| Service Description: |
Skilled Nursing Facility |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0022 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Skilled Nursing Facility |
0022 |
| Service Description: |
Room and Board – Private, Medical/Surgical/Gynecological |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0111 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Medical/Surgical/Gynecological |
0111 |
| Service Description: |
Room and Board – Private, OB |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0112 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, OB |
0112 |
| Service Description: |
Room and Board – Private, Pediatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0113 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Pediatric |
0113 |
| Service Description: |
Room and Board – Private, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0114 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Private, Psychiatric |
0114 |
| Service Description: |
Room and Board – Private, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0114 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Psychiatric |
0114 |
| Service Description: |
Detoxification Room and Board Private (one bed) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0116 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Private (one bed) |
0116 |
| Service Description: |
Room and Board – Private, Oncology |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0117 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Oncology |
0117 |
| Service Description: |
Room and Board – Private, Rehabilitation |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0118 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Rehabilitation |
0118 |
| Service Description: |
Room and Board – Private, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0119 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Private, Other |
0119 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Medical/Surgical/Gynecological |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0121 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Medical/Surgical/Gynecological |
0121 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Obstetric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0122 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Obstetric |
0122 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Pediatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0123 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Pediatric |
0123 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0124 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 2 Bed, Psychiatric |
0124 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0124 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Psychiatric |
0124 |
| Service Description: |
Detoxification Room and Board Semiprivate (two beds) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0126 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 2 Bed, Oncology |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0127 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Oncology |
0127 |
| Service Description: |
Room and Board – Semiprivate 2 Bed, Rehabilitation |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0128 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 2 Bed, Rehabilitation |
0128 |
| Service Description: |
Room and Board – Semiprivate, 2 Beds, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0129 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate, 2 Beds, Other |
0129 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Medical/Surgical/Gynecological |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0131 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Medical/Surgical/Gynecological |
0131 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Obstetric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0132 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Obstetric |
0132 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Pediatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0133 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Pediatric |
0133 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0134 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
0134 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0134 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0136 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board (3 and 4 beds) |
0136 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Oncology |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0137 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Oncology |
0137 |
| Service Description: |
Room and Board – Semiprivate 3 or 4 Bed, Rehabilitation |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0138 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate 3 or 4 Bed, Rehabilitation |
0138 |
| Service Description: |
Room and Board – Semiprivate, 3 and 4 Beds, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0139 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Semiprivate, 3 and 4 Beds, Other |
0139 |
| Service Description: |
Psychiatric Room and Board Deluxe Private |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0144 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0146 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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), Medical/Surgical/Gynecological |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0151 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Medical/Surgical/Gynecological |
0151 |
| Service Description: |
Room and Board – Ward (Medical or General), Obstetric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0152 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Obstetric |
0152 |
| Service Description: |
Room and Board – Ward (Medical or General), Pediatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0153 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Pediatric |
0153 |
| Service Description: |
Room and Board – Ward (Medical or General), Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0154 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Room and Board – Ward (Medical or General), Psychiatric |
0154 |
| Service Description: |
Room and Board – Ward (Medical or General), Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0154 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Psychiatric |
0154 |
| Service Description: |
Detoxification Room and Board Ward |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0156 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Detoxification Room and Board Ward |
0156 |
| Service Description: |
Room and Board – Ward (Medical or General), Oncology |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0157 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Oncology |
0157 |
| Service Description: |
Room and Board – Ward (Medical or General), Rehabilitation |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0158 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward (Medical or General), Rehabilitation |
0158 |
| Service Description: |
Room and Board – Ward, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0159 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board – Ward, Other |
0159 |
| Service Description: |
Room and Board, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0169 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board, Other |
0169 |
| Service Description: |
Nursery, General Classification |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0170 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Nursery, General Classification |
0170 |
| Service Description: |
Nursery, Newborn, Level I |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0171 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level I |
0171 |
| Service Description: |
Nursery, Newborn, Level II |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0172 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level II |
0172 |
| Service Description: |
Nursery, Newborn, Level III |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0173 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level III |
0173 |
| Service Description: |
Nursery, Newborn, Level IV |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0174 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Nursery, Newborn, Level IV |
0174 |
| Service Description: |
Room and Board, Subacute Pediatric (Private Hospital) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0190 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Pediatric (Private Hospital) |
0190 |
| Service Description: |
Room and Board, Subacute Pediatric (Private Hospital) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0190 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board, Subacute Pediatric (Private Hospital) |
0190 |
| Service Description: |
Subacute Care - Level I |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0191 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0192 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0193 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0194 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0199 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Admission to an Intermediate Care Facility (ICF) or a Skilled Nursing Facility (SNF) |
Room and Board, Subacute Adult (Private Hospital) |
0199 |
| Service Description: |
Room and Board, Subacute Adult (Private Hospital) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0199 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Room and Board, Subacute Adult (Private Hospital) |
0199 |
| Service Description: |
Intensive Care, General Classification |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0200 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, General Classification |
0200 |
| Service Description: |
Intensive Care, Surgical |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0201 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Surgical |
0201 |
| Service Description: |
Intensive Care, Medical |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0202 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Medical |
0202 |
| Service Description: |
Intensive Care, Pediatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0203 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Pediatric |
0203 |
| Service Description: |
Intensive Care, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0204 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Intensive Care, Psychiatric |
0204 |
| Service Description: |
Intensive Care, Psychiatric |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0204 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Psychiatric |
0204 |
| Service Description: |
Intensive Care, Intermediate ICU |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0206 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Intermediate ICU |
0206 |
| Service Description: |
Intensive Care, Burn Care |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0207 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Burn Care |
0207 |
| Service Description: |
Intensive Care, Trauma |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0208 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Trauma |
0208 |
| Service Description: |
Intensive Care, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0209 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Intensive Care, Other |
0209 |
| Service Description: |
Coronary Care, General Classification |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0210 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Coronary Care, General Classification |
0210 |
| Service Description: |
Coronary Care, Myocardial Infarction |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0211 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Coronary Care, Myocardial Infarction |
0211 |
| Service Description: |
Coronary Care, Pulmonary Care |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0212 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Coronary Care, Pulmonary Care |
0212 |
| Service Description: |
Coronary Care, Intermediate CCU |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0214 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Coronary Care, Intermediate CCU |
0214 |
| Service Description: |
Coronary Care, Other |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0219 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Coronary Care, Other |
0219 |
| Service Description: |
Inpatient respite care |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0655 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Hospice |
Inpatient respite care |
0655 |
| Service Description: |
General inpatient care (nonrespite) |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0656 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Hospice |
General inpatient care (nonrespite) |
0656 |
| Service Description: |
Lithotripsy, General Classification |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0790 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Inpatient Facility Admission - Planned |
Lithotripsy, General Classification |
0790 |
| Service Description: |
Behavioral Health Treatments/Services Partial hospitalization - less intensive |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0912 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
0913 |
| Service Code Type: |
REV |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Behavioral Health Treatments/Services Partial hospitalization - intensive |
0913 |
| Service Description: |
SUBCUTANEOUS HORMONE PELLET IMPLANTATION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
11980 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
SUBCUTANEOUS HORMONE PELLET IMPLANTATION |
11980 |
| Service Description: |
SKN SPLT A-GRFT FAC/NCK/HF/G |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15120 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKN SPLT A-GRFT FAC/NCK/HF/G |
15120 |
| Service Description: |
SKN SPLT A-GRFT F/N/HF/G ADD |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15121 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKN SPLT A-GRFT F/N/HF/G ADD |
15121 |
| Service Description: |
SKIN FULL GRFT FACE/GENIT/HF |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15240 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKIN FULL GRFT FACE/GENIT/HF |
15240 |
| Service Description: |
SKIN FULL GRAFT ADD-ON |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15241 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKIN FULL GRAFT ADD-ON |
15241 |
| Service Description: |
SKIN FULL GRAFT EEN & LIPS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15260 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKIN FULL GRAFT EEN & LIPS |
15260 |
| Service Description: |
SKIN FULL GRAFT ADD-ON |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15261 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
SKIN FULL GRAFT ADD-ON |
15261 |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15271 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15272 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15273 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15274 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15275 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15276 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15277 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15278 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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: |
DELAY FLAP TRUNK |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15600 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
DELAY FLAP TRUNK |
15600 |
| Service Description: |
DELAY FLAP EYE/NOS/EAR/LIP |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15630 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
DELAY FLAP EYE/NOS/EAR/LIP |
15630 |
| Service Description: |
MUSCLE-SKIN GRAFT TRUNK |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15734 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
MUSCLE-SKIN GRAFT TRUNK |
15734 |
| Service Description: |
MUSCLE-SKIN GRAFT LEG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15738 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
MUSCLE-SKIN GRAFT LEG |
15738 |
| Service Description: |
FREE MYO/SKIN FLAP MICROVASC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15756 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
FREE MYO/SKIN FLAP MICROVASC |
15756 |
| Service Description: |
FREE SKIN FLAP MICROVASC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15757 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
FREE SKIN FLAP MICROVASC |
15757 |
| Service Description: |
FREE FASCIAL FLAP MICROVASC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15758 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
FREE FASCIAL FLAP MICROVASC |
15758 |
| Service Description: |
GRFG AUTOL SOFT TISS DIR EXC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15769 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
GRFG AUTOL SOFT TISS DIR EXC |
15769 |
| Service Description: |
GRFG AUTOL FAT LIPO 50 CC/< |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15771 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
GRFG AUTOL FAT LIPO 50 CC/< |
15771 |
| Service Description: |
GRFG AUTOL FAT LIPO EA ADDL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15772 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
GRFG AUTOL FAT LIPO EA ADDL |
15772 |
| Service Description: |
ACELLULAR DERM MATRIX IMPLT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15777 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
ACELLULAR DERM MATRIX IMPLT |
15777 |
| Service Description: |
BLEPHAROPLASTY LOWER EYELID |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15820 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID |
15820 |
| Service Description: |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15821 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD |
15821 |
| Service Description: |
BLEPHAROPLASTY UPPER EYELID |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15822 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID |
15822 |
| Service Description: |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15823 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Blepharoplasty (plastic surgery of the eyelids) |
BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN |
15823 |
| Service Description: |
TEST FOR BLOOD FLOW IN GRAFT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
15860 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
TEST FOR BLOOD FLOW IN GRAFT |
15860 |
| Service Description: |
MASTECTOMY PARTIAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19301 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MASTECTOMY PARTIAL |
19301 |
| Service Description: |
MASTECTOMY SIMPLE COMPLETE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19303 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MASTECTOMY SIMPLE COMPLETE |
19303 |
| Service Description: |
MAST MOD RAD |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19307 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Integumentary |
MAST MOD RAD |
19307 |
| Service Description: |
MASTOPEXY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19316 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MASTOPEXY |
19316 |
| Service Description: |
REDUCTION MAMMAPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19318 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
REDUCTION MAMMAPLASTY |
19318 |
| Service Description: |
MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19324 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT |
19324 |
| Service Description: |
MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19324 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT |
19324 |
| Service Description: |
MAMMAPLASTY, AUGMENTATION; W/PROSTHETIC IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19325 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MAMMAPLASTY, AUGMENTATION; W/PROSTHETIC IMPLANT |
19325 |
| Service Description: |
MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19325 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT |
19325 |
| Service Description: |
REMOVAL, INTACT MAMMARY IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19328 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
REMOVAL, INTACT MAMMARY IMPLANT |
19328 |
| Service Description: |
REMOVAL, MAMMARY IMPLANT MATL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19330 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
REMOVAL, MAMMARY IMPLANT MATL |
19330 |
| Service Description: |
IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19340 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
19340 |
| Service Description: |
DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19342 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION |
19342 |
| Service Description: |
NIPPLE/AREOLA RECONSTRUCTION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19350 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
NIPPLE/AREOLA RECONSTRUCTION |
19350 |
| Service Description: |
CORRECTION OF INVERTED NIPPLES |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19355 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
CORRECTION OF INVERTED NIPPLES |
19355 |
| Service Description: |
BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19357 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ |
19357 |
| Service Description: |
Breast reconstruction with latissimus dorsi flap, without prosthetic implant |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19361 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with latissimus dorsi flap, without prosthetic implant |
19361 |
| Service Description: |
Breast reconstruction with free flap |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19364 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with free flap |
19364 |
| Service Description: |
Breast reconstruction with other technique |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19366 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with other technique |
19366 |
| Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19367 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site |
19367 |
| Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19368 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) |
19368 |
| Service Description: |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19369 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site |
19369 |
| Service Description: |
OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19370 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST |
19370 |
| Service Description: |
PERIPROSTHETIC CAPSULECTOMY, BREAST |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19371 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
PERIPROSTHETIC CAPSULECTOMY, BREAST |
19371 |
| Service Description: |
REVISION OF RECONSTRUCTED BREAST |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19380 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
REVISION OF RECONSTRUCTED BREAST |
19380 |
| Service Description: |
PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
19396 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT |
19396 |
| Service Description: |
INJECTION ENZYME PALMAR FASCIAL CORD |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
20527 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Xiaflex® (collagenase clostridium histolyticum) |
INJECTION ENZYME PALMAR FASCIAL CORD |
20527 |
| Service Description: |
Bone graft, any donor area; minor or small (e.g., dowel or button) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
20900 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Bone graft, any donor area; minor or small (e.g., dowel or button) |
20900 |
| Service Description: |
Bone graft, any donor area; major or large |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
20902 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Bone graft, any donor area; major or large |
20902 |
| Service Description: |
REMOVAL OF TISSUE FOR GRAFT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
20926 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REMOVAL OF TISSUE FOR GRAFT |
20926 |
| Service Description: |
GENIOPLASTY AUGMENTATION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21120 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY AUGMENTATION |
21120 |
| Service Description: |
GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21121 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE |
21121 |
| Service Description: |
GENIOPLASTY 2/> SLIDING OSTEOTOMIES |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21122 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOPLASTY 2/> SLIDING OSTEOTOMIES |
21122 |
| Service Description: |
GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21123 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS |
21123 |
| Service Description: |
AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21125 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL |
21125 |
| Service Description: |
AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21127 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL |
21127 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21141 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT |
21141 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21142 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT |
21142 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21143 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT |
21143 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21145 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS |
21145 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21146 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS |
21146 |
| Service Description: |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21147 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS |
21147 |
| Service Description: |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21193 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF |
21193 |
| Service Description: |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21194 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT |
21194 |
| Service Description: |
RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21195 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD |
21195 |
| Service Description: |
RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21196 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI |
21196 |
| Service Description: |
OSTEOTOMY MANDIBLE SEGMENTAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21198 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MANDIBLE SEGMENTAL |
21198 |
| Service Description: |
OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21199 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT |
21199 |
| Service Description: |
OSTEOTOMY MAXILLA SEGMENTAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21206 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
OSTEOTOMY MAXILLA SEGMENTAL |
21206 |
| Service Description: |
HYOID MYOTOMY & SUSPENSION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21685 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Orthognathic Surgery (including, but not limited to mandibular and maxillary osteotomies) |
HYOID MYOTOMY & SUSPENSION |
21685 |
| Service Description: |
Reconstructive repair of pectus excavatum or carinatum; open |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21740 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; open |
21740 |
| Service Description: |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21742 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy |
21742 |
| Service Description: |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21743 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Pectus Excavatum or Carinatum (surgical correction of chest deformity) |
Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy |
21743 |
| Service Description: |
REPAIR OF STERNUM SEPARATION |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21750 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REPAIR OF STERNUM SEPARATION |
21750 |
| Service Description: |
EXC BACK LES SC 3 CM/> |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
21931 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
EXC BACK LES SC 3 CM/> |
21931 |
| Service Description: |
INCIS 1 VERTEBRAL SEG THORAC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22212 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
INCIS 1 VERTEBRAL SEG THORAC |
22212 |
| Service Description: |
INCIS 1 VERTEBRAL SEG LUMBAR |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22214 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
INCIS 1 VERTEBRAL SEG LUMBAR |
22214 |
| Service Description: |
INCIS ADDL SPINE SEGMENT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22216 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
INCIS ADDL SPINE SEGMENT |
22216 |
| Service Description: |
ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22533 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR |
22533 |
| Service Description: |
ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22534 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR |
22534 |
| Service Description: |
ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22551 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 |
22551 |
| Service Description: |
ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22552 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC |
22552 |
| Service Description: |
ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22554 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 |
22554 |
| Service Description: |
ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22556 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC |
22556 |
| Service Description: |
ARTHRODESIS ANTERIOR INTERBODY LUMBAR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22558 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS ANTERIOR INTERBODY LUMBAR |
22558 |
| Service Description: |
ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22585 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC |
22585 |
| Service Description: |
NECK SPINE FUSION |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22600 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
NECK SPINE FUSION |
22600 |
| Service Description: |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL LUMBAR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22612 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL LUMBAR |
22612 |
| Service Description: |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL EA ADDL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22614 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR/ POSTEROLATERAL EA ADDL |
22614 |
| Service Description: |
ARTHRODESIS POSTERIOR INTERBODY LUMBAR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22630 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR INTERBODY LUMBAR |
22630 |
| Service Description: |
ARTHRODESIS POSTERIOR INTERBODY EA ADDL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22632 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHRODESIS POSTERIOR INTERBODY EA ADDL |
22632 |
| Service Description: |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTERBODY LUMBAR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22633 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTERBODY LUMBAR |
22633 |
| Service Description: |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTRBDYADL SPC/ SEG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22634 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Spinal Fusion (Elective) |
ARTHDSIS POST/ POSTEROLATRL/ POSTINTRBDYADL SPC/ SEG |
22634 |
| Service Description: |
CERV ARTIFIC DISKECTOMY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
22856 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
CERV ARTIFIC DISKECTOMY |
22856 |
| Service Description: |
Arthroplasty, glenohumeral joint; hemiarthroplasty |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
23470 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Shoulder - Center Of Excellence |
Arthroplasty, glenohumeral joint; hemiarthroplasty |
23470 |
| Service Description: |
Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total shoulder]) |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
23472 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Shoulder - Center Of Excellence |
Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total shoulder]) |
23472 |
| Service Description: |
Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
23473 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Shoulder - Center Of Excellence |
Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component |
23473 |
| Service Description: |
Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
23474 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Shoulder - Center Of Excellence |
Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component |
23474 |
| Service Description: |
INJECT SI JOINT ARTHRGRPHY&/ ANES/ STEROID W/ IMA |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27096 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Sacroiliac Joint Injection |
INJECT SI JOINT ARTHRGRPHY&/ ANES/ STEROID W/ IMA |
27096 |
| Service Description: |
PARTIAL HIP REPLACEMENT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27125 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
PARTIAL HIP REPLACEMENT |
27125 |
| Service Description: |
TOTAL HIP ARTHROPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27130 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
TOTAL HIP ARTHROPLASTY |
27130 |
| Service Description: |
TOTAL HIP ARTHROPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27132 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
TOTAL HIP ARTHROPLASTY |
27132 |
| Service Description: |
REVISE HIP JOINT REPLACEMENT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27134 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE HIP JOINT REPLACEMENT |
27134 |
| Service Description: |
REVISE HIP JOINT REPLACEMENT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27137 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE HIP JOINT REPLACEMENT |
27137 |
| Service Description: |
REVISE HIP JOINT REPLACEMENT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27138 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE HIP JOINT REPLACEMENT |
27138 |
| Service Description: |
ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27279 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Sacroiliac Joint Fusion |
ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS |
27279 |
| Service Description: |
LENGTHENING OF THIGH TENDONS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27394 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
LENGTHENING OF THIGH TENDONS |
27394 |
| Service Description: |
REPAIR OF KNEE LIGAMENT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27405 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REPAIR OF KNEE LIGAMENT |
27405 |
| Service Description: |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27412 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE |
27412 |
| Service Description: |
REVISION OF UNSTABLE KNEECAP |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27422 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REVISION OF UNSTABLE KNEECAP |
27422 |
| Service Description: |
RECONSTRUCTION KNEE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27427 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
RECONSTRUCTION KNEE |
27427 |
| Service Description: |
REVISE KNEECAP WITH IMPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27438 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE KNEECAP WITH IMPLANT |
27438 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27440 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27440 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27441 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27441 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27442 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27442 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27443 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27443 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27445 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27445 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27445 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27445 |
| Service Description: |
REVISION OF KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27446 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISION OF KNEE JOINT |
27446 |
| Service Description: |
TOTAL KNEE ARTHROPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27447 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
TOTAL KNEE ARTHROPLASTY |
27447 |
| Service Description: |
REVISE/REPLACE KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27486 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE/REPLACE KNEE JOINT |
27486 |
| Service Description: |
REVISE/REPLACE KNEE JOINT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27487 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REVISE/REPLACE KNEE JOINT |
27487 |
| Service Description: |
REMOVAL OF KNEE PROSTHESIS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27488 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
REMOVAL OF KNEE PROSTHESIS |
27488 |
| Service Description: |
TREATMENT OF THIGH FRACTURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27506 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
TREATMENT OF THIGH FRACTURE |
27506 |
| Service Description: |
UNLISTED PROCEDURE, FEMUR or KNEE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON FACILITY |
| Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED TO PREFERRED FACILITY |
| Service Code: |
27599 |
| Service Code Type: |
CPT |
| Effective Date: |
9/1/2022 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Hip/Knee - Center Of Excellence |
UNLISTED PROCEDURE, FEMUR or KNEE |
27599 |
| Service Description: |
EXPLORE/TREAT ANKLE JOINT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27610 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
EXPLORE/TREAT ANKLE JOINT |
27610 |
| Service Description: |
EXPLORATION OF ANKLE JOINT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27612 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
EXPLORATION OF ANKLE JOINT |
27612 |
| Service Description: |
REVISION OF LOWER LEG TENDON |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27685 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REVISION OF LOWER LEG TENDON |
27685 |
| Service Description: |
REPAIR OF ANKLE LIGAMENT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27698 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REPAIR OF ANKLE LIGAMENT |
27698 |
| Service Description: |
TREATMENT OF TIBIA FRACTURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27759 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
TREATMENT OF TIBIA FRACTURE |
27759 |
| Service Description: |
TREATMENT OF ANKLE FRACTURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27814 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
TREATMENT OF ANKLE FRACTURE |
27814 |
| Service Description: |
FUSION OF ANKLE JOINT OPEN |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
27870 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
FUSION OF ANKLE JOINT OPEN |
27870 |
| Service Description: |
PARTIAL REMOVAL OF FOOT BONE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28122 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
PARTIAL REMOVAL OF FOOT BONE |
28122 |
| Service Description: |
REPAIR OF FOOT TENDON |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28200 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REPAIR OF FOOT TENDON |
28200 |
| Service Description: |
REPAIR OF HAMMERTOE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28285 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REPAIR OF HAMMERTOE |
28285 |
| Service Description: |
CORRECTION HALLUX VALGUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28292 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
CORRECTION HALLUX VALGUS |
28292 |
| Service Description: |
CORRECTION HALLUX VALGUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28296 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
CORRECTION HALLUX VALGUS |
28296 |
| Service Description: |
CORRECTION HALLUX VALGUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28298 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
CORRECTION HALLUX VALGUS |
28298 |
| Service Description: |
CORRECTION HALLUX VALGUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28299 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
CORRECTION HALLUX VALGUS |
28299 |
| Service Description: |
INCISION OF MIDFOOT BONES |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28304 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
INCISION OF MIDFOOT BONES |
28304 |
| Service Description: |
REVISION OF BIG TOE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28310 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
REVISION OF BIG TOE |
28310 |
| Service Description: |
TREAT HEEL FRACTURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28415 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
TREAT HEEL FRACTURE |
28415 |
| Service Description: |
TREAT METATARSAL FRACTURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28485 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
TREAT METATARSAL FRACTURE |
28485 |
| Service Description: |
FUSION OF FOOT BONES |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28715 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
FUSION OF FOOT BONES |
28715 |
| Service Description: |
FUSION OF FOOT BONES |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28730 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
FUSION OF FOOT BONES |
28730 |
| Service Description: |
FUSION OF FOOT BONES |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28740 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
FUSION OF FOOT BONES |
28740 |
| Service Description: |
AMPUTATION THRU METATARSAL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28805 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
AMPUTATION THRU METATARSAL |
28805 |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
28890 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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: |
JAW ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29804 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
JAW ARTHROSCOPY/SURGERY |
29804 |
| Service Description: |
SHOULDER ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29822 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
SHOULDER ARTHROSCOPY/SURGERY |
29822 |
| Service Description: |
SHOULDER ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29824 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
SHOULDER ARTHROSCOPY/SURGERY |
29824 |
| Service Description: |
SHOULDER ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29826 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
SHOULDER ARTHROSCOPY/SURGERY |
29826 |
| Service Description: |
ARTHROSCOP ROTATOR CUFF REPR |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29827 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
ARTHROSCOP ROTATOR CUFF REPR |
29827 |
| Service Description: |
WRIST ENDOSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29848 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
WRIST ENDOSCOPY/SURGERY |
29848 |
| Service Description: |
HIP ARTHR0 W/DEBRIDEMENT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29862 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
HIP ARTHR0 W/DEBRIDEMENT |
29862 |
| Service Description: |
MENISCAL TRNSPL KNEE W/SCPE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29868 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
MENISCAL TRNSPL KNEE W/SCPE |
29868 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29874 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29874 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29876 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29876 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29880 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29880 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29881 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29881 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29887 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29887 |
| Service Description: |
KNEE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29888 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
KNEE ARTHROSCOPY/SURGERY |
29888 |
| Service Description: |
ANKLE ARTHROSCOPY/SURGERY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29898 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
ANKLE ARTHROSCOPY/SURGERY |
29898 |
| Service Description: |
HIP ARTHRO W/FEMOROPLASTY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29914 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
HIP ARTHRO W/FEMOROPLASTY |
29914 |
| Service Description: |
HIP ARTHRO ACETABULOPLASTY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29915 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
HIP ARTHRO ACETABULOPLASTY |
29915 |
| Service Description: |
HIP ARTHRO W/LABRAL REPAIR |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29916 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
HIP ARTHRO W/LABRAL REPAIR |
29916 |
| Service Description: |
ARTHROSCOPY OF JOINT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
29999 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Musculoskeletal |
ARTHROSCOPY OF JOINT |
29999 |
| Service Description: |
RESECT INFERIOR TURBINATE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30140 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
RESECT INFERIOR TURBINATE |
30140 |
| Service Description: |
INSERT NASAL SEPTAL BUTTON |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30220 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
INSERT NASAL SEPTAL BUTTON |
30220 |
| Service Description: |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30400 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
30400 |
| Service Description: |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30400 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINP PRIM LAT&ALAR CRTLGS&/ ELVTN NASAL TI |
30400 |
| Service Description: |
RHINP PRIM COMPLETE XTRNL PARTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30410 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINP PRIM COMPLETE XTRNL PARTS |
30410 |
| Service Description: |
RHINP PRIM COMPLETE XTRNL PARTS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30410 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINP PRIM COMPLETE XTRNL PARTS |
30410 |
| Service Description: |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30420 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
30420 |
| Service Description: |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30420 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR |
30420 |
| Service Description: |
RHINOPLASTY SECONDARY MINOR REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30430 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY MINOR REVISION |
30430 |
| Service Description: |
RHINOPLASTY SECONDARY MINOR REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30430 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY MINOR REVISION |
30430 |
| Service Description: |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30435 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
30435 |
| Service Description: |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30435 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY INTERMEDIATE REVISION |
30435 |
| Service Description: |
RHINOPLASTY SECONDARY MAJOR REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30450 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty as a standalone procedure or Rhinoplasty, with
or without septal repair, in conjunction with other planned medically necessary surgeries. |
RHINOPLASTY SECONDARY MAJOR REVISION |
30450 |
| Service Description: |
RHINOPLASTY SECONDARY MAJOR REVISION |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30450 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
RHINOPLASTY SECONDARY MAJOR REVISION |
30450 |
| Service Description: |
REVISION OF NOSE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30460 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
REVISION OF NOSE |
30460 |
| Service Description: |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30520 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
30520 |
| Service Description: |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30520 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries |
SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
30520 |
| Service Description: |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30620 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Rhinoplasty including major septal repair |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
30620 |
| Service Description: |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30620 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Septoplasty as a standalone procedure or septoplasty in conjunction with other planned medically necessary surgeries |
SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
30620 |
| Service Description: |
ABLATE INF TURBINATE SUBMUC |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30802 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
ABLATE INF TURBINATE SUBMUC |
30802 |
| Service Description: |
CONTROL OF NOSEBLEED |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30903 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
CONTROL OF NOSEBLEED |
30903 |
| Service Description: |
CONTROL OF NOSEBLEED |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30905 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
CONTROL OF NOSEBLEED |
30905 |
| Service Description: |
THER FX NASAL INF TURBINATE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30930 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
THER FX NASAL INF TURBINATE |
30930 |
| Service Description: |
NASAL SURGERY PROCEDURE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
30999 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL SURGERY PROCEDURE |
30999 |
| Service Description: |
IRRIGATION MAXILLARY SINUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31000 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
IRRIGATION MAXILLARY SINUS |
31000 |
| Service Description: |
EXPLORATION OF FRONTAL SINUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31070 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
EXPLORATION OF FRONTAL SINUS |
31070 |
| Service Description: |
REMOVAL OF FRONTAL SINUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31086 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
REMOVAL OF FRONTAL SINUS |
31086 |
| Service Description: |
NASAL ENDOSCOPY DX |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31231 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL ENDOSCOPY DX |
31231 |
| Service Description: |
NASAL/SINUS ENDOSCOPY SURG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31237 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL/SINUS ENDOSCOPY SURG |
31237 |
| Service Description: |
NASAL/SINUS ENDOSCOPY SURG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31238 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL/SINUS ENDOSCOPY SURG |
31238 |
| Service Description: |
NSL/SINS NDSC TOTAL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31253 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC TOTAL |
31253 |
| Service Description: |
NSL/SINS NDSC W/PRTL ETHMDCT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31254 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC W/PRTL ETHMDCT |
31254 |
| Service Description: |
NSL/SINS NDSC W/TOT ETHMDCT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31255 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC W/TOT ETHMDCT |
31255 |
| Service Description: |
EXPLORATION MAXILLARY SINUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31256 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
EXPLORATION MAXILLARY SINUS |
31256 |
| Service Description: |
NSL/SINS NDSC TOT W/SPHENDT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31257 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC TOT W/SPHENDT |
31257 |
| Service Description: |
NSL/SINS NDSC SPHN TISS RMVL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31259 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC SPHN TISS RMVL |
31259 |
| Service Description: |
ENDOSCOPY MAXILLARY SINUS |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31267 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
ENDOSCOPY MAXILLARY SINUS |
31267 |
| Service Description: |
NSL/SINS NDSC FRNT TISS RMVL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31276 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NSL/SINS NDSC FRNT TISS RMVL |
31276 |
| Service Description: |
NASAL/SINUS ENDOSCOPY SURG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31287 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL/SINUS ENDOSCOPY SURG |
31287 |
| Service Description: |
NASAL/SINUS ENDOSCOPY SURG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31288 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL/SINUS ENDOSCOPY SURG |
31288 |
| Service Description: |
NASAL/SINUS ENDOSCOPY SURG |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31292 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
NASAL/SINUS ENDOSCOPY SURG |
31292 |
| Service Description: |
SINUS ENDO W/BALLOON DIL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31296 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
SINUS ENDO W/BALLOON DIL |
31296 |
| Service Description: |
SINUS ENDO W/BALLOON DIL |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31297 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
SINUS ENDO W/BALLOON DIL |
31297 |
| Service Description: |
REMOVAL OF LARYNX |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
10/18/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31360 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - General |
REMOVAL OF LARYNX |
31360 |
| Service Description: |
LARYNGOPLASTY CRICOID SPLIT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31587 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
LARYNGOPLASTY CRICOID SPLIT |
31587 |
| Service Description: |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31660 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31661 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Bronchial Thermoplasty |
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes |
31661 |
| Service Description: |
TRACHEOPLASTY CERVICAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
31750 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgical Reconstruction |
TRACHEOPLASTY CERVICAL |
31750 |
| Service Description: |
RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32491 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Lung Volume Reduction Surgery |
RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG |
32491 |
| Service Description: |
Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32701 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment |
32701 |
| Service Description: |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32850 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
32850 |
| Service Description: |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32850 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR PNEUMONECTOMY FROM CADAVER DONOR |
32850 |
| Service Description: |
LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32851 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS |
32851 |
| Service Description: |
LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32852 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS |
32852 |
| Service Description: |
LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32853 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS |
32853 |
| Service Description: |
LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32854 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS |
32854 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32855 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI |
32855 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
32856 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI |
32856 |
| Service Description: |
Transmyocardial laser revascularization, by thoracotomy (separate procedure) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33140 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart) |
Transmyocardial laser revascularization, by thoracotomy (separate procedure) |
33140 |
| Service Description: |
Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33141 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart) |
Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) |
33141 |
| Service Description: |
DONOR CARDIECTOMY-PNEUMONECTOMY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33930 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR CARDIECTOMY-PNEUMONECTOMY |
33930 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33933 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT |
33933 |
| Service Description: |
HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33935 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC |
33935 |
| Service Description: |
DONOR CARDIECTOMY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33940 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR CARDIECTOMY |
33940 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33944 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT |
33944 |
| Service Description: |
HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33945 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY |
33945 |
| Service Description: |
Insertion of ventricular assist device; extracorporeal, single ventricle |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33975 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device; extracorporeal, single ventricle |
33975 |
| Service Description: |
Insertion of ventricular assist device; extracorporeal, biventricular |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33976 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device; extracorporeal, biventricular |
33976 |
| Service Description: |
Removal of ventricular assist device; extracorporeal, single ventricle |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33977 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device; extracorporeal, single ventricle |
33977 |
| Service Description: |
Removal of ventricular assist device; extracorporeal, biventricular |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33978 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device; extracorporeal, biventricular |
33978 |
| Service Description: |
Insertion of ventricular assist device, implantable intracorporeal, single ventricle |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33979 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, implantable intracorporeal, single ventricle |
33979 |
| Service Description: |
Removal of ventricular assist device, implantable intracorporeal, single ventricular |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33980 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Removal of ventricular assist device, implantable intracorporeal, single ventricular |
33980 |
| Service Description: |
Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33981 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump |
33981 |
| Service Description: |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33982 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass |
33982 |
| Service Description: |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33983 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass |
33983 |
| Service Description: |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33990 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only |
33990 |
| Service Description: |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33991 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture |
33991 |
| Service Description: |
Removal of percutaneous ventricular assist device at separate and distinct session from insertion |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33992 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Removal of percutaneous ventricular assist device at separate and distinct session from insertion |
33992 |
| Service Description: |
Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
33993 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Ventricular Assist Device (VAD) |
Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion |
33993 |
| Service Description: |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36465 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein) |
36465 |
| Service Description: |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36466 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg |
36466 |
| Service Description: |
1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36468 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK |
36468 |
| Service Description: |
NJX SCLEROSING SOLUTION SINGLE VEIN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36470 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
NJX SCLEROSING SOLUTION SINGLE VEIN |
36470 |
| Service Description: |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36471 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG |
36471 |
| Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36473 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED |
36473 |
| Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36474 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
36474 |
| Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36475 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN |
36475 |
| Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36476 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS |
36476 |
| Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36478 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN |
36478 |
| Service Description: |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36479 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS |
36479 |
| Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36482 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED |
36482 |
| Service Description: |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36483 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
36483 |
| Service Description: |
Insertion of tunneled centrally inserted central venous access device with subcutaneous pump |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
36563 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Intrathecal Infusion Pump |
Insertion of tunneled centrally inserted central venous access device with subcutaneous pump |
36563 |
| Service Description: |
VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37500 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX |
37500 |
| Service Description: |
LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37700 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ |
37700 |
| Service Description: |
LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37718 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN |
37718 |
| Service Description: |
LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37722 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW |
37722 |
| Service Description: |
LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37735 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS |
37735 |
| Service Description: |
LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37760 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG |
37760 |
| Service Description: |
LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37761 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG |
37761 |
| Service Description: |
STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37765 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS |
37765 |
| Service Description: |
STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37766 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS |
37766 |
| Service Description: |
LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37780 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX |
37780 |
| Service Description: |
LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37785 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG |
37785 |
| Service Description: |
UNLISTED PROCEDURE VASCULAR SURGERY |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
37799 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Varicose Vein Treatments |
UNLISTED PROCEDURE VASCULAR SURGERY |
37799 |
| Service Description: |
MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38204 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ |
38204 |
| Service Description: |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38205 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC |
38205 |
| Service Description: |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38206 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL |
38206 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38207 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR |
38207 |
| Service Description: |
TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38208 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR |
38208 |
| Service Description: |
TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38209 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR |
38209 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38210 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL |
38210 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38211 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ |
38211 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38212 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL |
38212 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38213 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ |
38213 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38214 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ |
38214 |
| Service Description: |
TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38215 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM |
38215 |
| Service Description: |
BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38230 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC |
38230 |
| Service Description: |
BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38232 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS |
38232 |
| Service Description: |
TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38240 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR |
38240 |
| Service Description: |
TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38241 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR |
38241 |
| Service Description: |
ALLOGENEIC LYMPHOCYTE INFUSIONS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38242 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
ALLOGENEIC LYMPHOCYTE INFUSIONS |
38242 |
| Service Description: |
TRNSPLJ HEMATOPOIETIC CELL BOOST |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
38243 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRNSPLJ HEMATOPOIETIC CELL BOOST |
38243 |
| Service Description: |
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43284 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Magnetic Esophageal Sphincter Augmentation (LINX) |
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed |
43284 |
| Service Description: |
Removal of esophageal sphincter augmentation device |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43285 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Magnetic Esophageal Sphincter Augmentation (LINX) |
Removal of esophageal sphincter augmentation device |
43285 |
| Service Description: |
LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43644 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM |
43644 |
| Service Description: |
LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43645 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ |
43645 |
| Service Description: |
LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43647 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| 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 |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43648 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Gastric Electrical Stimulation |
LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM |
43648 |
| Service Description: |
LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43770 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE |
43770 |
| Service Description: |
LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43771 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE |
43771 |
| Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43772 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE |
43772 |
| Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43773 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE |
43773 |
| Service Description: |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43774 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT |
43774 |
| Service Description: |
LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43775 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY |
43775 |
| Service Description: |
GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43842 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY |
43842 |
| Service Description: |
GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43843 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP |
43843 |
| Service Description: |
GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43845 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM |
43845 |
| Service Description: |
GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43846 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< |
43846 |
| Service Description: |
GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43847 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ |
43847 |
| Service Description: |
REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43848 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE |
43848 |
| Service Description: |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
43881 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Gastric Electrical Stimulation |
IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN |
43881 |
| Service Description: |
GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43886 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY |
43886 |
| Service Description: |
GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43887 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY |
43887 |
| Service Description: |
GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
NOT COVERED for INN / OON |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
RESTRICTED |
| Service Code: |
43888 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Surgery - Weight Loss - Center Of Excellence |
GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT |
43888 |
| Service Description: |
INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
44135 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR |
44135 |
| Service Description: |
INTESTINAL ALLOTRANSPLANTATION LIVING DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
44136 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
INTESTINAL ALLOTRANSPLANTATION LIVING DONOR |
44136 |
| Service Description: |
BKBENCH PREP CADAVER/LIVING DONOR INTESTINE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
44715 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREP CADAVER/LIVING DONOR INTESTINE |
44715 |
| Service Description: |
BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
44720 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA |
44720 |
| Service Description: |
BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
44721 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA |
44721 |
| Service Description: |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
| Prior Authorization required: Preferred: |
No |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
No |
| Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
46505 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
CHEMODENERVATION INTERNAL ANAL SPHINCTER |
46505 |
| Service Description: |
DONOR HEPATECTOMY CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47133 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY CADAVER DONOR |
47133 |
| Service Description: |
DONOR HEPATECTOMY CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47133 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY CADAVER DONOR |
47133 |
| Service Description: |
LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47135 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE |
47135 |
| Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG II & III |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47140 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG II & III |
47140 |
| Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG II III & IV |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47141 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG II III & IV |
47141 |
| Service Description: |
DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47142 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI |
47142 |
| Service Description: |
BKBENCH PREP CADAVER DONOR |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47143 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREP CADAVER DONOR |
47143 |
| Service Description: |
BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47144 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII |
47144 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47145 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI |
47145 |
| Service Description: |
BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47146 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA |
47146 |
| Service Description: |
BKBENCH RCNSTJ LVR GRF ARTL ANAST EA |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
47147 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ LVR GRF ARTL ANAST EA |
47147 |
| Service Description: |
PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48160 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS |
48160 |
| Service Description: |
DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48550 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT |
48550 |
| Service Description: |
BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48551 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT |
48551 |
| Service Description: |
BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48552 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA |
48552 |
| Service Description: |
TRANSPLANTATION PANCREATIC ALLOGRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48554 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
TRANSPLANTATION PANCREATIC ALLOGRAFT |
48554 |
| Service Description: |
RMVL TRANSPLANTED PANCREATIC ALLOGRAFT |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
48556 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
RMVL TRANSPLANTED PANCREATIC ALLOGRAFT |
48556 |
| Service Description: |
DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL |
| Prior Authorization required: Preferred: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: INN: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Prior Authorization required: OON: |
Yes |
| Effective Date for this Tier: |
1/1/2021 12:00:00 AM |
| Restricted to Preferred Facilities: |
|
| Service Code: |
50300 |
| Service Code Type: |
CPT |
| Effective Date: |
1/1/2021 12:00:00 AM |
| Age Range for Coverage: |
Any |
| Monetary Restrictions: |
No Restriction |
| Frequency Restriction for Coverage: |
No Restriction |
| Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL |
50300 |
|
|