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: |
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, 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: |
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: |
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: |
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, 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: |
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: |
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 c |
| 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: |
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: |
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, 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: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
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, 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: |
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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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 h |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
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: |
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: |
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 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: |
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 work |
| 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 workstat |
| 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: |
Unclassified drugs |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
RESTRICTED |
| 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: |
RESTRICTED |
| 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: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
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: |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
N/A |
| Service Code Type: |
HCPCS |
| Effective Date: |
1/1/2020 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: |
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: |
Injection, vedolizumab, 1 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
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, i |
| 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, i |
| 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, i |
| 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, i |
| 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 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: |
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, 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: |
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 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 procedur |
| 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: |
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 planta |
| 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: |
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 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: |
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: |
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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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: |
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: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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 le |
| 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 BR |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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 i |
| 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: |
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: |
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 a |
| 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 fo |
| 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 |
| 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 a |
| 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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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 |
| 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: |
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: |
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: |
Yes |
| Prior Authorization required: OON: |
Yes |
| 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: |
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, |
| 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, MSH |
| 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: |
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: |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0016U |
| 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 (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with q |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
0016U |
| Service Description: |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0023U |
| 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 (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication fo |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
0023U |
| Service Description: |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0046U |
| 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: |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0046U |
| Service Description: |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0049U |
| 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: |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0049U |
| 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 |
| 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., ex |
| 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 |
| 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 |
| 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), qualitati |
| 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 reactio |
| 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: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81341 |
| 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 direct probe methodology (e.g., Southern blot) |
| 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 direct probe methodology (e.g., Southern blot) |
81341 |
| Service Description: |
TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81342 |
| 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: |
TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
81342 |
| Service Description: |
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81450 |
| 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: |
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, K |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed |
81450 |
| Service Description: |
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
81455 |
| 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: |
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, |
| Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed |
81455 |
| Service Description: |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81107 |
| 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: |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-tr |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
81107 |
| Service Description: |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81108 |
| 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: |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), ge |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
81108 |
| Service Description: |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81109 |
| 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: |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gen |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
81109 |
| Service Description: |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81110 |
| 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: |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
81110 |
| Service Description: |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81111 |
| 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: |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-t |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
81111 |
| Service Description: |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81112 |
| 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: |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
81112 |
| Service Description: |
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluable) (eg, glioma), common variants (eg, R132H, R132C) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81120 |
| 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: |
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluable) (eg, glioma), common variants (eg, R132H, R132C) |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluable) (eg, glioma), common variants (eg, R132H, R132C) |
81120 |
| Service Description: |
IDH2 (isocitrate dehydrogenase 2 [NADP+], soluable) (eg, glioma), common variants (eg, R140W, R172M) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81121 |
| 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: |
IDH2 (isocitrate dehydrogenase 2 [NADP+], soluable) (eg, glioma), common variants (eg, R140W, R172M) |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
IDH2 (isocitrate dehydrogenase 2 [NADP+], soluable) (eg, glioma), common variants (eg, R140W, R172M) |
81121 |
| Service Description: |
DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81161 |
| 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: |
DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed |
81161 |
| Service Description: |
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81170 |
| 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: |
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain |
81170 |
| Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81171 |
| 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: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81171 |
| Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
| Prior Authorization required: Preferred: |
Yes |
| Prior Authorization required: INN: |
Yes |
| Prior Authorization required: OON: |
Yes |
| Restricted to Preferred Facilities: |
|
| Service Code: |
81172 |
| 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: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
81172 |
| Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) 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: |
81173 |
| 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: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence |
81173 |
| Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) 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: |
81174 |
| 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: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
81174 |
| Service Description: |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) 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: |
81177 |
| 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: |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
| Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81177 |
| Service Description: |
ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) 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: |
81178 |
| Service Code Type: |
CPT |
| Effective Date: |
2/1/2020 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| F | |