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 |
Service Description: |
DONOR NEPHRECTOMY OPEN 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: |
50320 |
Service Code Type: |
CPT |
Effective 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 OPEN LIVING DONOR |
50320 |
Service Description: |
BKBENCH PREPJ CADAVER DONOR RENAL 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: |
50323 |
Service Code Type: |
CPT |
Effective 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 RENAL ALLOGRAFT |
50323 |
Service Description: |
BKBENCH PREPJ LIVING RENAL DONOR 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: |
50325 |
Service Code Type: |
CPT |
Effective 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 LIVING RENAL DONOR ALLOGRAFT |
50325 |
Service Description: |
BKBENCH RCNSTJ RENAL ALGRFT 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: |
50327 |
Service Code Type: |
CPT |
Effective 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 RENAL ALGRFT VENOUS ANAST EA |
50327 |
Service Description: |
BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL 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: |
50328 |
Service Code Type: |
CPT |
Effective 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 RENAL ALLOGRAFT ARTERIAL ANAST EA |
50328 |
Service Description: |
BKBENCH RCNSTJ ALGRFT URETERAL 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: |
50329 |
Service Code Type: |
CPT |
Effective 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 ALGRFT URETERAL ANAST EA |
50329 |
Service Description: |
RECIPIENT NEPHRECTOMY 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: |
50340 |
Service Code Type: |
CPT |
Effective 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) |
RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE |
50340 |
Service Description: |
RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY |
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: |
50360 |
Service Code Type: |
CPT |
Effective 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) |
RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY |
50360 |
Service Description: |
RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY |
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: |
50365 |
Service Code Type: |
CPT |
Effective 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) |
RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY |
50365 |
Service Description: |
RMVL TRNSPLED RENAL 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: |
50370 |
Service Code Type: |
CPT |
Effective 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 TRNSPLED RENAL ALLOGRAFT |
50370 |
Service Description: |
RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY |
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: |
50380 |
Service Code Type: |
CPT |
Effective 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) |
RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY |
50380 |
Service Description: |
LAPAROSCOPY DONOR NEPHRECTOMY 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: |
50547 |
Service Code Type: |
CPT |
Effective 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) |
LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR |
50547 |
Service Description: |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
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: |
52287 |
Service Code Type: |
CPT |
Effective 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) |
CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER |
52287 |
Service Description: |
URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT |
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: |
53415 |
Service Code Type: |
CPT |
Effective 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 |
URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT |
53415 |
Service Description: |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE |
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: |
53420 |
Service Code Type: |
CPT |
Effective 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 |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE |
53420 |
Service Description: |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
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: |
53425 |
Service Code Type: |
CPT |
Effective 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 |
URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE |
53425 |
Service Description: |
URETHROPLASTY RCNSTJ FEMALE URETHRA |
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: |
53430 |
Service Code Type: |
CPT |
Effective 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 |
URETHROPLASTY RCNSTJ FEMALE URETHRA |
53430 |
Service Description: |
AMPUTATION PENIS 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: |
54120 |
Service Code Type: |
CPT |
Effective 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 |
AMPUTATION PENIS PARTIAL |
54120 |
Service Description: |
AMPUTATION PENIS 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: |
54125 |
Service Code Type: |
CPT |
Effective 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 |
AMPUTATION PENIS COMPLETE |
54125 |
Service Description: |
INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID |
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: |
54400 |
Service Code Type: |
CPT |
Effective 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 |
INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID |
54400 |
Service Description: |
INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED |
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: |
54401 |
Service Code Type: |
CPT |
Effective 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 |
INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED |
54401 |
Service Description: |
INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH |
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: |
54405 |
Service Code Type: |
CPT |
Effective 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 |
INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH |
54405 |
Service Description: |
RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH |
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: |
54406 |
Service Code Type: |
CPT |
Effective 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 |
RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH |
54406 |
Service Description: |
RPR COMPONENT INFLATABLE PENILE PROSTHESIS |
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: |
54408 |
Service Code Type: |
CPT |
Effective 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 |
RPR COMPONENT INFLATABLE PENILE PROSTHESIS |
54408 |
Service Description: |
RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS |
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: |
54410 |
Service Code Type: |
CPT |
Effective 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 |
RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS |
54410 |
Service Description: |
RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL |
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: |
54411 |
Service Code Type: |
CPT |
Effective 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 |
RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL |
54411 |
Service Description: |
RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT |
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: |
54415 |
Service Code Type: |
CPT |
Effective 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 |
RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT |
54415 |
Service Description: |
RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI |
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: |
54416 |
Service Code Type: |
CPT |
Effective 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 |
RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI |
54416 |
Service Description: |
RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD |
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: |
54417 |
Service Code Type: |
CPT |
Effective 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 |
RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD |
54417 |
Service Description: |
ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH |
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: |
54420 |
Service Code Type: |
CPT |
Effective 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 |
ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH |
54420 |
Service Description: |
INSJ TESTICULAR PROSTH 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: |
54660 |
Service Code Type: |
CPT |
Effective 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 |
INSJ TESTICULAR PROSTH SEPARATE PROCEDURE |
54660 |
Service Description: |
LAPAROSCOPY SURGICAL ORCHIECTOMY |
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: |
54690 |
Service Code Type: |
CPT |
Effective 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 |
LAPAROSCOPY SURGICAL ORCHIECTOMY |
54690 |
Service Description: |
SCROTOPLASTY SIMPLE |
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: |
55175 |
Service Code Type: |
CPT |
Effective 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 |
SCROTOPLASTY SIMPLE |
55175 |
Service Description: |
SCROTOPLASTY COMPLICATED |
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: |
55180 |
Service Code Type: |
CPT |
Effective 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 |
SCROTOPLASTY COMPLICATED |
55180 |
Service Description: |
UNLISTED PROCEDURE MALE GENITAL SYSTEM |
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: |
55899 |
Service Code Type: |
CPT |
Effective 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 |
UNLISTED PROCEDURE MALE GENITAL SYSTEM |
55899 |
Service Description: |
INTERSEX SURG MALE FEMALE |
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: |
55970 |
Service Code Type: |
CPT |
Effective 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 |
INTERSEX SURG MALE FEMALE |
55970 |
Service Description: |
INTERSEX SURG FEMALE MALE |
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: |
55980 |
Service Code Type: |
CPT |
Effective 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 |
INTERSEX SURG FEMALE MALE |
55980 |
Service Description: |
PARTIAL REMOVAL OF VULVA |
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: |
56620 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
PARTIAL REMOVAL OF VULVA |
56620 |
Service Description: |
VULVECTOMY 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: |
56625 |
Service Code Type: |
CPT |
Effective 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 |
VULVECTOMY SIMPLE COMPLETE |
56625 |
Service Description: |
PLASTIC REPAIR INTROITUS |
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: |
56800 |
Service Code Type: |
CPT |
Effective 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 |
PLASTIC REPAIR INTROITUS |
56800 |
Service Description: |
CLITOROPLASTY INTERSEX STATE |
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: |
56805 |
Service Code Type: |
CPT |
Effective 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 |
CLITOROPLASTY INTERSEX STATE |
56805 |
Service Description: |
PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL 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: |
56810 |
Service Code Type: |
CPT |
Effective 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 |
PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX |
56810 |
Service Description: |
VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL |
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: |
57106 |
Service Code Type: |
CPT |
Effective 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 |
VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL |
57106 |
Service Description: |
VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T |
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: |
57107 |
Service Code Type: |
CPT |
Effective 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 |
VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T |
57107 |
Service Description: |
VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL |
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: |
57110 |
Service Code Type: |
CPT |
Effective 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 |
VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL |
57110 |
Service Description: |
VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS |
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: |
57111 |
Service Code Type: |
CPT |
Effective 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 |
VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS |
57111 |
Service Description: |
CONSTRUCTION ARTIFICIAL VAGINA W/O 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: |
57291 |
Service Code Type: |
CPT |
Effective 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 |
CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT |
57291 |
Service Description: |
CONSTRUCTION ARTIFICIAL VAGINA 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: |
57292 |
Service Code Type: |
CPT |
Effective 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 |
CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT |
57292 |
Service Description: |
REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP |
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: |
57295 |
Service Code Type: |
CPT |
Effective 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 |
REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP |
57295 |
Service Description: |
REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR |
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: |
57296 |
Service Code Type: |
CPT |
Effective 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 |
REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR |
57296 |
Service Description: |
VAGINOPLASTY INTERSEX STATE |
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: |
57335 |
Service Code Type: |
CPT |
Effective 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 |
VAGINOPLASTY INTERSEX STATE |
57335 |
Service Description: |
TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY |
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: |
58150 |
Service Code Type: |
CPT |
Effective 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 |
TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY |
58150 |
Service Description: |
TOTAL HYSTERECTOMY |
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: |
58152 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
TOTAL HYSTERECTOMY |
58152 |
Service Description: |
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY |
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: |
58180 |
Service Code Type: |
CPT |
Effective 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 |
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY |
58180 |
Service Description: |
EXTENSIVE HYSTERECTOMY |
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: |
58200 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
EXTENSIVE HYSTERECTOMY |
58200 |
Service Description: |
VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
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: |
58260 |
Service Code Type: |
CPT |
Effective 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 |
VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
58260 |
Service Description: |
VAG HYST 250 GM/< W/RMVL TUBE&/OVARY |
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: |
58262 |
Service Code Type: |
CPT |
Effective 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 |
VAG HYST 250 GM/< W/RMVL TUBE&/OVARY |
58262 |
Service Description: |
VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY |
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: |
58275 |
Service Code Type: |
CPT |
Effective 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 |
VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY |
58275 |
Service Description: |
VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE |
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: |
58280 |
Service Code Type: |
CPT |
Effective 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 |
VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE |
58280 |
Service Description: |
VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION |
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: |
58285 |
Service Code Type: |
CPT |
Effective 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 |
VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION |
58285 |
Service Description: |
VAGINAL HYSTERECTOMY UTERUS > 250 GM |
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: |
58290 |
Service Code Type: |
CPT |
Effective 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 |
VAGINAL HYSTERECTOMY UTERUS > 250 GM |
58290 |
Service Description: |
VAG HYST > 250 GM RMVL TUBE&/OVARY |
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: |
58291 |
Service Code Type: |
CPT |
Effective 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 |
VAG HYST > 250 GM RMVL TUBE&/OVARY |
58291 |
Service Description: |
LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< |
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: |
58541 |
Service Code Type: |
CPT |
Effective 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 |
LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< |
58541 |
Service Description: |
LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR |
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: |
58542 |
Service Code Type: |
CPT |
Effective 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 |
LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR |
58542 |
Service Description: |
LAPS SUPRACERVICAL HYSTERECTOMY >250 |
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: |
58543 |
Service Code Type: |
CPT |
Effective 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 |
LAPS SUPRACERVICAL HYSTERECTOMY >250 |
58543 |
Service Description: |
LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY |
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: |
58544 |
Service Code Type: |
CPT |
Effective 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 |
LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY |
58544 |
Service Description: |
LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
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: |
58550 |
Service Code Type: |
CPT |
Effective 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 |
LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< |
58550 |
Service Description: |
LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES |
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: |
58552 |
Service Code Type: |
CPT |
Effective 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 |
LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES |
58552 |
Service Description: |
LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS |
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: |
58553 |
Service Code Type: |
CPT |
Effective 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 |
LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS |
58553 |
Service Description: |
LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR |
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: |
58554 |
Service Code Type: |
CPT |
Effective 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 |
LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR |
58554 |
Service Description: |
HYSTEROSCOPY DX SEP PROC |
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: |
58555 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
HYSTEROSCOPY DX SEP PROC |
58555 |
Service Description: |
HYSTEROSCOPY BIOPSY |
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: |
58558 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
HYSTEROSCOPY BIOPSY |
58558 |
Service Description: |
HYSTEROSCOPY ABLATION |
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: |
58563 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
HYSTEROSCOPY ABLATION |
58563 |
Service Description: |
LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< |
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: |
58570 |
Service Code Type: |
CPT |
Effective 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 |
LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< |
58570 |
Service Description: |
LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY |
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: |
58571 |
Service Code Type: |
CPT |
Effective 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 |
LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY |
58571 |
Service Description: |
LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM |
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: |
58572 |
Service Code Type: |
CPT |
Effective 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 |
LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM |
58572 |
Service Description: |
LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR |
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: |
58573 |
Service Code Type: |
CPT |
Effective 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 |
LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR |
58573 |
Service Description: |
LAPARO PROC UTERUS |
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: |
58578 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
LAPARO PROC UTERUS |
58578 |
Service Description: |
LAPAROSCOPY LYSIS |
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: |
58660 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
LAPAROSCOPY LYSIS |
58660 |
Service Description: |
LAPAROSCOPY EXCISE LESIONS |
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: |
58662 |
Service Code Type: |
CPT |
Effective 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 - Female genital system |
LAPAROSCOPY EXCISE LESIONS |
58662 |
Service Description: |
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI 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: |
58720 |
Service Code Type: |
CPT |
Effective 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 |
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX |
58720 |
Service Description: |
OOPHORECTOMY PARTIAL/TOTAL UNI/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: |
58940 |
Service Code Type: |
CPT |
Effective 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 |
OOPHORECTOMY PARTIAL/TOTAL UNI/BI |
58940 |
Service Description: |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
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: |
59072 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE |
59072 |
Service Description: |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
Prior Authorization required: Preferred: |
Yes |
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: |
59074 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
59074 |
Service Description: |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
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: |
59074 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE |
59074 |
Service Description: |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
Prior Authorization required: Preferred: |
Yes |
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: |
59076 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE |
59076 |
Service Description: |
INDUCED ABORTION DILATION AND CURETTAGE |
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: |
59840 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION DILATION AND CURETTAGE |
59840 |
Service Description: |
INDUCED ABORTION DILATION & EVACUATION |
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: |
59841 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION DILATION & EVACUATION |
59841 |
Service Description: |
INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ |
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: |
59850 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ |
59850 |
Service Description: |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C |
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: |
59851 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C |
59851 |
Service Description: |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM |
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: |
59852 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM |
59852 |
Service Description: |
INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS |
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: |
59855 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS |
59855 |
Service Description: |
INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC |
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: |
59856 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC |
59856 |
Service Description: |
INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT |
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: |
59857 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT |
59857 |
Service Description: |
PARTIAL REMOVAL OF THYROID |
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: |
60220 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
PARTIAL REMOVAL OF THYROID |
60220 |
Service Description: |
REMOVAL OF THYROID |
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: |
60240 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
REMOVAL OF THYROID |
60240 |
Service Description: |
REPEAT THYROID 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: |
60260 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
REPEAT THYROID SURGERY |
60260 |
Service Description: |
REMOVE THYROID DUCT LESION |
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: |
60280 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
REMOVE THYROID DUCT LESION |
60280 |
Service Description: |
REMOVAL OF THYMUS GLAND |
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: |
60521 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
REMOVAL OF THYMUS GLAND |
60521 |
Service Description: |
EXPLORE ADRENAL GLAND |
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: |
60540 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
EXPLORE ADRENAL GLAND |
60540 |
Service Description: |
EXPLORE ADRENAL GLAND |
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: |
60545 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
EXPLORE ADRENAL GLAND |
60545 |
Service Description: |
LAPAROSCOPY ADRENALECTOMY |
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: |
60650 |
Service Code Type: |
CPT |
Effective 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 - Endocrine system |
LAPAROSCOPY ADRENALECTOMY |
60650 |
Service Description: |
INCISE SKULL (PRESS RELIEF) |
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: |
61343 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
INCISE SKULL (PRESS RELIEF) |
61343 |
Service Description: |
INCISE SKULL FOR BRAIN WOUND |
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: |
61458 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
INCISE SKULL FOR BRAIN WOUND |
61458 |
Service Description: |
REMOVAL OF SKULL LESION |
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: |
61500 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVAL OF SKULL LESION |
61500 |
Service Description: |
REMOVE BRAIN LINING LESION |
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: |
61512 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE BRAIN LINING LESION |
61512 |
Service Description: |
REMOVAL OF PITUITARY GLAND |
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: |
61546 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVAL OF PITUITARY GLAND |
61546 |
Service Description: |
TRANSCATH OCCLUSION CNS |
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: |
61624 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
TRANSCATH OCCLUSION CNS |
61624 |
Service Description: |
TRANSCATH OCCLUSION NON-CNS |
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: |
61626 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
TRANSCATH OCCLUSION NON-CNS |
61626 |
Service Description: |
FUSION OF SKULL ARTERIES |
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: |
61711 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
FUSION OF SKULL ARTERIES |
61711 |
Service Description: |
SCAN PROC CRANIAL INTRA |
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: |
61781 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
SCAN PROC CRANIAL INTRA |
61781 |
Service Description: |
SCAN PROC CRANIAL EXTRA |
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: |
61782 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
SCAN PROC CRANIAL EXTRA |
61782 |
Service Description: |
SCAN PROC SPINAL |
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: |
61783 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
SCAN PROC SPINAL |
61783 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion |
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: |
61796 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion |
61796 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) |
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: |
61797 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) |
61797 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion |
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: |
61798 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion |
61798 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
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: |
61799 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
61799 |
Service Description: |
Application of stereotactic headframe for stereotactic radiosurgery (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: |
61800 |
Service Code Type: |
CPT |
Effective 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)) |
Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) |
61800 |
Service Description: |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
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: |
61850 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL |
61850 |
Service Description: |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
Prior Authorization required: Preferred: |
No |
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: |
61860 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL |
61860 |
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
Prior Authorization required: Preferred: |
No |
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: |
61863 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY |
61863 |
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
Prior Authorization required: Preferred: |
No |
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: |
61864 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY |
61864 |
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
Prior Authorization required: Preferred: |
No |
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: |
61867 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY |
61867 |
Service Description: |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
Prior Authorization required: Preferred: |
No |
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: |
61868 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY |
61868 |
Service Description: |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
Prior Authorization required: Preferred: |
No |
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: |
61870 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL |
61870 |
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
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: |
61885 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
61885 |
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
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: |
61885 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vagal Nerve Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR |
61885 |
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
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: |
61886 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Deep Brain Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
61886 |
Service Description: |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
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: |
61886 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vagal Nerve Stimulation |
INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS |
61886 |
Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
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: |
62263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS |
62263 |
Service Description: |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
Prior Authorization required: Preferred: |
Yes |
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: |
62264 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Lysis of Adhesions |
PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY |
62264 |
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
Prior Authorization required: Preferred: |
No |
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: |
62320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
62320 |
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
Prior Authorization required: Preferred: |
No |
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: |
62321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
62321 |
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
Prior Authorization required: Preferred: |
No |
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: |
62322 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
62322 |
Service Description: |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
Prior Authorization required: Preferred: |
No |
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: |
62323 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
62323 |
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
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: |
62324 |
Service Code Type: |
CPT |
Effective 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 |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance |
62324 |
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
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: |
62325 |
Service Code Type: |
CPT |
Effective 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 |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) |
62325 |
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
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: |
62326 |
Service Code Type: |
CPT |
Effective 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 |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance |
62326 |
Service Description: |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
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: |
62327 |
Service Code Type: |
CPT |
Effective 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 |
Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) |
62327 |
Service Description: |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM |
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: |
62350 |
Service Code Type: |
CPT |
Effective 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 |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM |
62350 |
Service Description: |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM |
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: |
62351 |
Service Code Type: |
CPT |
Effective 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 |
IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM |
62351 |
Service Description: |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR |
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: |
62360 |
Service Code Type: |
CPT |
Effective 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 |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR |
62360 |
Service Description: |
IMPLTJ/RPLCMT FS NON-PRGRBL 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: |
62361 |
Service Code Type: |
CPT |
Effective 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 |
IMPLTJ/RPLCMT FS NON-PRGRBL PUMP |
62361 |
Service Description: |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL 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: |
62362 |
Service Code Type: |
CPT |
Effective 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 |
IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP |
62362 |
Service Description: |
LAMINECTOMY W/O FFD 1/2 VERT SEG 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: |
63005 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR |
63005 |
Service Description: |
LAMINECTOMY W/RMVL ABNORMAL FACETS 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: |
63012 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR |
63012 |
Service Description: |
LAMINECTOMY W/O FFD > 2 VERT SEG 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: |
63017 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR |
63017 |
Service Description: |
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR |
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: |
63030 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR |
63030 |
Service Description: |
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/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: |
63035 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR |
63035 |
Service Description: |
LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC 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: |
63042 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR |
63042 |
Service Description: |
LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA 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: |
63044 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR |
63044 |
Service Description: |
REMOVE SPINE LAMINA 1 CRVL |
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: |
63045 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE SPINE LAMINA 1 CRVL |
63045 |
Service Description: |
REMOVE SPINE LAMINA 1 THRC |
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: |
63046 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE SPINE LAMINA 1 THRC |
63046 |
Service Description: |
LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT 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: |
63047 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT LUMBAR |
63047 |
Service Description: |
LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV 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: |
63048 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR |
63048 |
Service Description: |
REMOVE VERT BODY DCMPRN CRVL |
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: |
63081 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE VERT BODY DCMPRN CRVL |
63081 |
Service Description: |
REMOVE VERTEBRAL BODY 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: |
63082 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE VERTEBRAL BODY ADD-ON |
63082 |
Service Description: |
LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS |
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: |
63185 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS |
63185 |
Service Description: |
LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS |
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: |
63190 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS |
63190 |
Service Description: |
LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE |
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: |
63191 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Laminectomy (Elective) |
LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE |
63191 |
Service Description: |
RELEASE SPINAL CORD 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: |
63200 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
RELEASE SPINAL CORD LUMBAR |
63200 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion |
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: |
63620 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion |
63620 |
Service Description: |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (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: |
63621 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) |
63621 |
Service Description: |
Percutaneous implantation of neurostimulator electrode array, epidural |
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: |
63650 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Percutaneous implantation of neurostimulator electrode array, epidural |
63650 |
Service Description: |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
Prior Authorization required: Preferred: |
No |
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: |
63655 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural |
63655 |
Service Description: |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
Prior Authorization required: Preferred: |
No |
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: |
63685 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling |
63685 |
Service Description: |
NJX of ANES AGENT TRIGEMINAL NERVE |
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: |
64400 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
NJX of ANES AGENT TRIGEMINAL NERVE |
64400 |
Service Description: |
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV |
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: |
64405 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Occipital Nerve Block |
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV |
64405 |
Service Description: |
INJECTION ANESTHETIC AGENT SUPRASCAPULAR NERVE |
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: |
64418 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Suprascapular Nerve Block |
INJECTION ANESTHETIC AGENT SUPRASCAPULAR NERVE |
64418 |
Service Description: |
INJECTION ANESTHETIC AGENT 1 INTERCOSTAL NERVE |
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: |
64420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intercostal Nerve Block |
INJECTION ANESTHETIC AGENT 1 INTERCOSTAL NERVE |
64420 |
Service Description: |
MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES |
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: |
64421 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intercostal Nerve Block |
MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES |
64421 |
Service Description: |
N BLOCK INJ ILIO-ING/HYPOGI |
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: |
64425 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
N BLOCK INJ ILIO-ING/HYPOGI |
64425 |
Service Description: |
N BLOCK INJ FEM SINGLE |
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: |
64447 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
N BLOCK INJ FEM SINGLE |
64447 |
Service Description: |
N BLOCK OTHER PERIPHERAL |
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: |
64450 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
N BLOCK OTHER PERIPHERAL |
64450 |
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
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: |
64479 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL |
64479 |
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
Prior Authorization required: Preferred: |
No |
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: |
64480 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV |
64480 |
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
Prior Authorization required: Preferred: |
No |
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: |
64483 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL |
64483 |
Service Description: |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
Prior Authorization required: Preferred: |
No |
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: |
64484 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV |
64484 |
Service Description: |
TAP BLOCK UNI BY INFUSION |
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: |
64487 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
TAP BLOCK UNI BY INFUSION |
64487 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
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: |
64490 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL |
64490 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
Prior Authorization required: Preferred: |
No |
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: |
64491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL |
64491 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
Prior Authorization required: Preferred: |
No |
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: |
64492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL |
64492 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
Prior Authorization required: Preferred: |
No |
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: |
64493 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
64493 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
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: |
64493 |
Service Code Type: |
CPT |
Effective 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 |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL |
64493 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
Prior Authorization required: Preferred: |
No |
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: |
64494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
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: |
64494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
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: |
64494 |
Service Code Type: |
CPT |
Effective 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 |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL |
64494 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
Prior Authorization required: Preferred: |
No |
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: |
64495 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
64495 |
Service Description: |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
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: |
64495 |
Service Code Type: |
CPT |
Effective 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 |
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL |
64495 |
Service Description: |
INJECTION ANES AGENT SPHENOPALATINE GANGLION |
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: |
64505 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sympathetic Nerve Block |
INJECTION ANES AGENT SPHENOPALATINE GANGLION |
64505 |
Service Description: |
NJX ANES STELLATE GANGLION CRV SYMPATHETIC |
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: |
64510 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sympathetic Nerve Block |
NJX ANES STELLATE GANGLION CRV SYMPATHETIC |
64510 |
Service Description: |
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC |
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: |
64520 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sympathetic Nerve Block |
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC |
64520 |
Service Description: |
INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG |
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: |
64530 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sympathetic Nerve Block |
INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG |
64530 |
Service Description: |
PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING |
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: |
64561 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING |
64561 |
Service Description: |
NEUROELTRD STIM POST TIBIAL |
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: |
64566 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
NEUROELTRD STIM POST TIBIAL |
64566 |
Service Description: |
INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER |
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: |
64568 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vagal Nerve Stimulation |
INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER |
64568 |
Service Description: |
INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE |
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: |
64581 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE |
64581 |
Service Description: |
INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR |
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: |
64590 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sacral Nerve Stimulation - Interstim (including trial implantation) |
INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR |
64590 |
Service Description: |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
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: |
64611 |
Service Code Type: |
CPT |
Effective 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) |
CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS |
64611 |
Service Description: |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
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: |
64612 |
Service Code Type: |
CPT |
Effective 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) |
CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL |
64612 |
Service Description: |
DESTROY NERVE NECK MUSCLE |
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: |
64613 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
DESTROY NERVE NECK MUSCLE |
64613 |
Service Description: |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
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: |
64615 |
Service Code Type: |
CPT |
Effective 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) |
CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE |
64615 |
Service Description: |
CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA |
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: |
64616 |
Service Code Type: |
CPT |
Effective 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 MUSCLE NECK UNILAT FOR DYSTONIA |
64616 |
Service Description: |
CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG |
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: |
64617 |
Service Code Type: |
CPT |
Effective 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 MUSCLE LARYNX UNILAT W/EMG |
64617 |
Service Description: |
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE |
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: |
64620 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intercostal Nerve Block |
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE |
64620 |
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
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: |
64633 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA |
64633 |
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
Prior Authorization required: Preferred: |
No |
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: |
64634 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA |
64634 |
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
Prior Authorization required: Preferred: |
No |
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: |
64635 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL |
64635 |
Service Description: |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
Prior Authorization required: Preferred: |
No |
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: |
64636 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL |
64636 |
Service Description: |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
Prior Authorization required: Preferred: |
No |
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: |
64640 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE |
64640 |
Service Description: |
CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE |
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: |
64642 |
Service Code Type: |
CPT |
Effective 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 ONE EXTREMITY 1-4 MUSCLE |
64642 |
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
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: |
64643 |
Service Code Type: |
CPT |
Effective 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 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
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: |
64643 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet or Sacroiliac Joint Denervation |
CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE |
64643 |
Service Description: |
CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES |
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: |
64644 |
Service Code Type: |
CPT |
Effective 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 1 EXTREMITY 5 OR MORE MUSCLES |
64644 |
Service Description: |
CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES |
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: |
64645 |
Service Code Type: |
CPT |
Effective 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 1 EXTREMITY EA ADDL 5/> MUSCLES |
64645 |
Service Description: |
CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES |
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: |
64646 |
Service Code Type: |
CPT |
Effective 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 OF TRUNK MUSCLE 1-5 MUSCLES |
64646 |
Service Description: |
CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES |
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: |
64647 |
Service Code Type: |
CPT |
Effective 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 OF TRUNK 6 OR MORE MUSCLES |
64647 |
Service Description: |
CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE |
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: |
64650 |
Service Code Type: |
CPT |
Effective 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 ECCRINE GLANDS BOTH AXILLAE |
64650 |
Service Description: |
CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY |
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: |
64653 |
Service Code Type: |
CPT |
Effective 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 ECCRINE GLANDS OTH AREA PER DAY |
64653 |
Service Description: |
REVISION OF CRANIAL NERVE |
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: |
64716 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REVISION OF CRANIAL NERVE |
64716 |
Service Description: |
REVISE ULNAR NERVE AT ELBOW |
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: |
64718 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REVISE ULNAR NERVE AT ELBOW |
64718 |
Service Description: |
CARPAL TUNNEL 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: |
64721 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
CARPAL TUNNEL SURGERY |
64721 |
Service Description: |
RELIEVE PRESSURE ON NERVE(S) |
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: |
64722 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
RELIEVE PRESSURE ON NERVE(S) |
64722 |
Service Description: |
SEVER CRANIAL NERVE |
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: |
64771 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
SEVER CRANIAL NERVE |
64771 |
Service Description: |
REMOVE NERVE LESION |
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: |
64784 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REMOVE NERVE LESION |
64784 |
Service Description: |
IMPLANT NERVE END |
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: |
64787 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
IMPLANT NERVE END |
64787 |
Service Description: |
REPAIR OF DIGIT NERVE |
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: |
64831 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REPAIR OF DIGIT NERVE |
64831 |
Service Description: |
REPAIR/TRANSPOSE NERVE |
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: |
64856 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
REPAIR/TRANSPOSE NERVE |
64856 |
Service Description: |
NERVE GRAFT HEAD/NECK 4 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: |
64885 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
NERVE GRAFT HEAD/NECK 4 CM |
64885 |
Service Description: |
NRV RPR W/NRV ALGRFT 1ST |
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: |
64912 |
Service Code Type: |
CPT |
Effective 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 - Nervous System |
NRV RPR W/NRV ALGRFT 1ST |
64912 |
Service Description: |
IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS |
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: |
67027 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vitrasert® (ganciclovir intravitreal implant) |
IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS |
67027 |
Service Description: |
REMOVAL OF INNER EYE FLUID |
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: |
67036 |
Service Code Type: |
CPT |
Effective 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 - Eye |
REMOVAL OF INNER EYE FLUID |
67036 |
Service Description: |
LASER TREATMENT OF RETINA |
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: |
67039 |
Service Code Type: |
CPT |
Effective 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 - Eye |
LASER TREATMENT OF RETINA |
67039 |
Service Description: |
VIT FOR MACULAR PUCKER |
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: |
67041 |
Service Code Type: |
CPT |
Effective 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 - Eye |
VIT FOR MACULAR PUCKER |
67041 |
Service Description: |
VIT FOR MACULAR HOLE |
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: |
67042 |
Service Code Type: |
CPT |
Effective 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 - Eye |
VIT FOR MACULAR HOLE |
67042 |
Service Description: |
VIT FOR MEMBRANE DISSECT |
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: |
67043 |
Service Code Type: |
CPT |
Effective 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 - Eye |
VIT FOR MEMBRANE DISSECT |
67043 |
Service Description: |
REPAIR DETACHED RETINA |
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: |
67107 |
Service Code Type: |
CPT |
Effective 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 - Eye |
REPAIR DETACHED RETINA |
67107 |
Service Description: |
OCULAR PHOTODYNAMIC THER |
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: |
67221 |
Service Code Type: |
CPT |
Effective 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 - Eye |
OCULAR PHOTODYNAMIC THER |
67221 |
Service Description: |
CHEMODENERVATION EXTRAOCULAR MUSCLE |
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: |
67345 |
Service Code Type: |
CPT |
Effective 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 EXTRAOCULAR MUSCLE |
67345 |
Service Description: |
REPAIR BROW PTOSIS |
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: |
67900 |
Service Code Type: |
CPT |
Effective 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) |
REPAIR BROW PTOSIS |
67900 |
Service Description: |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
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: |
67901 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL |
67901 |
Service Description: |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
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: |
67902 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING |
67902 |
Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
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: |
67903 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL |
67903 |
Service Description: |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
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: |
67904 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL |
67904 |
Service Description: |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
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: |
67906 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING |
67906 |
Service Description: |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
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: |
67908 |
Service Code Type: |
CPT |
Effective 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) |
RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ |
67908 |
Service Description: |
REVISION OF 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: |
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: |
67950 |
Service Code Type: |
CPT |
Effective 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) |
REVISION OF EYELID |
67950 |
Service Description: |
MRI TEMPOROMANDIBULAR JOINT |
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: |
70336 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI TEMPOROMANDIBULAR JOINT |
70336 |
Service Description: |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
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: |
70450 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O CONTRAST MATERIAL |
70450 |
Service Description: |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
No |
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: |
70460 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/CONTRAST MATERIAL |
70460 |
Service Description: |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
No |
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: |
70470 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL |
70470 |
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
Prior Authorization required: Preferred: |
Yes |
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: |
70480 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL |
70480 |
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
Prior Authorization required: Preferred: |
Yes |
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: |
70481 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL |
70481 |
Service Description: |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
Prior Authorization required: Preferred: |
Yes |
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: |
70482 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR |
70482 |
Service Description: |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70486 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O CONTRAST MATERIAL |
70486 |
Service Description: |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70487 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/CONTRAST MATERIAL |
70487 |
Service Description: |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70488 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL |
70488 |
Service Description: |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70490 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O CONTRAST MATERIAL |
70490 |
Service Description: |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/CONTRAST MATERIAL |
70491 |
Service Description: |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
70492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL |
70492 |
Service Description: |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
Prior Authorization required: Preferred: |
No |
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: |
70496 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST |
70496 |
Service Description: |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
Prior Authorization required: Preferred: |
No |
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: |
70498 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST |
70498 |
Service Description: |
MRI ORBIT FACE &/NECK W/O CONTRAST |
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: |
70540 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE &/NECK W/O CONTRAST |
70540 |
Service Description: |
MRI ORBIT FACE & NECK W/CONTRAST 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: |
70542 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE & NECK W/CONTRAST MATERIAL |
70542 |
Service Description: |
MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL |
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: |
70543 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL |
70543 |
Service Description: |
MRA HEAD W/O CONTRST MATERIAL |
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: |
70544 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/O CONTRST MATERIAL |
70544 |
Service Description: |
MRA HEAD W/CONTRAST MATERIAL |
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: |
70545 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/CONTRAST MATERIAL |
70545 |
Service Description: |
MRA HEAD W/O & W/CONTRAST MATERIAL |
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: |
70546 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA HEAD W/O & W/CONTRAST MATERIAL |
70546 |
Service Description: |
MRA NECK W/O CONTRST MATERIAL |
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: |
70547 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/O CONTRST MATERIAL |
70547 |
Service Description: |
MRA NECK W/CONTRAST MATERIAL |
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: |
70548 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/CONTRAST MATERIAL |
70548 |
Service Description: |
MRA NECK W/O &W/CONTRAST MATERIAL |
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: |
70549 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA NECK W/O &W/CONTRAST MATERIAL |
70549 |
Service Description: |
MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL |
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: |
70551 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL |
70551 |
Service Description: |
MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL |
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: |
70552 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL |
70552 |
Service Description: |
MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL |
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: |
70553 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL |
70553 |
Service Description: |
MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION |
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: |
70554 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION |
70554 |
Service Description: |
MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION |
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: |
70555 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION |
70555 |
Service Description: |
CT THORAX W/O CONTRAST 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: |
71250 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O CONTRAST MATERIAL |
71250 |
Service Description: |
CT THORAX W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
71260 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/CONTRAST MATERIAL |
71260 |
Service Description: |
CT THORAX W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
71270 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORAX W/O & W/CONTRAST MATERIAL |
71270 |
Service Description: |
CTA chest (noncoronary) |
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: |
71275 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA chest (noncoronary) |
71275 |
Service Description: |
MRI CHEST W/O CONTRAST 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: |
71550 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/O CONTRAST MATERIAL |
71550 |
Service Description: |
MRI CHEST W/CONTRAST 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: |
71551 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/CONTRAST MATERIAL |
71551 |
Service Description: |
MRI CHEST W/O & W/CONTRAST 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: |
71552 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI CHEST W/O & W/CONTRAST MATERIAL |
71552 |
Service Description: |
MRA CHEST W/O & W/CONTRAST 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: |
71555 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA CHEST W/O & W/CONTRAST MATERIAL |
71555 |
Service Description: |
CT CERVICAL SPINE W/O CONTRAST 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: |
72125 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O CONTRAST MATERIAL |
72125 |
Service Description: |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72126 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
72126 |
Service Description: |
CT CERVICAL SPINE W/CONTRAST 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: |
72126 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/CONTRAST MATERIAL |
72126 |
Service Description: |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72127 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL |
72127 |
Service Description: |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72128 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O CONTRAST MATERIAL |
72128 |
Service Description: |
CT THORACIC SPINE W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72129 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/CONTRAST MATERIAL |
72129 |
Service Description: |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72130 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT THORACIC SPINE W/O & W/CONTRAST MATERIAL |
72130 |
Service Description: |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72131 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O CONTRAST MATERIAL |
72131 |
Service Description: |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72132 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/CONTRAST MATERIAL |
72132 |
Service Description: |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72133 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL |
72133 |
Service Description: |
MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL |
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: |
72141 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL |
72141 |
Service Description: |
MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL |
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: |
72142 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL |
72142 |
Service Description: |
MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL |
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: |
72146 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL |
72146 |
Service Description: |
MRI SPINAL CANAL THORACIC W/CONTRAST MATRL |
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: |
72147 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/CONTRAST MATRL |
72147 |
Service Description: |
MRI SPINAL CANAL LUMBAR W/O CONTRAST 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: |
72148 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL |
72148 |
Service Description: |
MRI SPINAL CANAL LUMBAR W/CONTRAST 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: |
72149 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL |
72149 |
Service Description: |
MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL |
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: |
72156 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL |
72156 |
Service Description: |
MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL |
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: |
72157 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL |
72157 |
Service Description: |
MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL |
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: |
72158 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL |
72158 |
Service Description: |
MRA SPINAL CANAL W/WO CONTRAST 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: |
72159 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA SPINAL CANAL W/WO CONTRAST MATERIAL |
72159 |
Service Description: |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
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: |
72191 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST |
72191 |
Service Description: |
CT PELVIS W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72192 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O CONTRAST MATERIAL |
72192 |
Service Description: |
CT PELVIS W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72193 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/CONTRAST MATERIAL |
72193 |
Service Description: |
CT PELVIS W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
72194 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT PELVIS W/O & W/CONTRAST MATERIAL |
72194 |
Service Description: |
MRI PELVIS W/O CONTRAST 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: |
72195 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/O CONTRAST MATERIAL |
72195 |
Service Description: |
MRI PELVIS W/CONTRAST 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: |
72196 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/CONTRAST MATERIAL |
72196 |
Service Description: |
MRI PELVIS W/O & W/CONTRAST 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: |
72197 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI PELVIS W/O & W/CONTRAST MATERIAL |
72197 |
Service Description: |
MRA PELVIS W/WO CONTRAST 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: |
72198 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA PELVIS W/WO CONTRAST MATERIAL |
72198 |
Service Description: |
CT UPPER EXTREMITY W/O CONTRAST 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: |
73200 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O CONTRAST MATERIAL |
73200 |
Service Description: |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
73201 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/CONTRAST MATERIAL |
73201 |
Service Description: |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
73202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL |
73202 |
Service Description: |
CT ANGIOGRAPHY UPPER EXTREMITY |
Prior Authorization required: Preferred: |
Yes |
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: |
73206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY UPPER EXTREMITY |
73206 |
Service Description: |
MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL |
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: |
73218 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL |
73218 |
Service Description: |
MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL |
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: |
73219 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL |
73219 |
Service Description: |
MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS |
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: |
73220 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS |
73220 |
Service Description: |
MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL |
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: |
73221 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL |
73221 |
Service Description: |
MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL |
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: |
73222 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL |
73222 |
Service Description: |
MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL |
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: |
73223 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL |
73223 |
Service Description: |
MRA UPPER EXTREMITY W/WO CONTRAST 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: |
73225 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL |
73225 |
Service Description: |
CT LOWER EXTREMITY W/O CONTRAST 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: |
73700 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O CONTRAST MATERIAL |
73700 |
Service Description: |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
73701 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/CONTRAST MATERIAL |
73701 |
Service Description: |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
Prior Authorization required: Preferred: |
Yes |
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: |
73702 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LOWER EXTREMITY W/O & W/CONTRAST MATRL |
73702 |
Service Description: |
CT ANGIOGRAPHY LOWER EXTREMITY |
Prior Authorization required: Preferred: |
Yes |
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: |
73706 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY LOWER EXTREMITY |
73706 |
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL |
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: |
73718 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL |
73718 |
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL |
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: |
73719 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL |
73719 |
Service Description: |
MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR |
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: |
73720 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR |
73720 |
Service Description: |
MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL |
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: |
73721 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL |
73721 |
Service Description: |
MRI ANY JT LOWER EXTREM W/CONTRAST 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: |
73722 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL |
73722 |
Service Description: |
MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL |
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: |
73723 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL |
73723 |
Service Description: |
MRA LOWER EXTREMITY W/WO CONTRAST 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: |
73725 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL |
73725 |
Service Description: |
CT ABDOMEN W/O CONTRAST 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: |
74150 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O CONTRAST MATERIAL |
74150 |
Service Description: |
CT ABDOMEN W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
74160 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/CONTRAST MATERIAL |
74160 |
Service Description: |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
74170 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN W/O & W/CONTRAST MATERIAL |
74170 |
Service Description: |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
Prior Authorization required: Preferred: |
Yes |
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: |
74174 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG |
74174 |
Service Description: |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
Prior Authorization required: Preferred: |
Yes |
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: |
74175 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST |
74175 |
Service Description: |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
74176 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL |
74176 |
Service Description: |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
Prior Authorization required: Preferred: |
Yes |
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: |
74177 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/CONTRAST MATERIAL |
74177 |
Service Description: |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
Prior Authorization required: Preferred: |
Yes |
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: |
74178 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE |
74178 |
Service Description: |
MRI ABDOMEN W/O CONTRAST 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: |
74181 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/O CONTRAST MATERIAL |
74181 |
Service Description: |
MRI ABDOMEN W/CONTRAST 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: |
74182 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/CONTRAST MATERIAL |
74182 |
Service Description: |
MRI ABDOMEN W/O & W/CONTRAST 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: |
74183 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MRI ABDOMEN W/O & W/CONTRAST MATERIAL |
74183 |
Service Description: |
MRA ABDOMEN W/WO CONTRAST 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: |
74185 |
Service Code Type: |
CPT |
Effective 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 Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MRA ABDOMEN W/WO CONTRAST MATERIAL |
74185 |
Service Description: |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST |
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: |
74261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Virtual Colonoscopy (Outpatient/Nonemergency) |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST |
74261 |
Service Description: |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST |
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: |
74262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Virtual Colonoscopy (Outpatient/Nonemergency) |
CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST |
74262 |
Service Description: |
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST |
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: |
75557 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST |
75557 |
Service Description: |
CARDIAC MRI W/O CONTRAST W/STRESS IMAGING |
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: |
75559 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/O CONTRAST W/STRESS IMAGING |
75559 |
Service Description: |
CARDIAC MRI W/WO CONTRAST & FURTHER SEQ |
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: |
75561 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/WO CONTRAST & FURTHER SEQ |
75561 |
Service Description: |
CARDIAC MRI W/W/O CONTRAST W/STRESS |
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: |
75563 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI W/W/O CONTRAST W/STRESS |
75563 |
Service Description: |
CARDIAC MRI FOR VELOCITY FLOW MAPPING |
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: |
75565 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
CARDIAC MRI FOR VELOCITY FLOW MAPPING |
75565 |
Service Description: |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
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: |
75571 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM |
75571 |
Service Description: |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
Prior Authorization required: Preferred: |
No |
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: |
75572 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH |
75572 |
Service Description: |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
Prior Authorization required: Preferred: |
No |
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: |
75573 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D |
75573 |
Service Description: |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
Prior Authorization required: Preferred: |
No |
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: |
75574 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST |
75574 |
Service Description: |
CONTRAST EXAM THORACIC AORTA |
Prior Authorization required: Preferred: |
No |
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: |
75605 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CONTRAST EXAM THORACIC AORTA |
75605 |
Service Description: |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
Prior Authorization required: Preferred: |
Yes |
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: |
75635 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP |
75635 |
Service Description: |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation |
Prior Authorization required: Preferred: |
Yes |
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: |
76376 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation |
76376 |
Service Description: |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation |
Prior Authorization required: Preferred: |
Yes |
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: |
76377 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation |
76377 |
Service Description: |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
Prior Authorization required: Preferred: |
Yes |
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: |
76380 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CT LIMITED/LOCALIZED FOLLOW UP STUDY |
76380 |
Service Description: |
UNLISTED COMPUTED TOMOGRAPHY 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: |
76497 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
UNLISTED COMPUTED TOMOGRAPHY PROCEDURE |
76497 |
Service Description: |
CT guidance for placement of radiation therapy fields |
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: |
77014 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
CT guidance for placement of radiation therapy fields |
77014 |
Service Description: |
Magnetic resonance imaging, breast, without contrast material(s); unilateral |
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: |
77046 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without contrast material(s); unilateral |
77046 |
Service Description: |
Magnetic resonance imaging, breast, without contrast material(s); bilateral |
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: |
77047 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without contrast material(s); bilateral |
77047 |
Service Description: |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; unilateral |
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: |
77048 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; unilateral |
77048 |
Service Description: |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; bilateral |
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: |
77049 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging, breast, without and/or with contrast material(s); including computer-aided detection (CAD) rea-time lesion detection, characterization and pharmacokinetic analysis, when performed; bilateral |
77049 |
Service Description: |
BONE MARROW BLOOD SUPPLY |
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: |
77084 |
Service Code Type: |
CPT |
Effective 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 Resonance Imaging (MRI) (Outpatient/Nonemergency) |
BONE MARROW BLOOD SUPPLY |
77084 |
Service Description: |
Therapeutic radiology treatment planning; simple |
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: |
77261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; simple |
77261 |
Service Description: |
Therapeutic radiology treatment planning; intermediate |
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: |
77262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; intermediate |
77262 |
Service Description: |
Therapeutic radiology treatment planning; complex |
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: |
77263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology treatment planning; complex |
77263 |
Service Description: |
Therapeutic radiology simulation-aided field setting; simple |
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: |
77280 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; simple |
77280 |
Service Description: |
Therapeutic radiology simulation-aided field setting; intermediate |
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: |
77285 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; intermediate |
77285 |
Service Description: |
Therapeutic radiology simulation-aided field setting; complex |
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: |
77290 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Therapeutic radiology simulation-aided field setting; complex |
77290 |
Service Description: |
4-D CT simulation study for conformal planning - Respiratory Management Simulation |
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: |
77293 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
4-D CT simulation study for conformal planning - Respiratory Management Simulation |
77293 |
Service Description: |
Therapeutic radiology simulation-aided field setting; 3-dimensional |
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: |
77295 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Therapeutic radiology simulation-aided field setting; 3-dimensional |
77295 |
Service Description: |
Unlisted procedure, therapeutic radiology clinical treatment planning |
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: |
77299 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Prep for Treatment |
Unlisted procedure, therapeutic radiology clinical treatment planning |
77299 |
Service Description: |
Basic radiation dosimetry calculation |
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: |
77300 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Basic radiation dosimetry calculation |
77300 |
Service Description: |
Intensity modulated radiotherapy plan (IMRT), including dose-volume histograms for target and critical structure partial tolerance specifications |
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: |
77301 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Intensity modulated radiotherapy plan (IMRT), including dose-volume histograms for target and critical structure partial tolerance specifications |
77301 |
Service Description: |
Dosimetry device Isodose Planning |
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: |
77306 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Dosimetry device Isodose Planning |
77306 |
Service Description: |
Teletherapy isodose plan complex |
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: |
77307 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Teletherapy isodose plan complex |
77307 |
Service Description: |
Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations |
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: |
77316 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; simple (1-4 sources or 1 channel), includes basic dosimetry calculations |
77316 |
Service Description: |
Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation |
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: |
77317 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; intermediate (5-10 sources or 2-12 channels), includes basic dosimetry calculation |
77317 |
Service Description: |
Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations |
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: |
77318 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Brachytherapy isodose plan; complex (over 10 sources or over 12 channels), includes basic dosimetry calculations |
77318 |
Service Description: |
Special teletherapy port plan, particles, hemibody, total body |
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: |
77321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special teletherapy port plan, particles, hemibody, total body |
77321 |
Service Description: |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
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: |
77331 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
77331 |
Service Description: |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
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: |
77331 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician |
77331 |
Service Description: |
Treatment devices, design and construction; simple (simple block, simple bolus) |
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: |
77332 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; simple (simple block, simple bolus) |
77332 |
Service Description: |
Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) |
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: |
77333 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) |
77333 |
Service Description: |
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) |
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: |
77334 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) |
77334 |
Service Description: |
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy |
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: |
77336 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy |
77336 |
Service Description: |
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan |
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: |
77338 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan |
77338 |
Service Description: |
Special medical radiation physics consultation |
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: |
77370 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology- Dosimetry, Devices and Special Services |
Special medical radiation physics consultation |
77370 |
Service Description: |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; multi-source Cobalt 60 based |
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: |
77371 |
Service Code Type: |
CPT |
Effective 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)) |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; multi-source Cobalt 60 based |
77371 |
Service Description: |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; linear accelerator based |
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: |
77372 |
Service Code Type: |
CPT |
Effective 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)) |
Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session; linear accelerator based |
77372 |
Service Description: |
Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed 5 fractions |
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: |
77373 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed 5 fractions |
77373 |
Service Description: |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple |
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: |
77385 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; simple |
77385 |
Service Description: |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex |
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: |
77386 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking when performed; complex |
77386 |
Service Description: |
Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed |
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: |
77387 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed |
77387 |
Service Description: |
Radiation treatment delivery, superficial and/or ortho voltage |
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: |
77401 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, superficial and/or ortho voltage |
77401 |
Service Description: |
Radiation treatment delivery, 1 treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV |
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: |
77402 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 1 treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV |
77402 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3+ ports on a single treatment area, use of multiple blocks; up to 5 MeV |
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: |
77407 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3+ ports on a single treatment area, use of multiple blocks; up to 5 MeV |
77407 |
Service Description: |
Radiation treatment delivery, 3+ separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
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: |
77412 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3+ separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
77412 |
Service Description: |
Therapeutic radiology port film(s) |
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: |
77417 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Therapeutic radiology port film(s) |
77417 |
Service Description: |
High energy neutron radiation treatment delivery; 1 treatment area using a single port or parallel-opposed ports with no blocks or simple blocking |
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: |
77422 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
High energy neutron radiation treatment delivery; 1 treatment area using a single port or parallel-opposed ports with no blocks or simple blocking |
77422 |
Service Description: |
One or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) |
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: |
77423 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
One or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) |
77423 |
Service Description: |
Intraoperative radiation treatment delivery, x-ray, single treatment session |
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: |
77424 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intraoperative radiation treatment delivery, x-ray, single treatment session |
77424 |
Service Description: |
Intraoperative radiation treatment delivery, electrons, single treatment session |
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: |
77425 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intraoperative radiation treatment delivery, electrons, single treatment session |
77425 |
Service Description: |
Radiation treatment management, 5 treatments |
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: |
77427 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
Radiation treatment management, 5 treatments |
77427 |
Service Description: |
Radiation therapy management with complete course of therapy; 1-2 fractions |
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: |
77431 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
Radiation therapy management with complete course of therapy; 1-2 fractions |
77431 |
Service Description: |
Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) |
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: |
77432 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) |
77432 |
Service Description: |
Stereotactic body radiation therapy, treatment management, per treatment course, to 1+ lesions, including image guidance, entire course not to exceed 5 fractions |
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: |
77435 |
Service Code Type: |
CPT |
Effective 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)) |
Stereotactic body radiation therapy, treatment management, per treatment course, to 1+ lesions, including image guidance, entire course not to exceed 5 fractions |
77435 |
Service Description: |
Intraoperative radiation treatment management |
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: |
77469 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
Intraoperative radiation treatment management |
77469 |
Service Description: |
Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) |
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: |
77470 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) |
77470 |
Service Description: |
Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 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: |
77600 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) |
77600 |
Service Description: |
Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 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: |
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: |
77605 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 cm) |
77605 |
Service Description: |
Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators |
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: |
77610 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators |
77610 |
Service Description: |
Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators |
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: |
77615 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators |
77615 |
Service Description: |
Hyperthermia generated by intracavitary probe(s) |
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: |
77620 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Hyperthermia generated by intracavitary probe(s) |
77620 |
Service Description: |
Clinical Brachytherapy- Intracavitary radiation |
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: |
77750 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Clinical Brachytherapy- Intracavitary radiation |
77750 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
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: |
77761 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77761 |
Service Description: |
intracavitary brachytherapy using 10 sources; intermediate |
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: |
77762 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
intracavitary brachytherapy using 10 sources; intermediate |
77762 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
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: |
77763 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77763 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel |
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: |
77770 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel |
77770 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels |
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: |
77771 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels |
77771 |
Service Description: |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels |
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: |
77772 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels |
77772 |
Service Description: |
Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when performed |
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: |
77778 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when performed |
77778 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
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: |
77789 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77789 |
Service Description: |
Treatment Deliveries - LDR Brachytherapy |
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: |
77790 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Treatment Deliveries - LDR Brachytherapy |
77790 |
Service Description: |
LIVER IMAGING SPECT |
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: |
78205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Liver |
LIVER IMAGING SPECT |
78205 |
Service Description: |
LIVER IMAGING SPECT W/VASCULAR FLOW |
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: |
78206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Liver |
LIVER IMAGING SPECT W/VASCULAR FLOW |
78206 |
Service Description: |
Bone and/or Joint imaging; Limited 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: |
78300 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Limited area |
78300 |
Service Description: |
Bone and/or Joint imaging; Multiple areas |
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: |
78305 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Multiple areas |
78305 |
Service Description: |
Bone and/or Joint imaging; Whole Body |
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: |
78306 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; Whole Body |
78306 |
Service Description: |
Bone and/or Joint imaging; 3 phase study |
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: |
78315 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging: Bone and Joint |
Bone and/or Joint imaging; 3 phase study |
78315 |
Service Description: |
BONE &/JOINT IMAGING TOMOGRAPHIC SPECT |
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: |
78320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Bone and Joint |
BONE &/JOINT IMAGING TOMOGRAPHIC SPECT |
78320 |
Service Description: |
MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS |
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: |
78451 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS |
78451 |
Service Description: |
MYOCARDIAL SPECT MULTIPLE STUDIES |
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: |
78452 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL SPECT MULTIPLE STUDIES |
78452 |
Service Description: |
MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS |
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: |
78453 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS |
78453 |
Service Description: |
MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES |
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: |
78454 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES |
78454 |
Service Description: |
MYOCARDIAL IMAGING PET METABOLIC EVALUATION |
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: |
78459 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCARDIAL IMAGING PET METABOLIC EVALUATION |
78459 |
Service Description: |
MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN |
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: |
78466 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN |
78466 |
Service Description: |
MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ |
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: |
78468 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ |
78468 |
Service Description: |
MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ |
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: |
78469 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ |
78469 |
Service Description: |
CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS |
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: |
78472 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS |
78472 |
Service Description: |
CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT |
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: |
78473 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT |
78473 |
Service Description: |
CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT |
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: |
78481 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT |
78481 |
Service Description: |
CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT |
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: |
78483 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT |
78483 |
Service Description: |
MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS |
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: |
78491 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS |
78491 |
Service Description: |
MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS |
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: |
78492 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS |
78492 |
Service Description: |
CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT |
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: |
78494 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT |
78494 |
Service Description: |
CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT |
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: |
78496 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT |
78496 |
Service Description: |
UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE |
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: |
78499 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cardiac |
UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE |
78499 |
Service Description: |
BRAIN IMAGING TOMOGRAPHIC SPECT |
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: |
78607 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Brain |
BRAIN IMAGING TOMOGRAPHIC SPECT |
78607 |
Service Description: |
BRAIN IMAGING PET METABOLIC EVALUATION |
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: |
78608 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
BRAIN IMAGING PET METABOLIC EVALUATION |
78608 |
Service Description: |
BRAIN IMAGING PET PERFUSION EVALUATION |
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: |
78609 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
BRAIN IMAGING PET PERFUSION EVALUATION |
78609 |
Service Description: |
CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT |
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: |
78647 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Cerebrospinal Fluid Flow |
CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT |
78647 |
Service Description: |
K FLOW/FUNCT IMAGE W/DRUG |
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: |
78708 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
K FLOW/FUNCT IMAGE W/DRUG |
78708 |
Service Description: |
KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC |
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: |
78710 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nuclear Imaging (SPECT): Kidney |
KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC |
78710 |
Service Description: |
TUMOR IMAGING WHOLE BODY |
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: |
78802 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
TUMOR IMAGING WHOLE BODY |
78802 |
Service Description: |
TUMOR IMAGING WHOLE BODY |
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: |
78804 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Management |
TUMOR IMAGING WHOLE BODY |
78804 |
Service Description: |
PET IMAGING LIMITED AREA CHEST HEAD/NECK |
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: |
78811 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING LIMITED AREA CHEST HEAD/NECK |
78811 |
Service Description: |
PET IMAGING SKULL BASE TO MID-THIGH |
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: |
78812 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING SKULL BASE TO MID-THIGH |
78812 |
Service Description: |
PET IMAGING WHOLE BODY |
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: |
78813 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING WHOLE BODY |
78813 |
Service Description: |
PET IMAGING CT FOR ATTENUATION LIMITED 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: |
78814 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING CT FOR ATTENUATION LIMITED AREA |
78814 |
Service Description: |
PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH |
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: |
78815 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH |
78815 |
Service Description: |
PET IMAGING FOR CT ATTENUATION WHOLE BODY |
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: |
78816 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
PET IMAGING FOR CT ATTENUATION WHOLE BODY |
78816 |
Service Description: |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
Prior Authorization required: Preferred: |
Yes |
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: |
81107 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human platelet Antigen 3 genotyping (HPA-3) ITGA2B integrin, alpha 2b [platelet gyycoprotein Illb of Illb/Illa complex], antigen CD41 [GPIlb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-3a/b (I843S) |
81107 |
Service Description: |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
Prior Authorization required: Preferred: |
Yes |
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: |
81108 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 4 genotyping (HPA-4) ITGB3 (integrin, beta 3 [platelet glycoprotein Illa], antigen CD61 [GPIlla]) (eg, neonatal alloimmune thrombocytopenia [NAIT]. Post-transfusion purpura), gene analysis, common variant, HPA-4a/b (R143Q) |
81108 |
Service Description: |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
Prior Authorization required: Preferred: |
Yes |
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: |
81109 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 5 genotyping (HPA-5) ITGA2 (integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2 receptor] {Gpla)] 9eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant (eg, HPA-5a/b (K505e)) |
81109 |
Service Description: |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
Prior Authorization required: Preferred: |
Yes |
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: |
81110 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin , beta 3 [platelet glycoprotein Illa, antigen CD61] (GPIlla)) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura) gene analysis, common variant, HPA-6a/b (r489Q) |
81110 |
Service Description: |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
Prior Authorization required: Preferred: |
Yes |
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: |
81111 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alph 2b [platelet glycoprotein Illb of Illb/Illa complex, antigen CD41] [GpIlb]) (eg, neonatal alloimmune thromocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-9a/b (V837M) |
81111 |
Service Description: |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
Prior Authorization required: Preferred: |
Yes |
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: |
81112 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 moelcule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common variant, HPA-15a/b (S682Y) |
81112 |
Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
Prior Authorization required: Preferred: |
Yes |
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: |
81171 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81171 |
Service Description: |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
Prior Authorization required: Preferred: |
Yes |
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: |
81172 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) |
81172 |
Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
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: |
81174 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant |
81174 |
Service Description: |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence |
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: |
81175 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence |
81175 |
Service Description: |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) |
Prior Authorization required: Preferred: |
Yes |
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: |
81176 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
ASXL 1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) |
81176 |
Service Description: |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81177 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81177 |
Service Description: |
ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
Prior Authorization required: Preferred: |
Yes |
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: |
81178 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81178 |
Service Description: |
ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81179 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81179 |
Service Description: |
ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81180 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81180 |
Service Description: |
ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81181 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81181 |
Service Description: |
ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81182 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81182 |
Service Description: |
ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81183 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81183 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
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: |
81184 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81184 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
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: |
81185 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
81185 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
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: |
81185 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence |
81185 |
Service Description: |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant |
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: |
81186 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant |
81186 |
Service Description: |
CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81187 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81187 |
Service Description: |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence |
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: |
81188 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles 81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence |
81188 |
Service Description: |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(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: |
81190 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) |
81190 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
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: |
81202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
81202 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
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: |
81202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants |
81202 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
Prior Authorization required: Preferred: |
Yes |
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: |
81203 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion varian |
81203 |
Service Description: |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants |
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: |
81203 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants |
81203 |
Service Description: |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) |
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: |
81204 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) |
81204 |
Service Description: |
BCKDHB GENE ANALYSIS COMMON VARIANTS |
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: |
81205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
BCKDHB GENE ANALYSIS COMMON VARIANTS |
81205 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
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: |
81206 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative |
81206 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
Prior Authorization required: Preferred: |
Yes |
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: |
81207 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative |
81207 |
Service Description: |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
Prior Authorization required: Preferred: |
Yes |
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: |
81208 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, other breakpoint, qualitative or quantitative |
81208 |
Service Description: |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
Prior Authorization required: Preferred: |
Yes |
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: |
81218 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), gene analysis, full gene sequence |
81218 |
Service Description: |
CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 |
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: |
81219 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 |
81219 |
Service Description: |
CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
Prior Authorization required: Preferred: |
Yes |
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: |
81221 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
81221 |
Service Description: |
CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS |
Prior Authorization required: Preferred: |
Yes |
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: |
81222 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS |
81222 |
Service Description: |
CFTR GENE ANALYSIS FULL GENE SEQUENCE |
Prior Authorization required: Preferred: |
Yes |
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: |
81223 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS FULL GENE SEQUENCE |
81223 |
Service Description: |
CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS |
Prior Authorization required: Preferred: |
Yes |
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: |
81224 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS |
81224 |
Service Description: |
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) |
Prior Authorization required: Preferred: |
Yes |
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: |
81225 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) |
81225 |
Service Description: |
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) |
Prior Authorization required: Preferred: |
Yes |
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: |
81226 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) |
81226 |
Service Description: |
CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) |
Prior Authorization required: Preferred: |
Yes |
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: |
81227 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) |
81227 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
Prior Authorization required: Preferred: |
Yes |
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: |
81228 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Comparative Genomic Hybridization (CGH) or Chromosomal Microarray Analysis (CMA) for Evaluation of Developmental Delay |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
81228 |
Service Description: |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
Prior Authorization required: Preferred: |
Yes |
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: |
81228 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or oligobased comparative genomic hybridization [CGH] microarray analysis) |
81228 |
Service Description: |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
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: |
81233 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) |
81233 |
Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
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: |
81234 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles |
81234 |
Service Description: |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence |
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: |
81236 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence |
81236 |
Service Description: |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large Bcell lymphoma) gene analysis, common variant(s) (eg, codon 646) 81238 F9(coagulation factor IX) (eg, hemophilia B) full gene sequence |
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: |
81237 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large Bcell lymphoma) gene analysis, common variant(s) (eg, codon 646) 81238 F9(coagulation factor IX) (eg, hemophilia B) full gene sequence |
81237 |
Service Description: |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
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: |
81239 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) |
81239 |
Service Description: |
FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL RETARDATION) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE AND PROMOTER METHYLATION STATUS) |
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: |
81244 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL RETARDATION) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE AND PROMOTER METHYLATION STATUS) |
81244 |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15) |
Prior Authorization required: Preferred: |
Yes |
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: |
81245 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (i.e., exons 14, 15) |
81245 |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
Prior Authorization required: Preferred: |
Yes |
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: |
81246 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) |
81246 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) |
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: |
81247 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) |
81247 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(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: |
81248 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) |
81248 |
Service Description: |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence |
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: |
81249 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence |
81249 |
Service Description: |
G6PC GENE ANALYSIS COMMON VARIANTS |
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: |
81250 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
G6PC GENE ANALYSIS COMMON VARIANTS |
81250 |
Service Description: |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
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: |
81251 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS |
81251 |
Service Description: |
GJB2 GENE ANALYSIS FULL GENE SEQUENCE |
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: |
81252 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
GJB2 GENE ANALYSIS FULL GENE SEQUENCE |
81252 |
Service Description: |
GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
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: |
81253 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS |
81253 |
Service Description: |
HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D) |
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: |
81256 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D) |
81256 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) |
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: |
81257 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) |
81257 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; known familial variant |
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: |
81258 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; known familial variant |
81258 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; full gene sequence |
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: |
81259 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; full gene sequence |
81259 |
Service Description: |
IKBKAP GENE ANALYSIS COMMON VARIANTS |
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: |
81260 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
IKBKAP GENE ANALYSIS COMMON VARIANTS |
81260 |
Service Description: |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot) |
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: |
81262 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot) |
81262 |
Service Description: |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis |
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: |
81263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis |
81263 |
Service Description: |
IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
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: |
81264 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) |
81264 |
Service Description: |
COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC |
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: |
81265 |
Service Code Type: |
CPT |
Effective 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) |
COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC |
81265 |
Service Description: |
COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN |
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: |
81266 |
Service Code Type: |
CPT |
Effective 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) |
COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN |
81266 |
Service Description: |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; duplication/deletion variants |
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: |
81269 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, Hbh disease), gene analysis; duplication/deletion variants |
81269 |
Service Description: |
JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant |
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: |
81270 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant |
81270 |
Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
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: |
81271 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles |
81271 |
Service Description: |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
Prior Authorization required: Preferred: |
Yes |
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: |
81274 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) |
81274 |
Service Description: |
MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), promoter methylation analysis |
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: |
81287 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), promoter methylation analysis |
81287 |
Service Description: |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Prior Authorization required: Preferred: |
Yes |
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: |
81288 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81288 |
Service Description: |
MTHFR GENE ANALYSIS COMMON VARIANTS |
Prior Authorization required: Preferred: |
Yes |
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: |
81291 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
MTHFR GENE ANALYSIS COMMON VARIANTS |
81291 |
Service Description: |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
Prior Authorization required: Preferred: |
Yes |
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: |
81296 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; |
81296 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
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: |
81302 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis |
81302 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
Prior Authorization required: Preferred: |
Yes |
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: |
81303 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant |
81303 |
Service Description: |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
Prior Authorization required: Preferred: |
Yes |
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: |
81304 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants |
81304 |
Service Description: |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
Prior Authorization required: Preferred: |
Yes |
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: |
81305 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
81305 |
Service Description: |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
Prior Authorization required: Preferred: |
Yes |
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: |
81305 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants |
81305 |
Service Description: |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative |
Prior Authorization required: Preferred: |
Yes |
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: |
81315 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative |
81315 |
Service Description: |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative |
Prior Authorization required: Preferred: |
Yes |
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: |
81316 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative |
81316 |
Service Description: |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
Prior Authorization required: Preferred: |
Yes |
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: |
81320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) |
81320 |
Service Description: |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant |
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: |
81322 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant |
81322 |
Service Description: |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant |
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: |
81323 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant |
81323 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
Prior Authorization required: Preferred: |
Yes |
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: |
81324 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis |
81324 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
Prior Authorization required: Preferred: |
Yes |
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: |
81325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis |
81325 |
Service Description: |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
Prior Authorization required: Preferred: |
Yes |
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: |
81326 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Dystrophic or Degenerative Disorders |
PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant |
81326 |
Service Description: |
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis |
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: |
81331 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis |
81331 |
Service Description: |
SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, Member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z) |
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: |
81332 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, Member 1) (e.g., alpha-1-antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z) |
81332 |
Service Description: |
TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) |
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: |
81333 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) |
81333 |
Service Description: |
RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) |
Prior Authorization required: Preferred: |
Yes |
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: |
81334 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) |
81334 |
Service Description: |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction) |
Prior Authorization required: Preferred: |
Yes |
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: |
81340 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction) |
81340 |
Service Description: |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot) |
Prior Authorization required: Preferred: |
Yes |
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: |
81341 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot) |
81341 |
Service Description: |
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81343 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81343 |
Service Description: |
TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
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: |
81344 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles |
81344 |
Service Description: |
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) |
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: |
81345 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) |
81345 |
Service Description: |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
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: |
81350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) |
81350 |
Service Description: |
VKORC1 GENE ANALYSIS COMMON VARIANTS |
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: |
81355 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
VKORC1 GENE ANALYSIS COMMON VARIANTS |
81355 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); known familial variant(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: |
81362 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); known familial variant(s) |
81362 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); duplication/deletion variant(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: |
81363 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) |
81363 |
Service Description: |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); full gene sequence |
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: |
81364 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia beta thalassemia, hemoglobinopathy); full gene sequence |
81364 |
Service Description: |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, -C, DRB 1/3/4/5, and –DQB1 |
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: |
81370 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, -C, DRB 1/3/4/5, and –DQB1 |
81370 |
Service Description: |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, and – DRB1 (e.g. verification typing) |
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: |
81371 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I and II typing, low resolution (e.g., antigen equivalents): HLA-A, -B, and – DRB1 (e.g. verification typing) |
81371 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); complete (i.e., HLA-A, -B, and-C) |
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: |
81372 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, low resolution (e.g., antigen equivalents); complete (i.e., HLA-A, -B, and-C) |
81372 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLA-A, -B, or –C), each |
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: |
81373 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLA-A, -B, or –C), each |
81373 |
Service Description: |
HLA Class I typing, low resolution (e.g., antigen equivalents); one antigen equivalent (e.g. B*27), each |
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: |
81374 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, low resolution (e.g., antigen equivalents); one antigen equivalent (e.g. B*27), each |
81374 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); HLA-DRB1/3/4/5 and – DQB1 |
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: |
81375 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class II typing, low resolution (e.g., antigen equivalents); HLA-DRB1/3/4/5 and – DQB1 |
81375 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLADRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or –DPA1), each |
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: |
81376 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class II typing, low resolution (e.g., antigen equivalents); one locus (e.g. HLADRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or –DPA1), each |
81376 |
Service Description: |
HLA Class II typing, low resolution (e.g., antigen equivalents); one antigen equivalent , each |
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: |
81377 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class II typing, low resolution (e.g., antigen equivalents); one antigen equivalent , each |
81377 |
Service Description: |
HLA Class I and II typing, high resolution (i.e., alleles or allele groups), HLA-A, -B, -C, and -DRB1 |
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: |
81378 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I and II typing, high resolution (i.e., alleles or allele groups), HLA-A, -B, -C, and -DRB1 |
81378 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); complete (i.e., HLA-A, B, and -C) |
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: |
81379 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); complete (i.e., HLA-A, B, and -C) |
81379 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 locus (e.g., HLA-A, B, or -C), each |
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: |
81380 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 locus (e.g., HLA-A, B, or -C), each |
81380 |
Service Description: |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., B*57:01P), each |
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: |
81381 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class I typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., B*57:01P), each |
81381 |
Service Description: |
HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLADRB1, - DRB3, 4/5, -DQB1, -DQA1, -DPB1, or -DP |
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: |
81382 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (e.g., HLADRB1, - DRB3, 4/5, -DQB1, -DQA1, -DPB1, or -DP |
81382 |
Service Description: |
HLA Class II typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., HLA-DQB1*06:02P), each |
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: |
81383 |
Service Code Type: |
CPT |
Effective 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) |
HLA Class II typing, high resolution (i.e., alleles or allele groups); 1 allele or allele group (e.g., HLA-DQB1*06:02P), each |
81383 |
Service Description: |
Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of > 50 exons, sequence analysis of multiple genes on 1 platform) |
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: |
81407 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Molecular pathology procedure, Level 8 (e.g., analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of > 50 exons, sequence analysis of multiple genes on 1 platform) |
81407 |
Service Description: |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
Prior Authorization required: Preferred: |
Yes |
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: |
81410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
81410 |
Service Description: |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
Prior Authorization required: Preferred: |
Yes |
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: |
81410 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK |
81410 |
Service Description: |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 |
Prior Authorization required: Preferred: |
Yes |
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: |
81411 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 |
81411 |
Service Description: |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A |
Prior Authorization required: Preferred: |
Yes |
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: |
81413 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A |
81413 |
Service Description: |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 |
Prior Authorization required: Preferred: |
Yes |
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: |
81414 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 |
81414 |
Service Description: |
EXOME SEQUENCE ANALYSIS |
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: |
81415 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Whole Exome Sequencing |
EXOME SEQUENCE ANALYSIS |
81415 |
Service Description: |
EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME |
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: |
81416 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Whole Exome Sequencing |
EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME |
81416 |
Service Description: |
EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ |
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: |
81417 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Whole Exome Sequencing |
EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ |
81417 |
Service Description: |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 |
Prior Authorization required: Preferred: |
Yes |
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: |
81432 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 |
81432 |
Service Description: |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 |
Prior Authorization required: Preferred: |
Yes |
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: |
81433 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Hereditary Breast Cancer-related disorders (e.g., hereditary Breast Cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 |
81433 |
Service Description: |
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, conerod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A |
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: |
81434 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, conerod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A |
81434 |
Service Description: |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2 |
Prior Authorization required: Preferred: |
Yes |
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: |
81435 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2 |
81435 |
Service Description: |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH |
Prior Authorization required: Preferred: |
Yes |
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: |
81436 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH |
81436 |
Service Description: |
Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL |
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: |
81437 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Hereditary neuroendocrine tumor disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL |
81437 |
Service Description: |
HEREDITARY NEUROENDOCRINE TUMOR DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR SDHB, SDHC, SDHD, AND VHL |
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: |
81438 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
HEREDITARY NEUROENDOCRINE TUMOR DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR SDHB, SDHC, SDHD, AND VHL |
81438 |
Service Description: |
Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN 81479 Unlisted molecular pathology procedure |
Prior Authorization required: Preferred: |
Yes |
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: |
81439 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN 81479 Unlisted molecular pathology procedure |
81439 |
Service Description: |
NOONAN SPECTRUM DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 12 GENES, INCLUDING BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, AND SOS1 |
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: |
81442 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
NOONAN SPECTRUM DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 12 GENES, INCLUDING BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, AND SOS1 |
81442 |
Service Description: |
GENETIC TSTG SEVERE INH COND |
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: |
81443 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
GENETIC TSTG SEVERE INH COND |
81443 |
Service Description: |
TARGETED GENOMIC SEQ ANALYS |
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: |
81445 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
TARGETED GENOMIC SEQ ANALYS |
81445 |
Service Description: |
X-LINKED INTELLECTUAL DBLT |
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: |
81470 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
X-LINKED INTELLECTUAL DBLT |
81470 |
Service Description: |
X-LINKED INTELLECTUAL DBLT |
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: |
81471 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Maternal, Prenatal or Neonatal |
X-LINKED INTELLECTUAL DBLT |
81471 |
Service Description: |
UNLISTED MOLELCULAR PATHOLOGY 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: |
81479 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE |
81479 |
Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
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: |
81500 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS |
81500 |
Service Description: |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
Prior Authorization required: Preferred: |
Yes |
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: |
81503 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS |
81503 |
Service Description: |
ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL |
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: |
81506 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL |
81506 |
Service Description: |
Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (MammaPrint®, Agendia, Inc) |
Prior Authorization required: Preferred: |
Yes |
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: |
81521 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Breast or Ovarian Cancer |
Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (MammaPrint®, Agendia, Inc) |
81521 |
Service Description: |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
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: |
81525 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES |
81525 |
Service Description: |
ONCOLOGY PROSTATE PROB SCORE |
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: |
81539 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
ONCOLOGY PROSTATE PROB SCORE |
81539 |
Service Description: |
Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (Prolaris ®, Myriad Genetic Laboratories, Inc.) |
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: |
81541 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score (Prolaris ®, Myriad Genetic Laboratories, Inc.) |
81541 |
Service Description: |
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious) (Afirma® Gene Expression Classifier, Veracyte, Inc.) 81599 Unlisted molecular pathology procedure 84999 Unlisted chemistry procedure 86386 Nuclear Matrix Protein 22 (NMP22), qualitative |
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: |
81545 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious) (Afirma® Gene Expression Classifier, Veracyte, Inc.) 81599 Unlisted molecular pathology procedure 84999 Unlisted chemistry procedure 86386 Nuclear Matrix Protein 22 (NMP22), qualitative |
81545 |
Service Description: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
Prior Authorization required: Preferred: |
Yes |
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: |
81599 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Advanced Molecular Topographic Genotyping |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
81599 |
Service Description: |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
Prior Authorization required: Preferred: |
Yes |
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: |
81599 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS |
81599 |
Service Description: |
Unlisted chemistry procedure |
Prior Authorization required: Preferred: |
Yes |
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: |
84999 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted chemistry procedure |
84999 |
Service Description: |
STEM CELLS TOTAL COUNT |
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: |
86367 |
Service Code Type: |
CPT |
Effective 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) |
STEM CELLS TOTAL COUNT |
86367 |
Service Description: |
SERUM SCREENING % REACTIVE ANTIBODY STANDRD METH |
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: |
86807 |
Service Code Type: |
CPT |
Effective 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) |
SERUM SCREENING % REACTIVE ANTIBODY STANDRD METH |
86807 |
Service Description: |
SERUM SCREENING % REACTIVE ANTIBODY QUICK METH |
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: |
86808 |
Service Code Type: |
CPT |
Effective 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) |
SERUM SCREENING % REACTIVE ANTIBODY QUICK METH |
86808 |
Service Description: |
HLA TYPING A/B/C SINGLE ANTIGEN |
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: |
86812 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING A/B/C SINGLE ANTIGEN |
86812 |
Service Description: |
HLA TYPING A/B/C MULTIPLE ANTIGENS |
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: |
86813 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING A/B/C MULTIPLE ANTIGENS |
86813 |
Service Description: |
HLA TYPING DR/DQ SINGLE ANTIGEN |
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: |
86816 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING DR/DQ SINGLE ANTIGEN |
86816 |
Service Description: |
HLA TYPING DR/DQ MULTIPLE ANTIGENS |
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: |
86817 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING DR/DQ MULTIPLE ANTIGENS |
86817 |
Service Description: |
HLA TYPING LYMPHOCYTE CULTURE MIXED |
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: |
86821 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING LYMPHOCYTE CULTURE MIXED |
86821 |
Service Description: |
HLA TYPING LYMPHOCYTE CULTURE PRIMED |
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: |
86822 |
Service Code Type: |
CPT |
Effective 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) |
HLA TYPING LYMPHOCYTE CULTURE PRIMED |
86822 |
Service Description: |
COMPATIBILITY EACH UNIT IMMEDIATE SPIN 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: |
86920 |
Service Code Type: |
CPT |
Effective 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) |
COMPATIBILITY EACH UNIT IMMEDIATE SPIN TECHNIQUE |
86920 |
Service Description: |
COMPATIBILITY EACH UNIT INCUBATION |
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: |
86921 |
Service Code Type: |
CPT |
Effective 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) |
COMPATIBILITY EACH UNIT INCUBATION |
86921 |
Service Description: |
COMPATIBILITY EACH UNIT ANTIGLOBULIN |
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: |
86922 |
Service Code Type: |
CPT |
Effective 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) |
COMPATIBILITY EACH UNIT ANTIGLOBULIN |
86922 |
Service Description: |
COMPATIBILITY EACH UNIT ELECTRONIC |
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: |
86923 |
Service Code Type: |
CPT |
Effective 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) |
COMPATIBILITY EACH UNIT ELECTRONIC |
86923 |
Service Description: |
Tissue culture for non-neoplastic disorders; lymphocyte |
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: |
88230 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Tissue culture for non-neoplastic disorders; lymphocyte |
88230 |
Service Description: |
Chromosome analysis; count 5 cells, 1 karyotype, with banding |
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: |
88261 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Chromosome analysis; count 5 cells, 1 karyotype, with banding |
88261 |
Service Description: |
Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding |
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: |
88263 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding |
88263 |
Service Description: |
Chromosome analysis; additional high resolution study |
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: |
88289 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Chromosome analysis; additional high resolution study |
88289 |
Service Description: |
UNLISTED CYTOGENETIC STUDY |
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: |
88299 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
UNLISTED CYTOGENETIC STUDY |
88299 |
Service Description: |
IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN |
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: |
88366 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN |
88366 |
Service Description: |
M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN |
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: |
88367 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN |
88367 |
Service Description: |
M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL |
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: |
88368 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL |
88368 |
Service Description: |
UNLISTED IN VIVO LAB SERVICE |
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: |
88749 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
UNLISTED IN VIVO LAB SERVICE |
88749 |
Service Description: |
Unlisted miscellaneous pathology test |
Prior Authorization required: Preferred: |
Yes |
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: |
89240 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Advanced Molecular Topographic Genotyping |
Unlisted miscellaneous pathology test |
89240 |
Service Description: |
RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E |
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: |
90378 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Synagis® (palivizumab) |
RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E |
90378 |
Service Description: |
Psychiatric diagnostic evaluation |
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: |
1/1/2021 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: |
90791 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychiatric diagnostic evaluation |
90791 |
Service Description: |
Psychiatric diagnostic evaluation with medical services |
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: |
1/1/2021 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: |
90792 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychiatric diagnostic evaluation with medical services |
90792 |
Service Description: |
Electroconvulsive therapy; includes necessary monitoring |
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: |
90870 |
Service Code Type: |
CPT |
Effective 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: Outpatient electro-convulsive treatment |
Electroconvulsive therapy; includes necessary monitoring |
90870 |
Service Description: |
BIOFEEDBACK TRAINING ANY MODALITY |
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: |
90901 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Biofeedback for Non Behavioral Health diagnoses |
BIOFEEDBACK TRAINING ANY MODALITY |
90901 |
Service Description: |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
Prior Authorization required: Preferred: |
No |
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: |
90911 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Biofeedback for Non Behavioral Health diagnoses |
BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG |
90911 |
Service Description: |
Hearing aid exam and selection, monaural |
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: |
92590 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid exam and selection, monaural |
92590 |
Service Description: |
Hearing aid exam and selection, binaural |
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: |
92591 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid exam and selection, binaural |
92591 |
Service Description: |
Hearing aid check, monaural |
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: |
92592 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid check, monaural |
92592 |
Service Description: |
Hearing aid check, binaural |
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: |
92593 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid check, binaural |
92593 |
Service Description: |
Electroacoustic evaluation for hearing aid, monaural |
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: |
92594 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Electroacoustic evaluation for hearing aid, monaural |
92594 |
Service Description: |
Electroacoustic evaluation for hearing aid, binaural |
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: |
92595 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Electroacoustic evaluation for hearing aid, binaural |
92595 |
Service Description: |
Ear protector evaluation |
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: |
92596 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Ear protector evaluation |
92596 |
Service Description: |
Cardioassist-hyphenmethod of circulatory assist; internal |
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: |
92970 |
Service Code Type: |
CPT |
Effective 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) |
Cardioassist-hyphenmethod of circulatory assist; internal |
92970 |
Service Description: |
Cardioassist-hyphenmethod of circulatory assist; external |
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: |
92971 |
Service Code Type: |
CPT |
Effective 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) |
Cardioassist-hyphenmethod of circulatory assist; external |
92971 |
Service Description: |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
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: |
93303 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY |
93303 |
Service Description: |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
Prior Authorization required: Preferred: |
No |
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: |
93304 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY |
93304 |
Service Description: |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
Prior Authorization required: Preferred: |
No |
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: |
93306 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D |
93306 |
Service Description: |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
Prior Authorization required: Preferred: |
No |
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: |
93307 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP |
93307 |
Service Description: |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
Prior Authorization required: Preferred: |
No |
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: |
93308 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD |
93308 |
Service Description: |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
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: |
93312 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R |
93312 |
Service Description: |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
Prior Authorization required: Preferred: |
No |
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: |
93313 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO R-T 2D W/PROBE PLACEMENT ONLY |
93313 |
Service Description: |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
Prior Authorization required: Preferred: |
No |
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: |
93314 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY |
93314 |
Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
Prior Authorization required: Preferred: |
No |
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: |
93315 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R |
93315 |
Service Description: |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
Prior Authorization required: Preferred: |
No |
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: |
93316 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY |
93316 |
Service Description: |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
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: |
93317 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT |
93317 |
Service Description: |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
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: |
93318 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ |
93318 |
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
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: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
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: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
Service Description: |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
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: |
93320 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY |
93320 |
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
Prior Authorization required: Preferred: |
No |
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: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
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: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
Service Description: |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
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: |
93321 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD |
93321 |
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
Prior Authorization required: Preferred: |
No |
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: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
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: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transesophageal |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
Service Description: |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
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: |
93325 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
DOP ECHOCARD COLOR FLOW VELOCITY MAPPING |
93325 |
Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
Prior Authorization required: Preferred: |
No |
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: |
93350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST |
93350 |
Service Description: |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
Prior Authorization required: Preferred: |
No |
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: |
93351 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG |
93351 |
Service Description: |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
Prior Authorization required: Preferred: |
No |
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: |
93352 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Stress |
USE OF ECHO CONTRAST AGENT DURING STRESS ECHO |
93352 |
Service Description: |
Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow & volume status, recovery), with programming, if performed, & report |
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: |
93750 |
Service Code Type: |
CPT |
Effective 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) |
Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow & volume status, recovery), with programming, if performed, & report |
93750 |
Service Description: |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
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: |
1/1/2021 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: |
96130 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
96130 |
Service Description: |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
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: |
1/1/2021 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: |
96131 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
96131 |
Service Description: |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
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: |
1/1/2021 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: |
96132 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
96132 |
Service Description: |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
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: |
1/1/2021 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: |
96133 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) |
96133 |
Service Description: |
PSYCL/NRPSYC TST PHY/QHP 1ST |
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: |
96136 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TST PHY/QHP 1ST |
96136 |
Service Description: |
PSYCL/NRPSYC TST PHY/QHP EA |
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: |
96137 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TST PHY/QHP EA |
96137 |
Service Description: |
PSYCL/NRPSYC TST PHY/QHP EA |
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: |
96137 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TST PHY/QHP EA |
96137 |
Service Description: |
PSYCL/NRPSYC TECH 1ST |
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: |
96138 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TECH 1ST |
96138 |
Service Description: |
PSYCL/NRPSYC TST TECH EA |
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: |
96139 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TST TECH EA |
96139 |
Service Description: |
PSYCL/NRPSYC TST AUTO RESULT |
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: |
96146 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PSYCL/NRPSYC TST AUTO RESULT |
96146 |
Service Description: |
OFFICE OUTPATIENT NEW 10 MINUTES |
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: |
1/1/2021 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: |
99201 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 10 MINUTES |
99201 |
Service Description: |
OFFICE OUTPATIENT NEW 20 MINUTES |
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: |
1/1/2021 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: |
99202 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 20 MINUTES |
99202 |
Service Description: |
OFFICE OUTPATIENT NEW 30 MINUTES |
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: |
1/1/2021 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: |
99203 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 30 MINUTES |
99203 |
Service Description: |
OFFICE OUTPATIENT NEW 45 MINUTES |
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: |
1/1/2021 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: |
99204 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 45 MINUTES |
99204 |
Service Description: |
OFFICE OUTPATIENT NEW 60 MINUTES |
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: |
1/1/2021 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: |
99205 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT NEW 60 MINUTES |
99205 |
Service Description: |
OFFICE OUTPATIENT VISIT 5 MINUTES |
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: |
1/1/2021 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: |
99211 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 5 MINUTES |
99211 |
Service Description: |
OFFICE OUTPATIENT VISIT 10 MINUTES |
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: |
1/1/2021 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: |
99212 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 10 MINUTES |
99212 |
Service Description: |
OFFICE OUTPATIENT VISIT 15 MINUTES |
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: |
1/1/2021 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: |
99213 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 15 MINUTES |
99213 |
Service Description: |
OFFICE OUTPATIENT VISIT 25 MINUTES |
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: |
1/1/2021 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: |
99214 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 25 MINUTES |
99214 |
Service Description: |
OFFICE OUTPATIENT VISIT 40 MINUTES |
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: |
1/1/2021 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: |
99215 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE OUTPATIENT VISIT 40 MINUTES |
99215 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN |
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: |
1/1/2021 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: |
99241 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN |
99241 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 30 MIN |
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: |
1/1/2021 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: |
99242 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 30 MIN |
99242 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 40 MIN |
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: |
1/1/2021 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: |
99243 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 40 MIN |
99243 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN |
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: |
1/1/2021 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: |
99244 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN |
99244 |
Service Description: |
OFFICE CONSULTATION NEW/ESTAB PATIENT 80 MIN |
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: |
1/1/2021 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: |
99245 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
OFFICE CONSULTATION NEW/ESTAB PATIENT 80 MIN |
99245 |
Service Description: |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN |
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: |
1/1/2021 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: |
99339 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN |
99339 |
Service Description: |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> |
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: |
1/1/2021 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: |
99340 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> |
99340 |
Service Description: |
HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES |
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: |
1/1/2021 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: |
99341 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES |
99341 |
Service Description: |
HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES |
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: |
1/1/2021 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: |
99342 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES |
99342 |
Service Description: |
HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES |
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: |
1/1/2021 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: |
99343 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES |
99343 |
Service Description: |
HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES |
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: |
1/1/2021 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: |
99344 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES |
99344 |
Service Description: |
HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN |
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: |
1/1/2021 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: |
99345 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN |
99345 |
Service Description: |
HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES |
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: |
1/1/2021 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: |
99347 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES |
99347 |
Service Description: |
HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES |
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: |
1/1/2021 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: |
99348 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES |
99348 |
Service Description: |
HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES |
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: |
1/1/2021 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: |
99349 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES |
99349 |
Service Description: |
HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS |
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: |
1/1/2021 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: |
99350 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS |
99350 |
Service Description: |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR |
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: |
1/1/2021 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: |
99354 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR |
99354 |
Service Description: |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 |
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: |
1/1/2021 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: |
99355 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 |
99355 |
Service Description: |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 30 M |
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: |
1/1/2021 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: |
99411 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 30 M |
99411 |
Service Description: |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 60 M |
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: |
1/1/2021 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: |
99412 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 60 M |
99412 |
Service Description: |
PROLNG CLINCL STAFF SVC DURING O/P E/M 1ST HR |
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: |
1/1/2021 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: |
99415 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG CLINCL STAFF SVC DURING O/P E/M 1ST HR |
99415 |
Service Description: |
PROLNG CLINCL STAFF SVC DURING O/P E/M EA 30 MIN |
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: |
1/1/2021 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: |
99416 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
PROLNG CLINCL STAFF SVC DURING O/P E/M EA 30 MIN |
99416 |
Service Description: |
ADMN & INTERPJ HEALTH RISK ASSESSMENT INSTRUMENT |
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: |
1/1/2021 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: |
99420 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
ADMN & INTERPJ HEALTH RISK ASSESSMENT INSTRUMENT |
99420 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review |
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: |
1/1/2021 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: |
99446 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review |
99446 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review |
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: |
1/1/2021 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: |
99447 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review |
99447 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review |
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: |
1/1/2021 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: |
99448 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review |
99448 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review |
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: |
1/1/2021 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: |
99449 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review |
99449 |
Service Description: |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient's treating/requesting physician or other qualified health care professional; 5 minutes or more of medical consultative time |
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: |
1/1/2021 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: |
99451 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient's treating/requesting physician or other qualified health care professional; 5 minutes or more of medical consultative time |
99451 |
Service Description: |
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes |
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: |
1/1/2021 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: |
99452 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes |
99452 |
Service Description: |
UNLISTED EVALUATION AND MANAGEMENT SERVICE |
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: |
1/1/2021 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: |
99499 |
Service Code Type: |
CPT |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
UNLISTED EVALUATION AND MANAGEMENT SERVICE |
99499 |
Service Description: |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
Prior Authorization required: Preferred: |
Yes |
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: |
0016U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation (BCR-ABL1 major and minor breakpoint fusion transcripts, University of Iowa, Department of Pathology, Asuragen) |
0016U |
Service Description: |
Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected (JAK2 Mutation, University of Iowa,Department of Pathology) |
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: |
0017U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected (JAK2 Mutation, University of Iowa,Department of Pathology) |
0017U |
Service Description: |
Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider (Oncomine™ Dx Target Test, Thermo Fisher Scientific ) |
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: |
0022U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider (Oncomine™ Dx Target Test, Thermo Fisher Scientific ) |
0022U |
Service Description: |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
Prior Authorization required: Preferred: |
Yes |
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: |
0023U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin (LeukoStrat® CDx FLT3 Mutation Assay, Invivoscribe Technologies, Inc.) |
0023U |
Service Description: |
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 (JAK2 Exons 12 to 15 Sequencing, Mayo Clinic) |
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: |
0027U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 (JAK2 Exons 12 to 15 Sequencing, Mayo Clinic) |
0027U |
Service Description: |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
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: |
0042T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME |
0042T |
Service Description: |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
Prior Authorization required: Preferred: |
Yes |
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: |
0046U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative (FLT3 ITD MRD by NGS, LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0046U |
Service Description: |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
Prior Authorization required: Preferred: |
Yes |
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: |
0049U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Leukemia and Lymphoma |
NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative (LabPMM LLC, an Invivoscribe Technologies, Inc. Co.) |
0049U |
Service Description: |
Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalinfixed paraffin-embedded tissue, algorithm reported as an expression score (miR31now™, GoPath Laboratories) |
Prior Authorization required: Preferred: |
Yes |
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: |
0069U |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Colorectal Cancer |
Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalinfixed paraffin-embedded tissue, algorithm reported as an expression score (miR31now™, GoPath Laboratories) |
0069U |
Service Description: |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
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: |
0101T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy |
0101T |
Service Description: |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
Prior Authorization required: Preferred: |
Yes |
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: |
0102T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle |
0102T |
Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
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: |
0213T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL |
0213T |
Service Description: |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
Prior Authorization required: Preferred: |
No |
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: |
0214T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL |
0214T |
Service Description: |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
Prior Authorization required: Preferred: |
No |
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: |
0215T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL |
0215T |
Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
Prior Authorization required: Preferred: |
No |
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: |
0216T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL |
0216T |
Service Description: |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
Prior Authorization required: Preferred: |
No |
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: |
0217T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 |
0217T |
Service Description: |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
Prior Authorization required: Preferred: |
No |
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: |
0218T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Facet Injections |
NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL |
0218T |
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
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: |
0228T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL |
0228T |
Service Description: |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
Prior Authorization required: Preferred: |
No |
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: |
0229T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL |
0229T |
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
Prior Authorization required: Preferred: |
No |
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: |
0230T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL |
0230T |
Service Description: |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
Prior Authorization required: Preferred: |
No |
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: |
0231T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epidural Injections |
NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL |
0231T |
Service Description: |
HDR electronic skin surface brachytherapy 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: |
0394T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
HDR electronic skin surface brachytherapy treatment |
0394T |
Service Description: |
HDR electronic brachytherapy for treating sites other than skin (interstitial or intracavitary) |
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: |
0395T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
HDR electronic brachytherapy for treating sites other than skin (interstitial or intracavitary) |
0395T |
Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
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: |
0512T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound |
0512T |
Service Description: |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) |
Prior Authorization required: Preferred: |
Yes |
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: |
0513T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications |
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) |
0513T |
Service Description: |
Kymriah or Yescarta |
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: |
0537T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0537T |
Service Description: |
Kymriah or Yescarta |
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: |
0537T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0537T |
Service Description: |
Kymriah or Yescarta |
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: |
0538T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0538T |
Service Description: |
Kymriah or Yescarta |
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: |
0538T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0538T |
Service Description: |
Kymriah or Yescarta |
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: |
0539T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0539T |
Service Description: |
Kymriah or Yescarta |
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: |
0539T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0539T |
Service Description: |
Kymriah or Yescarta |
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: |
0540T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kymriah (tisagenleclencel) |
Kymriah or Yescarta |
0540T |
Service Description: |
Kymriah or Yescarta |
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: |
0540T |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yescarta (axicabtagene ciloleucel) |
Kymriah or Yescarta |
0540T |
Service Description: |
Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement 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: |
A4555 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Tumor Treatment Fields |
Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only |
A4555 |
Service Description: |
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe |
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: |
A5510 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe |
A5510 |
Service Description: |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, prefabricated, each |
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: |
A5512 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, prefabricated, each |
A5512 |
Service Description: |
Helmet, protective, soft, prefabricated, includes all components and accessories |
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: |
A8000 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
Helmet, protective, soft, prefabricated, includes all components and accessories |
A8000 |
Service Description: |
Helmet, protective, hard, prefabricated, includes all components and accessories |
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: |
A8001 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
Helmet, protective, hard, prefabricated, includes all components and accessories |
A8001 |
Service Description: |
Foot pressure off loading/supportive device, any type, each |
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: |
A9283 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
Foot pressure off loading/supportive device, any type, each |
A9283 |
Service Description: |
Lutetium lu 177, dotatate, therapeutic, 1 millicurie |
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: |
A9513 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Lutathera (luteum Lu 177 dotate) |
Lutetium lu 177, dotatate, therapeutic, 1 millicurie |
A9513 |
Service Description: |
Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries |
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: |
A9542 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zevalin® In-111 and Zevalin® Y-90 (ibritumomab) |
Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries |
A9542 |
Service Description: |
Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries |
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: |
A9543 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zevalin® In-111 and Zevalin® Y-90 (ibritumomab) |
Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries |
A9543 |
Service Description: |
Radium ra-223 dichloride, therapeutic, per microcurie |
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: |
A9606 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xofigo® (radium Ra 223 dichloride) |
Radium ra-223 dichloride, therapeutic, per microcurie |
A9606 |
Service Description: |
Radiopharmaceutical, therapeutic, not otherwise classified |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
A9699 |
Service Code Type: |
HCPCS |
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: |
|
|
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) |
Radiopharmaceutical, therapeutic, not otherwise classified |
A9699 |
Service Description: |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
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: |
B4034 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4034 |
Service Description: |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
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: |
B4035 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4035 |
Service Description: |
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
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: |
B4036 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
B4036 |
Service Description: |
Nasogastric tubing with stylet |
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: |
B4081 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Nasogastric tubing with stylet |
B4081 |
Service Description: |
Nasogastric tubing without stylet |
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: |
B4082 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Nasogastric tubing without stylet |
B4082 |
Service Description: |
Stomach tube - levine type |
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: |
B4083 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Stomach tube - levine type |
B4083 |
Service Description: |
Gastrostomy/jejunostomy tube, standard, any material, any type, each |
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: |
B4087 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Gastrostomy/jejunostomy tube, standard, any material, any type, each |
B4087 |
Service Description: |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
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: |
B4088 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each |
B4088 |
Service Description: |
Food thickener, administered orally, per ounce |
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: |
B4100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Food thickener, administered orally, per ounce |
B4100 |
Service Description: |
Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
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: |
B4102 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
B4102 |
Service Description: |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
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: |
B4103 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit |
B4103 |
Service Description: |
Additive for enteral formula (e.g. fiber) |
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: |
B4104 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Additive for enteral formula (e.g. fiber) |
B4104 |
Service Description: |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
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: |
B4149 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
B4149 |
Service Description: |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
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: |
B4149 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding |
B4149 |
Service Description: |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calor |
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: |
B4150 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calor |
B4150 |
Service Description: |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fibe |
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: |
B4152 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fibe |
B4152 |
Service Description: |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral fe |
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: |
B4153 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral fe |
B4153 |
Service Description: |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, |
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: |
B4154 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, |
B4154 |
Service Description: |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain |
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: |
B4155 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain |
B4155 |
Service Description: |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered |
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: |
B4157 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered |
B4157 |
Service Description: |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an ent |
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: |
B4158 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an ent |
B4158 |
Service Description: |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered thro |
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: |
B4159 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered thro |
B4159 |
Service Description: |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, m |
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: |
B4160 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, m |
B4160 |
Service Description: |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube |
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: |
B4161 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube |
B4161 |
Service Description: |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an |
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: |
B4162 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an |
B4162 |
Service Description: |
Enteral nutrition infusion pump - with alarm |
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: |
B9002 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Enteral nutrition infusion pump - with alarm |
B9002 |
Service Description: |
Noc for enteral supplies |
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: |
B9998 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nutritional Supplements |
Noc for enteral supplies |
B9998 |
Service Description: |
Prosthesis, penile, inflatable |
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: |
C1813 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Surgical Reconstruction |
Prosthesis, penile, inflatable |
C1813 |
Service Description: |
Prosthesis, penile, non-inflatable |
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: |
C2622 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Surgical Reconstruction |
Prosthesis, penile, non-inflatable |
C2622 |
Service Description: |
MR ANGIO W/O CONTRST W/CONTRST ABD |
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: |
C8902 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Magnetic Resonance Angiography (MRA) (Outpatient/Nonemergency) |
MR ANGIO W/O CONTRST W/CONTRST ABD |
C8902 |
Service Description: |
MR NO CONTRST FLW CNTRST BRST; BIL |
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: |
C8908 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
MR NO CONTRST FLW CNTRST BRST; BIL |
C8908 |
Service Description: |
TTE CMPL SPC & COLR FLOW DPPLR ECHO |
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: |
C8929 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Echocardiogram: Transthoracic |
TTE CMPL SPC & COLR FLOW DPPLR ECHO |
C8929 |
Service Description: |
Perseris (risperidone) |
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: |
C9037 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Perseris (risperidone) |
Perseris (risperidone) |
C9037 |
Service Description: |
Poteligeo (mogamulizumab-kpkc) |
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: |
C9038 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Poteligeo (mogamulizumab-kpkc) |
Poteligeo (mogamulizumab-kpkc) |
C9038 |
Service Description: |
Andexxa (adnexanet alfa) |
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: |
C9041 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Andexxa (adnexanet alfa) |
Andexxa (adnexanet alfa) |
C9041 |
Service Description: |
Libtayo (cemiplimab-rwlc) |
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: |
C9044 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Libtayo (cemiplimab-rwlc) |
Libtayo (cemiplimab-rwlc) |
C9044 |
Service Description: |
Injection, moxetumomab pasudotox-tdfk, 0.01 mg |
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: |
C9045 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Lumoxiti |
Injection, moxetumomab pasudotox-tdfk, 0.01 mg |
C9045 |
Service Description: |
Injection, lefamulin (xenleta), 1 mg |
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: |
C9054 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xenleta (lefamulin) |
Injection, lefamulin (xenleta), 1 mg |
C9054 |
Service Description: |
sacituzumab govitecan-hziy for injection |
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: |
C9066 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Trodelvy (sacituzumab govitecan-hziy) |
sacituzumab govitecan-hziy for injection |
C9066 |
Service Description: |
Mometasone furoate sinus implant, 10 micrograms (sinuva) |
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: |
C9122 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sinuva (Mometasone furoate sinus implant) |
Mometasone furoate sinus implant, 10 micrograms (sinuva) |
C9122 |
Service Description: |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
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: |
C9250 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2ml |
C9250 |
Service Description: |
Injection, glucarpidase, 10 units |
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: |
C9293 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Voraxaze® (glucarpidase) |
Injection, glucarpidase, 10 units |
C9293 |
Service Description: |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
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: |
C9363 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Skin substitute, integra meshed bilayer wound matrix, per square centimeter |
C9363 |
Service Description: |
Unclassified drugs or biologicals |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
C9399 |
Service Code Type: |
HCPCS |
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: |
|
|
Abecma (idecabtagene vicleucel) |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
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: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
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: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
C9399 |
Service Code Type: |
HCPCS |
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: |
|
|
Kimmtrak (tebentafusp-tebn) |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
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: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Padcev (enfortumab vedotin-ejfv) |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
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: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zolgensma |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Unclassified drugs or biologicals |
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: |
C9399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zulresso (brexanolone) |
Unclassified drugs or biologicals |
C9399 |
Service Description: |
Azedra (iobenguane i 131) |
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: |
C9407 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9407 |
Service Description: |
Azedra (iobenguane i 131) |
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: |
C9408 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Azedra (iobenguane i 131) |
Azedra (iobenguane i 131) |
C9408 |
Service Description: |
Baxdela (delafloxacin) |
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: |
C9462 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Baxdela (delafloxacin) |
Baxdela (delafloxacin) |
C9462 |
Service Description: |
Exondys 51 (eteplirsen) |
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: |
C9484 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Exondys 51 (eteplirsen) |
Exondys 51 (eteplirsen) |
C9484 |
Service Description: |
Cranial prosthesis |
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: |
D5924 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial prosthesis |
D5924 |
Service Description: |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
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: |
E0485 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment |
E0485 |
Service Description: |
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet 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: |
E0691 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less |
E0691 |
Service Description: |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel |
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: |
E0692 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel |
E0692 |
Service Description: |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel |
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: |
E0693 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel |
E0693 |
Service Description: |
Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection |
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: |
E0694 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Phototherapy for the Treatment of Dermatological Conditions |
Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection |
E0694 |
Service Description: |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment 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: |
E0761 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Electrical Stimulation to aid wound healing |
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device |
E0761 |
Service Description: |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
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: |
E0766 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Tumor Treatment Fields |
Electrical stimulation device used for cancer treatment, includes all accessories, any type |
E0766 |
Service Description: |
Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session |
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: |
G0173 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session |
G0173 |
Service Description: |
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
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: |
G0235 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
Positron Emisssion Tomography (PET) Scan (Outpatient/Nonemergency) |
G0235 |
Service Description: |
Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment |
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: |
G0251 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment |
G0251 |
Service Description: |
Electrical stimulation, (unattended), to one or more areas, for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers not demonstrating measurable |
Prior Authorization required: Preferred: |
Yes |
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: |
G0281 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Electrical Stimulation to aid wound healing |
Electrical stimulation, (unattended), to one or more areas, for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers, and venous statsis ulcers not demonstrating measurable |
G0281 |
Service Description: |
Electromagnetic therapy, to one or more areas for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healin |
Prior Authorization required: Preferred: |
Yes |
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: |
G0329 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Electrical Stimulation to aid wound healing |
Electromagnetic therapy, to one or more areas for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healin |
G0329 |
Service Description: |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated 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: |
G0339 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment |
G0339 |
Service Description: |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment |
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: |
G0340 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM)) |
Image guided robotic linear accelerator-hyphenbased stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment |
G0340 |
Service Description: |
Ultrasonic guidance for placement of radiation therapy fields |
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: |
G6001 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Ultrasonic guidance for placement of radiation therapy fields |
G6001 |
Service Description: |
Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy |
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: |
G6002 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy |
G6002 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 MeV |
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: |
G6003 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 MeV |
G6003 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 MeV |
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: |
G6004 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10 MeV |
G6004 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 MeV |
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: |
G6005 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19 MeV |
G6005 |
Service Description: |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater |
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: |
G6006 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater |
G6006 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 MeV |
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: |
G6007 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5 MeV |
G6007 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 MeV |
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: |
G6008 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10 MeV |
G6008 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19 MeV |
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: |
G6009 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19 MeV |
G6009 |
Service Description: |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 MeV or greater |
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: |
G6010 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 MeV or greater |
G6010 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
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: |
G6011 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV |
G6011 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV |
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: |
G6012 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV |
G6012 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV |
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: |
G6013 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV |
G6013 |
Service Description: |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater |
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: |
G6014 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater |
G6014 |
Service Description: |
Intensity modulated Treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session |
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: |
G6015 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intensity modulated Treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session |
G6015 |
Service Description: |
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session |
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: |
G6016 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session |
G6016 |
Service Description: |
Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment |
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: |
G6017 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radiation Oncology-Treatment Delivery |
Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment |
G6017 |
Service Description: |
Verification and documentation of sudden or rapidly progressive hearing loss |
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: |
G8565 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Verification and documentation of sudden or rapidly progressive hearing loss |
G8565 |
Service Description: |
Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care |
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: |
1/1/2021 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: |
GCG0X |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Out of Network Specialist Services (Prior authorization for Out-of-Network service is required, including any associated ancillary services) |
Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care |
GCG0X |
Service Description: |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
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: |
H0008 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) |
H0008 |
Service Description: |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
Prior Authorization required: Preferred: |
Yes |
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: |
H0009 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (hospital inpatient) |
H0009 |
Service Description: |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
Prior Authorization required: Preferred: |
Yes |
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: |
H0010 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) |
H0010 |
Service Description: |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
Prior Authorization required: Preferred: |
Yes |
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: |
H0011 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) |
H0011 |
Service Description: |
ALCOHL&/RX SRVC; INTENSV OP; INTRVN |
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: |
H0015 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHL&/RX SRVC; INTENSV OP; INTRVN |
H0015 |
Service Description: |
BHVAL HEALTH; RES W/O ROOM&BD-DIEM |
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: |
H0017 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
BHVAL HEALTH; RES W/O ROOM&BD-DIEM |
H0017 |
Service Description: |
BHVAL HLTH; SHRT-TERM RES PER DIEM |
Prior Authorization required: Preferred: |
No |
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: |
H0018 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: Planned Inpatient services |
BHVAL HLTH; SHRT-TERM RES PER DIEM |
H0018 |
Service Description: |
ALCOHL&/RX SRVC;METHDONE ADMN&/SRVC |
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: |
H0020 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHL&/RX SRVC;METHDONE ADMN&/SRVC |
H0020 |
Service Description: |
MENTAL HEALTH PART HOSP TX < 24 HR |
Prior Authorization required: Preferred: |
No |
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: |
H0035 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
MENTAL HEALTH PART HOSP TX < 24 HR |
H0035 |
Service Description: |
ALCOHOL &OR OTH DRUG ABS SRVC NOS |
Prior Authorization required: Preferred: |
No |
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: |
H0047 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHOL &OR OTH DRUG ABS SRVC NOS |
H0047 |
Service Description: |
ALCOHOL &OR OTH DRUG TX PROGM-DIEM |
Prior Authorization required: Preferred: |
No |
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: |
H2036 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
ALCOHOL &OR OTH DRUG TX PROGM-DIEM |
H2036 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J0122 |
Service Code Type: |
HCPCS |
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: |
|
|
Xerava (eravacycline) |
Not otherwise classified, antineoplastic drugs |
J0122 |
Service Description: |
Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
Prior Authorization required: Preferred: |
Yes |
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: |
J0129 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orencia® (abatacept) |
Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
J0129 |
Service Description: |
Injection, brolucizumab-dbll, 1 mg |
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: |
J0179 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Beovu (brolucizumab-dbll) |
Injection, brolucizumab-dbll, 1 mg |
J0179 |
Service Description: |
Injection, agalsidase beta, 1 mg |
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: |
J0180 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fabrazyme® (agalsidase beta) |
Injection, agalsidase beta, 1 mg |
J0180 |
Service Description: |
Injection, alemtuzumab, 1 mg |
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: |
J0202 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Lemtrada (alemtuzumab) |
Injection, alemtuzumab, 1 mg |
J0202 |
Service Description: |
Injection, avalglucosidase alfa-ngpt, 4 mg |
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 |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0219 |
Service Code Type: |
HCPCS |
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: |
|
|
Nexviazyme (avalglucosidase alfa-ngpt) |
Injection, avalglucosidase alfa-ngpt, 4 mg |
J0219 |
Service Description: |
Injection, alglucosidase alfa, (lumizyme), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0221 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Lumizyme® (Alglucosidase alfa) |
Injection, alglucosidase alfa, (lumizyme), 10 mg |
J0221 |
Service Description: |
Injection, givosiran, 0.5 mg |
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: |
J0223 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Givlaari (givosiran) |
Injection, givosiran, 0.5 mg |
J0223 |
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aralast™ (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Prolastin® (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0256 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zemaira® (human alpha1-proteinase inhibitor) |
Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg |
J0256 |
Service Description: |
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0257 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Glassia (alpha1-proteinase inhibitor, human) |
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg |
J0257 |
Service Description: |
Injection, anidulafungin, 1 mg |
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: |
J0348 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Eraxis™ (anidulafungin) |
Injection, anidulafungin, 1 mg |
J0348 |
Service Description: |
Injection, aripiprazole, extended release, 1 mg |
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: |
J0401 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Abilify Maintena® (aripiprazole) |
Injection, aripiprazole, extended release, 1 mg |
J0401 |
Service Description: |
Injection, belatacept, 1 mg |
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: |
J0485 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nulojix® (belatacept) |
Injection, belatacept, 1 mg |
J0485 |
Service Description: |
Injection, belatacept, 1 mg |
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: |
J0485 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nulojix® (belatacept) |
Injection, belatacept, 1 mg |
J0485 |
Service Description: |
Injection, belimumab, 10 mg |
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: |
J0490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Benlysta® (belimumab) |
Injection, belimumab, 10 mg |
J0490 |
Service Description: |
Injection, anifrolumab-fnia, 1 mg |
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 |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0491 |
Service Code Type: |
HCPCS |
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: |
|
|
Saphnelo (anifromlumab-fnia) |
Injection, anifrolumab-fnia, 1 mg |
J0491 |
Service Description: |
Injection, benralizumab, 1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J0517 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fasenra (benralizumab) |
Injection, benralizumab, 1 mg |
J0517 |
Service Description: |
Injection, bezlotoxumab, 10 mg |
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: |
J0565 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zinplava (bezlotoxumab) |
Injection, bezlotoxumab, 10 mg |
J0565 |
Service Description: |
Injection, cerliponase alfa, 1 mg |
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: |
J0567 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Brineura (injection, cerliponase alfa) |
Injection, cerliponase alfa, 1 mg |
J0567 |
Service Description: |
Buprenorphine implant, 74.2 mg |
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: |
J0570 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Probuphine (buprenorphine implant) |
Buprenorphine implant, 74.2 mg |
J0570 |
Service Description: |
Injection, burosumab-twza 1 mg |
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: |
J0584 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Crysvita (burosumab-twza) |
Injection, burosumab-twza 1 mg |
J0584 |
Service Description: |
Injection, onabotulinumtoxina, 1 unit |
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: |
J0585 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Chemodenervation-Botox® (Botulinum toxin Type A) |
Injection, onabotulinumtoxina, 1 unit |
J0585 |
Service Description: |
Injection, abobotulinumtoxina, 5 units |
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: |
J0586 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dysport® (Botulinum toxin Type A) |
Injection, abobotulinumtoxina, 5 units |
J0586 |
Service Description: |
Injection, rimabotulinumtoxinb, 100 units |
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: |
J0587 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Myobloc® (botulinum toxin Type B) |
Injection, rimabotulinumtoxinb, 100 units |
J0587 |
Service Description: |
Injection, incobotulinumtoxin a, 1 unit |
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: |
J0588 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xeomin® (Botulinum toxin Type A) |
Injection, incobotulinumtoxin a, 1 unit |
J0588 |
Service Description: |
Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units |
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: |
J0596 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ruconest® (C1 esterase inhibitor, recocmbinant) |
Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units |
J0596 |
Service Description: |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
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: |
J0597 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Berinert® (C1 esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), berinert, 10 units |
J0597 |
Service Description: |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
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: |
J0598 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cinryze™ (C1-esterase inhibitor) |
Injection, c-1 esterase inhibitor (human), cinryze, 10 units |
J0598 |
Service Description: |
Injection, etelcalcetide, 0.1 mg |
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: |
J0606 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Parsabiv (etelcalcetide) |
Injection, etelcalcetide, 0.1 mg |
J0606 |
Service Description: |
Injection, canakinumab, 1 mg |
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: |
J0638 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ilaris® (canakinumab) |
Injection, canakinumab, 1 mg |
J0638 |
Service Description: |
Injection, cefiderocol, 10 mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J0699 |
Service Code Type: |
HCPCS |
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: |
|
|
Fetroja (cefiderocol) |
Injection, cefiderocol, 10 mg |
J0699 |
Service Description: |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
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: |
J0714 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Avycaz® (ceftazidime/avibactam) |
Injection, ceftazidime and avibactam, 0.5 g/0.125 g |
J0714 |
Service Description: |
Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
Prior Authorization required: Preferred: |
Yes |
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: |
J0717 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cimzia® (certolizumab pegol) |
Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) |
J0717 |
Service Description: |
Injection, cabotegravir and rilpivirine, 2mg/3mg |
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 |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J0741 |
Service Code Type: |
HCPCS |
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: |
|
|
Apretude (cabotegravir-rilpivirine) injection |
Injection, cabotegravir and rilpivirine, 2mg/3mg |
J0741 |
Service Description: |
Injection, collagenase, clostridium histolyticum, 0.01 mg |
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: |
J0775 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xiaflex® (collagenase clostridium histolyticum) |
Injection, collagenase, clostridium histolyticum, 0.01 mg |
J0775 |
Service Description: |
Injection, crizanlizumab-tmca, 5 mg |
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: |
J0791 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Adakveo (crizanlizumab-tmca) |
Injection, crizanlizumab-tmca, 5 mg |
J0791 |
Service Description: |
Injection, dalbavancin, 5 mg |
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: |
J0875 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dalvance™ (dalbavancin) |
Injection, dalbavancin, 5 mg |
J0875 |
Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
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: |
J0881 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
Service Description: |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
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: |
J0881 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (non-esrd use) |
J0881 |
Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
Prior Authorization required: Preferred: |
No |
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: |
J0882 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aranesp® (darbepoetin alfa) |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
Service Description: |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
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: |
J0882 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) |
J0882 |
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
Prior Authorization required: Preferred: |
No |
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: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Epogen® (epoetin alpha) |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
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: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
Service Description: |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
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: |
J0885 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Procrit® (epoetin alpha) |
Injection, epoetin alfa, (for non-esrd use), 1000 units |
J0885 |
Service Description: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
Prior Authorization required: Preferred: |
No |
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: |
J0887 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
J0887 |
Service Description: |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
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: |
J0887 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Mircera® (epoetin beta) |
Injection, epoetin beta, 1 microgram, (for esrd on dialysis) |
J0887 |
Service Description: |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
Prior Authorization required: Preferred: |
No |
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: |
J0888 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injectin, epoetin beta, 1 microgram, (for non esrd use) |
J0888 |
Service Description: |
Injection, epoetin beta, 1 microgram, (for non esrd use) |
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: |
J0888 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Mircera® (epoetin beta) |
Injection, epoetin beta, 1 microgram, (for non esrd use) |
J0888 |
Service Description: |
Injection, decitabine, 1 mg |
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: |
J0894 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dacogen® (decitabine) |
Injection, decitabine, 1 mg |
J0894 |
Service Description: |
Injection, luspatercept-aamt, 0.25 mg |
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: |
J0896 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Reblozyl® or Erythropoietin Stimulating Agent |
Injection, luspatercept-aamt, 0.25 mg |
J0896 |
Service Description: |
Injection, denosumab, 1 mg |
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: |
J0897 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Prolia™ (denosumab) |
Injection, denosumab, 1 mg |
J0897 |
Service Description: |
Injection, denosumab, 1 mg |
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: |
J0897 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xgeva™ (denosumab) |
Injection, denosumab, 1 mg |
J0897 |
Service Description: |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
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: |
J1095 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dexycu (Dexamethasone) |
Injection, dexamethasone 9 percent, intraocular, 1 microgram |
J1095 |
Service Description: |
Dexametha opth insert 0.1 mg |
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: |
J1096 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dextenza (dexamethasone ophthalmic insert) |
Dexametha opth insert 0.1 mg |
J1096 |
Service Description: |
Injection, ecallantide, 1 mg |
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: |
J1290 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kalbitor® (ecallantide) |
Injection, ecallantide, 1 mg |
J1290 |
Service Description: |
Injection, eculizumab, 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J1300 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Soliris® (eculizumab) |
Injection, eculizumab, 10 mg |
J1300 |
Service Description: |
Injection, edaravone, 1 mg |
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: |
J1301 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Radicava (edaravone) |
Injection, edaravone, 1 mg |
J1301 |
Service Description: |
Injection, inclisiran, 1 mg |
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 |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1306 |
Service Code Type: |
HCPCS |
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: |
|
|
Leqvio (inclisiran) |
Injection, inclisiran, 1 mg |
J1306 |
Service Description: |
Injection, elosulfase alfa, 1mg |
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: |
J1322 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vimizim® (elosulfase alfa) |
Injection, elosulfase alfa, 1mg |
J1322 |
Service Description: |
Injection, epoprostenol, 0.5 mg |
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: |
J1325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Flolan® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
Service Description: |
Injection, epoprostenol, 0.5 mg |
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: |
J1325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Veletri® (epoprostenol) |
Injection, epoprostenol, 0.5 mg |
J1325 |
Service Description: |
Injection, golodirsen, 10 mg |
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: |
J1429 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vyondys 53 (golodirsen) |
Injection, golodirsen, 10 mg |
J1429 |
Service Description: |
Injection, filgrastim (g-csf), 1 microgram |
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: |
J1442 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Neupogen® (filgrastim) |
Injection, filgrastim (g-csf), 1 microgram |
J1442 |
Service Description: |
Injection, filgrastim (g-csf), 1 microgram |
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: |
J1442 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, filgrastim (g-csf), 1 microgram |
J1442 |
Service Description: |
Injection, tbo-filgrastim, 1 microgram |
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: |
J1447 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Granix® (TBO-filgrastim) |
Injection, tbo-filgrastim, 1 microgram |
J1447 |
Service Description: |
Injection, tbo-filgrastim, 1 microgram |
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: |
J1447 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, tbo-filgrastim, 1 microgram |
J1447 |
Service Description: |
Injection, galsulfase, 1 mg |
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: |
J1458 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Naglazyme® (galsulfase) |
Injection, galsulfase, 1 mg |
J1458 |
Service Description: |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1459 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1459 |
Service Description: |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1459 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Privigen (intravenous immune globulin) |
Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1459 |
Service Description: |
Injection, immune globulin (cuvitru), 100 mg |
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: |
J1555 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cuvitru (Subcutaneous immune globulin) |
Injection, immune globulin (cuvitru), 100 mg |
J1555 |
Service Description: |
Injection, immune globulin (bivigam), 500 mg |
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: |
J1556 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (bivigam), 500 mg |
J1556 |
Service Description: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1557 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1557 |
Service Description: |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1557 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1557 |
Service Description: |
Injection, immune globulin (xembify), 100 mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J1558 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xembify (inj immune globulin) |
Injection, immune globulin (xembify), 100 mg |
J1558 |
Service Description: |
Injection, immune globulin (hizentra), 100 mg |
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: |
J1559 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (hizentra), 100 mg |
J1559 |
Service Description: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
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: |
J1561 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gammaked/Gamunex/Gamunex-C/Gammaplex (intravenous immune globulin) |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
J1561 |
Service Description: |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
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: |
J1561 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 mg |
J1561 |
Service Description: |
Injection, immune globulin (vivaglobin), 100 mg |
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: |
J1562 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin (vivaglobin), 100 mg |
J1562 |
Service Description: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
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: |
J1566 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Carimune (intraveneous immune globulin) |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
J1566 |
Service Description: |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
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: |
J1566 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg |
J1566 |
Service Description: |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1568 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1568 |
Service Description: |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1568 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Octagam (intravenous immune globulin) |
Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1568 |
Service Description: |
Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg |
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: |
J1569 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g. liquid), 500 mg |
J1569 |
Service Description: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1572 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Flebogamma (intravenous immune globulin) |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1572 |
Service Description: |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
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: |
J1572 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g. liquid), 500 mg |
J1572 |
Service Description: |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
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: |
J1575 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
HyQvia (immune globulin/hyaluronidase) |
Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin |
J1575 |
Service Description: |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
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: |
J1599 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
J1599 |
Service Description: |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
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: |
J1599 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Panzyga (immune globulin intravenous, human – ifas) |
Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
J1599 |
Service Description: |
Injection, golimumab, 1 mg, for intravenous use |
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: |
J1602 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Simponi® Aria (golimumab) |
Injection, golimumab, 1 mg, for intravenous use |
J1602 |
Service Description: |
Inj, granisetron, xr, 0.1 mg |
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: |
J1627 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sustol (granisetron extended release) |
Inj, granisetron, xr, 0.1 mg |
J1627 |
Service Description: |
Injection, brexanolone, 1 mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J1632 |
Service Code Type: |
HCPCS |
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: |
|
|
Zulresso (brexanolone) |
Injection, brexanolone, 1 mg |
J1632 |
Service Description: |
Injection, hydroxyprogesterone caproate, (makena), 10 mg |
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: |
J1726 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Makena® (hydroxyprogesterone caproate) |
Injection, hydroxyprogesterone caproate, (makena), 10 mg |
J1726 |
Service Description: |
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg |
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: |
J1729 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Makena® (hydroxyprogesterone caproate) |
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg |
J1729 |
Service Description: |
Injection, meloxicam, 1 mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J1738 |
Service Code Type: |
HCPCS |
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: |
|
|
Anjeso (meloxicam injection) |
Injection, meloxicam, 1 mg |
J1738 |
Service Description: |
Injection, ibandronate sodium, 1 mg |
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: |
J1740 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous (IV) Boniva® (ibandronate sodium) |
Injection, ibandronate sodium, 1 mg |
J1740 |
Service Description: |
Injection, idursulfase, 1 mg |
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: |
J1743 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Elaprase® (idursulfase) |
Injection, idursulfase, 1 mg |
J1743 |
Service Description: |
Injection infliximab, 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J1745 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Remicade® (infliximab) |
Injection infliximab, 10 mg |
J1745 |
Service Description: |
Injection, ibalizumab-uiyk, 10 mg |
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: |
J1746 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Trogarzo (ibalizumab-uiyk) |
Injection, ibalizumab-uiyk, 10 mg |
J1746 |
Service Description: |
Injection, imiglucerase, 10 units |
Prior Authorization required: Preferred: |
Yes |
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: |
J1786 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cerezyme® (imiglucerase) |
Injection, imiglucerase, 10 units |
J1786 |
Service Description: |
Injection, isavuconazonium, 1 mg |
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: |
J1833 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cresemba® IV (isavuconazonium sulfate) |
Injection, isavuconazonium, 1 mg |
J1833 |
Service Description: |
Injection, laronidase, 0.1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J1931 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aldurazyme® (laronidase) |
Injection, laronidase, 0.1 mg |
J1931 |
Service Description: |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
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: |
J1943 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada initio), 1 mg |
J1943 |
Service Description: |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J1944 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aristada™ initio (aripiprazole lauroxil) |
Injection, aripiprazole lauroxil, (aristada), 1 mg |
J1944 |
Service Description: |
Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
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: |
J1950 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Leuprolide Acetate |
Injection, leuprolide acetate (for depot suspension), per 3.75 mg |
J1950 |
Service Description: |
Injection, mepolizumab, 1 mg |
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: |
J2182 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nucala® (mepolizumab) |
Injection, mepolizumab, 1 mg |
J2182 |
Service Description: |
Injection, meropenem and vaborbactam, 10mg/10mg (20mg) |
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: |
J2186 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vabomere (meropenem/vaborbactam) |
Injection, meropenem and vaborbactam, 10mg/10mg (20mg) |
J2186 |
Service Description: |
Injection, ziconotide, 1 microgram |
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: |
J2278 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Prialt® (ziconotide intrathecal infusion) |
Injection, ziconotide, 1 microgram |
J2278 |
Service Description: |
Injection, naltrexone, depot form, 1 mg |
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: |
J2315 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vivitrol (naltrexone microspheres) |
Injection, naltrexone, depot form, 1 mg |
J2315 |
Service Description: |
Injection, natalizumab, 1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J2323 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Tysabri® (natalizumab) |
Injection, natalizumab, 1 mg |
J2323 |
Service Description: |
Injection, nusinersen, 0.1 mg |
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: |
J2326 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Spinraza (nusinersen) |
Injection, nusinersen, 0.1 mg |
J2326 |
Service Description: |
Injection, ocrelizumab, 1 mg |
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: |
J2350 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ocrevus (ocrelizumab) |
Injection, ocrelizumab, 1 mg |
J2350 |
Service Description: |
Injection, octreotide, depot form for intramuscular injection, 1 mg |
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: |
J2353 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sandostatin LAR® (Octreotide acetate) |
Injection, octreotide, depot form for intramuscular injection, 1 mg |
J2353 |
Service Description: |
Injection, omalizumab, 5 mg |
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: |
J2357 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xolair® (omalizumab) |
Injection, omalizumab, 5 mg |
J2357 |
Service Description: |
Injection, olanzapine, long-acting, 1 mg |
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: |
J2358 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zyprexa Relprevv® (olanzapine) |
Injection, olanzapine, long-acting, 1 mg |
J2358 |
Service Description: |
Injection, olanzapine, long-acting, 1 mg |
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: |
J2358 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zyprexa Relprevv® (olanzapine) |
Injection, olanzapine, long-acting, 1 mg |
J2358 |
Service Description: |
Injection, paliperidone palmitate extended release, 1 mg |
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: |
J2426 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Invega Sustenna® (paliperidone palmitate extended release) |
Injection, paliperidone palmitate extended release, 1 mg |
J2426 |
Service Description: |
Injection, palonosetron hcl, 25 mcg |
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: |
J2469 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aloxi (palonosetron) |
Injection, palonosetron hcl, 25 mcg |
J2469 |
Service Description: |
Injection, pasireotide long acting, 1 mg |
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: |
J2502 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Signifor® LAR (pasireotide) |
Injection, pasireotide long acting, 1 mg |
J2502 |
Service Description: |
Injection, pegfilgrastim, 6 mg |
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: |
J2505 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Neulasta® (pegfilgrastim) |
Injection, pegfilgrastim, 6 mg |
J2505 |
Service Description: |
Injection, pegfilgrastim, 6 mg |
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: |
J2505 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, pegfilgrastim, 6 mg |
J2505 |
Service Description: |
Injection, plerixafor, 1 mg |
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: |
J2562 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Mozobil (plerixafor) |
Injection, plerixafor, 1 mg |
J2562 |
Service Description: |
Injection, rasburicase, 0.5 mg |
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: |
J2783 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Elitek® (rasburicase) |
Injection, rasburicase, 0.5 mg |
J2783 |
Service Description: |
Injection, reslizumab, 1 mg |
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: |
J2786 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cinqair (reslizumab) |
Injection, reslizumab, 1 mg |
J2786 |
Service Description: |
Injection, risperidone, long acting, 0.5 mg |
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: |
J2794 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Risperdal Consta® (risperidone) |
Injection, risperidone, long acting, 0.5 mg |
J2794 |
Service Description: |
Injection, romiplostim, 10 micrograms |
Prior Authorization required: Preferred: |
Yes |
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: |
J2796 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nplate™ (romiplostim) |
Injection, romiplostim, 10 micrograms |
J2796 |
Service Description: |
Injection, sargramostim (gm-csf), 50 mcg |
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: |
J2820 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Leukine® (sargramostim) |
Injection, sargramostim (gm-csf), 50 mcg |
J2820 |
Service Description: |
Injection, sargramostim (gm-csf), 50 mcg |
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: |
J2820 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, sargramostim (gm-csf), 50 mcg |
J2820 |
Service Description: |
Inj sebelipase alfa 1 mg |
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: |
J2840 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kanuma® (sebelipase alfa) |
Inj sebelipase alfa 1 mg |
J2840 |
Service Description: |
Injection, siltuximab, 10 mg |
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: |
J2860 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sylvant™ (siltuximab) |
Injection, siltuximab, 10 mg |
J2860 |
Service Description: |
Injection, eptinezumab-jjmr, 1 mg |
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: |
J3032 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vyepti (eptinezumab-jjmr) |
Injection, eptinezumab-jjmr, 1 mg |
J3032 |
Service Description: |
Injection, taliglucerace alfa, 10 units |
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: |
J3060 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Elelyso™ (taliglucerase alfa) |
Injection, taliglucerace alfa, 10 units |
J3060 |
Service Description: |
Injection, tedizolid phosphate, 1 mg |
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: |
J3090 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sivextro® (tedizolid phosphate) |
Injection, tedizolid phosphate, 1 mg |
J3090 |
Service Description: |
Injection, romosozumab-aqqg, 1 mg |
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: |
J3111 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Evenity (romosozumab-aqqg) |
Injection, romosozumab-aqqg, 1 mg |
J3111 |
Service Description: |
Injection, testosterone undecanoate, 1 mg |
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: |
J3145 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aveed® (testosterone) |
Injection, testosterone undecanoate, 1 mg |
J3145 |
Service Description: |
Injection, teprotumumab-trbw, 10 mg |
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: |
J3241 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Tepezza (teprotumumab-trbw) |
Injection, teprotumumab-trbw, 10 mg |
J3241 |
Service Description: |
Injection, tocilizumab, 1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J3262 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Actemra® (tocilizumab) |
Injection, tocilizumab, 1 mg |
J3262 |
Service Description: |
Injection, treprostinil, 1 mg |
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: |
J3285 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Remodulin® (treprostinil) |
Injection, treprostinil, 1 mg |
J3285 |
Service Description: |
Injection, Durvalumab, 10 mg |
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: |
J3304 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zilretta (triamcinolone acetonide ER injection) |
Injection, Durvalumab, 10 mg |
J3304 |
Service Description: |
Ustekinumab, for subcutaneous injection, 1 mg |
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: |
J3357 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stelara™ (ustekinumab) |
Ustekinumab, for subcutaneous injection, 1 mg |
J3357 |
Service Description: |
Ustekinumab, for intravenous injection, 1 mg |
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: |
J3358 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Stelara™ (ustekinumab) |
Ustekinumab, for intravenous injection, 1 mg |
J3358 |
Service Description: |
Injection, vedolizumab, 1 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
J3380 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Entyvio® (vedolizumab) |
Injection, vedolizumab, 1 mg |
J3380 |
Service Description: |
Injection, velaglucerase alfa, 100 units |
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: |
J3385 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
VPRIV® (velaglucerase alfa) |
Injection, velaglucerase alfa, 100 units |
J3385 |
Service Description: |
Inj., vestronidase alfa-vjbk |
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: |
J3397 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Mepsevii (vestronidase alfa-vjbk) |
Inj., vestronidase alfa-vjbk |
J3397 |
Service Description: |
Inj luxturna 1 billion vec g |
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: |
J3398 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Luxturna (voretigeneneparvovec-rzyl) |
Inj luxturna 1 billion vec g |
J3398 |
Service Description: |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes |
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: |
J3399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gene Therapy |
Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes |
J3399 |
Service Description: |
Injection, Zolgensma, Onasemnogene abeparvovec-xioi, per treatment, up to 5x1015 vector genomes |
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: |
J3399 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zolgensma |
Injection, Zolgensma, Onasemnogene abeparvovec-xioi, per treatment, up to 5x1015 vector genomes |
J3399 |
Service Description: |
Injection, hyaluronidase, up to 150 units |
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: |
J3470 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, up to 150 units |
J3470 |
Service Description: |
Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) |
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: |
J3471 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) |
J3471 |
Service Description: |
Injection, hyaluronidase, ovine, preservative free, per 1000 usp units |
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: |
J3472 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, ovine, preservative free, per 1000 usp units |
J3472 |
Service Description: |
Injection, hyaluronidase, recombinant, 1 usp unit |
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: |
J3473 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Injection, hyaluronidase, recombinant, 1 usp unit |
J3473 |
Service Description: |
Injection, hyaluronidase, recombinant, 1 usp unit |
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: |
J3473 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Injection, hyaluronidase, recombinant, 1 usp unit |
J3473 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J3490 |
Service Code Type: |
HCPCS |
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: |
|
|
Olinvyk - olivrtidinr |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Revcovi (elapegademase-lvlr) |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Unituxin (dinutuximab) |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zolgensma |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified drugs |
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: |
J3490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zulresso (brexanolone) |
Unclassified drugs |
J3490 |
Service Description: |
Unclassified biologics |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
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: |
|
|
Aduhelm (aducanumab) |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cosentyx® (secukinumab) vials |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cutaquig (immunue globulin subcutaneous [Human] - hiip, 16.5% soluiton |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
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: |
|
|
fosdenopterin, 0.1 mg Injection |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Intravenous Immune Globulin (IVIG) |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
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: |
|
|
Olinvyk - olivrtidinr |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Praxbind (idarucizumab) |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Revcovi (elapegademase-lvlr) |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J3590 |
Service Code Type: |
HCPCS |
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: |
|
|
Rylaze (Asparaginase Erwinia Chrysanthemi (Recombinant)-rywn Injection) |
Unclassified biologics |
J3590 |
Service Description: |
Unclassified biologics |
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: |
J3590 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Unituxin (dinutuximab) |
Unclassified biologics |
J3590 |
Service Description: |
Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7169 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg |
J7169 |
Service Description: |
Injection, emicizumab-kxwh, 0.5 mg |
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: |
J7170 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hemlibra (emicizumab-kxwh) |
Injection, emicizumab-kxwh, 0.5 mg |
J7170 |
Service Description: |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7180 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii (antihemophilic factor, human), 1 i.u. |
J7180 |
Service Description: |
Injection, factor xiii a-subunit, (recombinant), per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7181 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor xiii a-subunit, (recombinant), per iu |
J7181 |
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7182 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu |
J7182 |
Service Description: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7183 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
J7183 |
Service Description: |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7185 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. |
J7185 |
Service Description: |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7186 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u. |
J7186 |
Service Description: |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7187 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, von willebrand factor complex (humate-p), per iu vwf:rco |
J7187 |
Service Description: |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7188 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u. |
J7188 |
Service Description: |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7189 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viia (antihemophilic factor, recombinant), per 1 microgram |
J7189 |
Service Description: |
Factor viii (antihemophilic factor, human) per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7190 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, human) per i.u. |
J7190 |
Service Description: |
Factor viii (antihemophilic factor (porcine)), per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7191 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor (porcine)), per i.u. |
J7191 |
Service Description: |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7192 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified |
J7192 |
Service Description: |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7193 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix (antihemophilic factor, purified, non-recombinant) per i.u. |
J7193 |
Service Description: |
Factor ix, complex, per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7194 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Factor ix, complex, per i.u. |
J7194 |
Service Description: |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7195 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified |
J7195 |
Service Description: |
Injection, antithrombin recombinant, 50 i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7196 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, antithrombin recombinant, 50 i.u. |
J7196 |
Service Description: |
Antithrombin iii (human), per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7197 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Antithrombin iii (human), per i.u. |
J7197 |
Service Description: |
Anti-inhibitor, per i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7198 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Anti-inhibitor, per i.u. |
J7198 |
Service Description: |
Hemophilia clotting factor, not otherwise classified |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7199 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Hemophilia clotting factor, not otherwise classified |
J7199 |
Service Description: |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7200 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu |
J7200 |
Service Description: |
Injection, factor ix, fc fusion protein (recombinant), per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7201 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, fc fusion protein (recombinant), per iu |
J7201 |
Service Description: |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7202 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. |
J7202 |
Service Description: |
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7203 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Rebinyn (coagulation factor IX [recombinant], glycoPEGylated) |
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu |
J7203 |
Service Description: |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7204 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Esperoct (Injection, factor viii, antihemophilic factor ,recombinant,glycopegylated-exei) |
Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu |
J7204 |
Service Description: |
Injection, factor viii fc fusion protein (recombinant), per iu |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7205 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii fc fusion protein (recombinant), per iu |
J7205 |
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: INN: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Prior Authorization required: OON: |
NOT COVERED for INN / OON |
Effective Date for this Tier: |
10/1/2021 12:00:00 AM |
Restricted to Preferred Facilities: |
RESTRICTED |
Service Code: |
J7207 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u. |
J7207 |
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u |
Prior Authorization required: Preferred: |
Yes |
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: |
1/1/2021 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: |
J7208 |
Service Code Type: |
HCPCS |
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: |
|
|
Jivi (antihemophilic factor VIII [recombinant]) |
Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u |
J7208 |
Service Description: |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
10/1/2021 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: |
J7209 |
Service Code Type: |
HCPCS |
Effective Date: |
10/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blood clotting factors given in a nonemergency outpatient Facility setting |
Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u |
J7209 |
Service Description: |
Ganciclovir, 4.5 mg, long-acting implant |
Prior Authorization required: Preferred: |
Yes |
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: |
J7310 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vitrasert® (ganciclovir intravitreal implant) |
Ganciclovir, 4.5 mg, long-acting implant |
J7310 |
Service Description: |
fluocinolone acetonide intravitreal 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: |
J7313 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Iluvien® (fluocinolone acetonide) |
fluocinolone acetonide intravitreal implant |
J7313 |
Service Description: |
Sodium hyaluronate per 20 to 25 mg dose |
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: |
J7317 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Sodium hyaluronate per 20 to 25 mg dose |
J7317 |
Service Description: |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
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: |
J7318 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Durolane (hyaluronic acid) |
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
J7318 |
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
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: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
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: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
GenVisc® 850 (hyaluronan or derivative) |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
Service Description: |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
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: |
J7320 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg |
J7320 |
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
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: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyalgan® (hyaluronate sodium) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
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: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
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: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Supartz™ (hyaluronate sodium) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
Service Description: |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
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: |
J7321 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose |
J7321 |
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
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: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
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: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
Service Description: |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
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: |
J7322 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hymovis ® (hyaluronan or derivative) |
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg |
J7322 |
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
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: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
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: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthovisc® (hyaluronate sodium) |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
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: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthovisc® (hyaluronate sodium) |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
Service Description: |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
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: |
J7324 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose |
J7324 |
Service Description: |
HYALURONAN/DERIV SYNVISC INJ 1 MG |
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: |
J7325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
HYALURONAN/DERIV SYNVISC INJ 1 MG |
J7325 |
Service Description: |
HYALURONAN/DERIV SYNVISC INJ 1 MG |
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: |
J7325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Synvisc |
HYALURONAN/DERIV SYNVISC INJ 1 MG |
J7325 |
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
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: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gel-One® (hyaluronan or derivative) |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
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: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
Service Description: |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
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: |
J7326 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, gel-one, for intra-articular injection, per dose |
J7326 |
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
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: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hyaluronidase Products |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
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: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Monovisc® (hyaluronan or derivative) |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
Service Description: |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
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: |
J7327 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Viscosupplemention (Hyalgan®, Orthovisc®, Supartz™, Monovisc® and Gel-One®) |
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose |
J7327 |
Service Description: |
Autologous cultured chondrocytes, 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: |
J7330 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
Autologous cultured chondrocytes, implant |
J7330 |
Service Description: |
Aminolevulinic acid, 10% gel |
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: |
J7345 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ameluz (aminolevulinic acid) |
Aminolevulinic acid, 10% gel |
J7345 |
Service Description: |
Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg |
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: |
J7686 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Remodulin® (treprostinil) |
Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg |
J7686 |
Service Description: |
COMPOUNDED DRUG NOC |
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: |
J7999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Unclassified drugs |
COMPOUNDED DRUG NOC |
J7999 |
Service Description: |
Injection, asparaginase (erwinaze), 1,000 iu |
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: |
J9019 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erwinaze® (asparaginase) |
Injection, asparaginase (erwinaze), 1,000 iu |
J9019 |
Service Description: |
Injection, atezolizumab, 10 mg |
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: |
J9022 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Tecentriq™ (atezolizumab) |
Injection, atezolizumab, 10 mg |
J9022 |
Service Description: |
Injection, avelumab, 10 mg |
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: |
J9023 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bavencio (avelumab) |
Injection, avelumab, 10 mg |
J9023 |
Service Description: |
Injection, clofarabine, 1 mg |
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: |
J9027 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Clolar® (clofarabine) |
Injection, clofarabine, 1 mg |
J9027 |
Service Description: |
Injection, belinostat, 10 mg |
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: |
J9032 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Beleodaq® (belinostat) |
Injection, belinostat, 10 mg |
J9032 |
Service Description: |
Injection, bendamustine hcl, 1 mg |
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: |
J9033 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Treanda (bendamustine) |
Injection, bendamustine hcl, 1 mg |
J9033 |
Service Description: |
Injection, blinatumomab, 1 microgram |
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: |
J9039 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Blincyto® (blintatumomab) |
Injection, blinatumomab, 1 microgram |
J9039 |
Service Description: |
Injection, bortezomib, 0.1 mg |
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: |
J9041 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Velcade® (bortezomib) |
Injection, bortezomib, 0.1 mg |
J9041 |
Service Description: |
Injection, brentuximab vedotin, 1 mg |
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: |
J9042 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Adcetris (brentuximab vedotin) |
Injection, brentuximab vedotin, 1 mg |
J9042 |
Service Description: |
Injection, cabazitaxel, 1 mg |
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: |
J9043 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Jevtana® (cabazitaxel) |
Injection, cabazitaxel, 1 mg |
J9043 |
Service Description: |
Injection, carfilzomib, 1 mg |
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: |
J9047 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kyprolis® (carfilzomib) |
Injection, carfilzomib, 1 mg |
J9047 |
Service Description: |
Injection, cetuximab, 10 mg |
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: |
J9055 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erbitux (cetuximab) |
Injection, cetuximab, 10 mg |
J9055 |
Service Description: |
Injection, copanlisib, 1 mg |
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: |
J9057 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Aliqopa (copanlisib) |
Injection, copanlisib, 1 mg |
J9057 |
Service Description: |
injection, daratumumab, 10 mg and hyaluronidase-fihj |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9144 |
Service Code Type: |
HCPCS |
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: |
|
|
Darzalex Faspro |
injection, daratumumab, 10 mg and hyaluronidase-fihj |
J9144 |
Service Description: |
Injection, daratumumab, 10 mg |
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: |
J9145 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Darzalex™ (daratumumab) |
Injection, daratumumab, 10 mg |
J9145 |
Service Description: |
Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine |
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: |
J9153 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vyxeos (daunorubicin/cytarabine liposomal) |
Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine |
J9153 |
Service Description: |
Injection, denileukin diftitox, 300 micrograms |
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: |
J9160 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ontak® (denileukin diftitox) |
Injection, denileukin diftitox, 300 micrograms |
J9160 |
Service Description: |
Injection, durvalumab, 10 mg |
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: |
J9173 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Imfinzi (durvalumab) |
Injection, durvalumab, 10 mg |
J9173 |
Service Description: |
Injection, elotuzumab, 1mg |
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: |
J9176 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Empliciti™ (elotuzumab) |
Injection, elotuzumab, 1mg |
J9176 |
Service Description: |
Injection, enfortumab vedotin-ejfv, 0.25 mg |
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: |
J9177 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Padcev (enfortumab vedotin-ejfv) |
Injection, enfortumab vedotin-ejfv, 0.25 mg |
J9177 |
Service Description: |
Injection, eribulin mesylate, 0.1 mg |
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: |
J9179 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Halaven - T™ (eribulin mesylate) |
Injection, eribulin mesylate, 0.1 mg |
J9179 |
Service Description: |
Gemtuzumab ozogamicin 0.1 mg |
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: |
J9203 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Mylotarg (gemfuzumab ozogamicin) |
Gemtuzumab ozogamicin 0.1 mg |
J9203 |
Service Description: |
Injection, irinotecan liposome, 1 mg |
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: |
J9205 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Onivyde™ (irinotecan liposome) |
Injection, irinotecan liposome, 1 mg |
J9205 |
Service Description: |
Injection, ixabepilone, 1 mg |
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: |
J9207 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ixempra™ (ixabepilone) |
Injection, ixabepilone, 1 mg |
J9207 |
Service Description: |
Leuprolide acetate (for depot suspension), 7.5 mg |
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: |
J9217 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Leuprolide Acetate |
Leuprolide acetate (for depot suspension), 7.5 mg |
J9217 |
Service Description: |
Leuprolide acetate, per 1 mg |
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: |
J9218 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Leuprolide Acetate |
Leuprolide acetate, per 1 mg |
J9218 |
Service Description: |
Leuprolide acetate implant, 65 mg |
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: |
J9219 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Leuprolide Acetate |
Leuprolide acetate implant, 65 mg |
J9219 |
Service Description: |
Histrelin implant (supprelin la), 50 mg |
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: |
J9226 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Supprelin® LA (histrelin acetate implant) |
Histrelin implant (supprelin la), 50 mg |
J9226 |
Service Description: |
Injection, ipilimumab, 1 mg |
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: |
J9228 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yervoy™ (ipilimumab) |
Injection, ipilimumab, 1 mg |
J9228 |
Service Description: |
Injection, inotuzumab ozogamicin, 0.1 mg |
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: |
J9229 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Besponsa |
Injection, inotuzumab ozogamicin, 0.1 mg |
J9229 |
Service Description: |
Injection, melphalan (evomela), 1 mg |
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: |
J9246 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Evomela |
Injection, melphalan (evomela), 1 mg |
J9246 |
Service Description: |
Injection, melphalan flufenamide, 1mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9247 |
Service Code Type: |
HCPCS |
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: |
|
|
PEPAXTO (melphalan flufenamide) |
Injection, melphalan flufenamide, 1mg |
J9247 |
Service Description: |
Injection, nelarabine, 50 mg |
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: |
J9261 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Arranon® (nelarabine) |
Injection, nelarabine, 50 mg |
J9261 |
Service Description: |
Injection, omacetaxine mepesuccinate, 0.01 mg |
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: |
J9262 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Synribo™ (omacetaxine mepesuccinate) |
Injection, omacetaxine mepesuccinate, 0.01 mg |
J9262 |
Service Description: |
Injection, oxaliplatin, 0.5 mg |
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: |
J9263 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Eloxatin (oxaliplatin) |
Injection, oxaliplatin, 0.5 mg |
J9263 |
Service Description: |
Injection, paclitaxel protein-bound particles, 1 mg |
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: |
J9264 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Abraxane® (paclitaxel protein-bound particles) |
Injection, paclitaxel protein-bound particles, 1 mg |
J9264 |
Service Description: |
Injection, pembrolizumab, 1 mg |
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: |
J9271 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Keytruda® (pembrolizumab) |
Injection, pembrolizumab, 1 mg |
J9271 |
Service Description: |
Inj, olaratumab, 10 mg |
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: |
J9285 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Lartruvo (olaratumab) |
Inj, olaratumab, 10 mg |
J9285 |
Service Description: |
Injection, necitumumab, 1 mg |
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: |
J9295 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Portrazza™ (necitumumab) |
Injection, necitumumab, 1 mg |
J9295 |
Service Description: |
Injection, nivolumab, 1 mg |
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: |
J9299 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Opdivo® (nivolumab) |
Injection, nivolumab, 1 mg |
J9299 |
Service Description: |
Injection, obinutuzumab, 10 mg |
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: |
J9301 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Gazyva™ (obinutuzumab) |
Injection, obinutuzumab, 10 mg |
J9301 |
Service Description: |
Injection, ofatumumab, 10 mg |
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: |
J9302 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Arzerra™ (ofatumumab) |
Injection, ofatumumab, 10 mg |
J9302 |
Service Description: |
Injection, panitumumab, 10 mg |
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: |
J9303 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Vectibix® (panitumumab) |
Injection, panitumumab, 10 mg |
J9303 |
Service Description: |
Injection, pemetrexed, 10 mg |
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: |
J9305 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Amilta (pemetrexed) |
Injection, pemetrexed, 10 mg |
J9305 |
Service Description: |
Injection, ramucirumab, 5 mg |
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: |
J9308 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cyramza® (ramucirumab) |
Injection, ramucirumab, 5 mg |
J9308 |
Service Description: |
Injection, polatuzumab vedotin-piiq, 1 mg |
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: |
J9309 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Polivy (polatuzumab vedotin-piiq) |
Injection, polatuzumab vedotin-piiq, 1 mg |
J9309 |
Service Description: |
Injection, rituximab 10 mg and hyaluronidase |
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: |
J9311 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Rituxin Hycela (rituximab/hyaluronidase) |
Injection, rituximab 10 mg and hyaluronidase |
J9311 |
Service Description: |
Injection, rituximab, 10 mg |
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: |
J9312 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Rituxan® (rituximab) Rituxan for Non-Hodgkin’s Lymphoma does not require prior authorization. |
Injection, rituximab, 10 mg |
J9312 |
Service Description: |
Injection, romidepsin, 1 mg |
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: |
J9315 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Istodax® (romidepsin) |
Injection, romidepsin, 1 mg |
J9315 |
Service Description: |
Injection, talimogene laherparepvec, per 1 million plaque forming units |
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: |
J9325 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Imlygic™ (talimogene laherparepvec) |
Injection, talimogene laherparepvec, per 1 million plaque forming units |
J9325 |
Service Description: |
Injection, temsirolimus, 1 mg |
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: |
J9330 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Torisel™ (temsirolimus) |
Injection, temsirolimus, 1 mg |
J9330 |
Service Description: |
Injection, sirolimus protein-bound particles, 1 mg |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9331 |
Service Code Type: |
HCPCS |
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: |
|
|
Fyarro (sirolimus protein-bound particles for injectable
suspension) (albumin-bound) |
Injection, sirolimus protein-bound particles, 1 mg |
J9331 |
Service Description: |
Injection, thiotepa, 15 mg |
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: |
J9340 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Tepadina (thiotepa) |
Injection, thiotepa, 15 mg |
J9340 |
Service Description: |
Injection, trabectedin, 0.1 mg |
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: |
J9352 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yondelis® (trabectedin) |
Injection, trabectedin, 0.1 mg |
J9352 |
Service Description: |
Injection, ado-trastuzumab emtansine, 1 mg |
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: |
J9354 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kadcyla® (abo-trastuzumab emtansine) |
Injection, ado-trastuzumab emtansine, 1 mg |
J9354 |
Service Description: |
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
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: |
J9358 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
J9358 |
Service Description: |
Injection, vincristine sulfate liposome, 1 mg |
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: |
J9371 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Marqibo® (vincristine sulfate liposome injection) |
Injection, vincristine sulfate liposome, 1 mg |
J9371 |
Service Description: |
Injection, ziv-aflibercept, 1 mg |
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: |
J9400 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zaltrap® (ziv-aflibercept) |
Injection, ziv-aflibercept, 1 mg |
J9400 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Enhertu (fam-trastuzumab deruxtecan-nxki) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
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: |
|
|
Jemperli (Dostarlimab-gxly) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
9/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
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: |
|
|
Kimmtrak (tebentafusp-tebn) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Padcev (enfortumab vedotin-ejfv) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Polivy (polatuzumab vedotin-piiq) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Revcovi (elapegademase-lvlr) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
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: |
|
|
Rybrevant (Amivantamab-vmjw) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Unituxin (dinutuximab) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
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: |
J9999 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Xerava (eravacycline) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Not otherwise classified, antineoplastic drugs |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
J9999 |
Service Code Type: |
HCPCS |
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: |
|
|
Zynlonta (Loncastuximab Tesirine-lpyl ) |
Not otherwise classified, antineoplastic drugs |
J9999 |
Service Description: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
Prior Authorization required: Preferred: |
No |
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: |
L0112 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
L0112 |
Service Description: |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
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: |
L0112 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Orthoses |
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
L0112 |
Service Description: |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
Prior Authorization required: Preferred: |
No |
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: |
L0113 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
L0113 |
Service Description: |
Implantable neurostimulator, pulse generator, any type |
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: |
L8679 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator, pulse generator, any type |
L8679 |
Service Description: |
Implantable neurostimulator electrode, each |
Prior Authorization required: Preferred: |
No |
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: |
L8680 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator electrode, each |
L8680 |
Service Description: |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
Prior Authorization required: Preferred: |
No |
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: |
L8681 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator |
L8681 |
Service Description: |
Implantable neurostimulator radiofrequency receiver |
Prior Authorization required: Preferred: |
No |
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: |
L8682 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator radiofrequency receiver |
L8682 |
Service Description: |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
Prior Authorization required: Preferred: |
No |
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: |
L8683 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver |
L8683 |
Service Description: |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
Prior Authorization required: Preferred: |
No |
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: |
L8685 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension |
L8685 |
Service Description: |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
Prior Authorization required: Preferred: |
No |
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: |
L8686 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension |
L8686 |
Service Description: |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
Prior Authorization required: Preferred: |
No |
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: |
L8687 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension |
L8687 |
Service Description: |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
Prior Authorization required: Preferred: |
No |
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: |
L8688 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Dorsal Column Stimulation (spinal column stimulation) |
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension |
L8688 |
Service Description: |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
Prior Authorization required: Preferred: |
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: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
Prior authorization is required for purchased or rented DME items when the allowed amount per individual item is
$500 or more |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
Durable Medical Equipment (Outpatient - see Monetary Restrictions) |
N/A |
Service Description: |
|
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: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Health Care Services associated with Non-covered Services (including but not limited to deep sedation and general anesthesia) |
|
N/A |
Service Description: |
Off Label Drug Use-Oncology Indications |
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: |
N/A |
Service Code Type: |
|
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
Any off-label drug or biologic used for an oncologic indication not included in the FDA approved labeling for the drug requires prior authorization. |
|
Off Label Drug Use-Oncology Indications |
Off Label Drug Use-Oncology Indications |
N/A |
Service Description: |
Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0477 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0477 |
Service Description: |
Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type |
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: |
Q0478 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type |
Q0478 |
Service Description: |
Power module for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0479 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0479 |
Service Description: |
Driver for use with pneumatic ventricular assist device, replacement 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: |
Q0480 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Driver for use with pneumatic ventricular assist device, replacement only |
Q0480 |
Service Description: |
Driver for use with pneumatic ventricular assist device, replacement 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: |
Q0480 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Driver for use with pneumatic ventricular assist device, replacement only |
Q0480 |
Service Description: |
Microprocessor control unit for use with electric ventricular assist device, replacement 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: |
Q0481 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Microprocessor control unit for use with electric ventricular assist device, replacement only |
Q0481 |
Service Description: |
Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement 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: |
Q0482 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only |
Q0482 |
Service Description: |
Monitor/display module for use with electric ventricular assist device, replacement 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: |
Q0483 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Monitor/display module for use with electric ventricular assist device, replacement only |
Q0483 |
Service Description: |
Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0484 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0484 |
Service Description: |
Monitor control cable for use with electric ventricular assist device, replacement 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: |
Q0485 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Monitor control cable for use with electric ventricular assist device, replacement only |
Q0485 |
Service Description: |
Monitor control cable for use with electric/pneumatic ventricular assist device, replacement 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: |
Q0486 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only |
Q0486 |
Service Description: |
Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement 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: |
Q0487 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only |
Q0487 |
Service Description: |
Power pack base for use with electric ventricular assist device, replacement 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: |
Q0488 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power pack base for use with electric ventricular assist device, replacement only |
Q0488 |
Service Description: |
Power pack base for use with electric/pneumatic ventricular assist device, replacement 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: |
Q0489 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power pack base for use with electric/pneumatic ventricular assist device, replacement only |
Q0489 |
Service Description: |
Emergency power source for use with electric ventricular assist device, replacement 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: |
Q0490 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Emergency power source for use with electric ventricular assist device, replacement only |
Q0490 |
Service Description: |
Emergency power source for use with electric/pneumatic ventricular assist device, replacement 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: |
Q0491 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Emergency power source for use with electric/pneumatic ventricular assist device, replacement only |
Q0491 |
Service Description: |
Emergency power supply cable for use with electric ventricular assist device, replacement 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: |
Q0492 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Emergency power supply cable for use with electric ventricular assist device, replacement only |
Q0492 |
Service Description: |
Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement 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: |
Q0493 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only |
Q0493 |
Service Description: |
Emergency hand pump for use with electric/pneumatic ventricular assist device, replacement 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: |
Q0494 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Emergency hand pump for use with electric/pneumatic ventricular assist device, replacement only |
Q0494 |
Service Description: |
Battery power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0495 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Battery power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0495 |
Service Description: |
Battery, other than lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0496 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Battery, other than lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0496 |
Service Description: |
Battery clip for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0497 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Battery clip for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0497 |
Service Description: |
Holster for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0498 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Holster for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0498 |
Service Description: |
Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement |
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: |
Q0499 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement |
Q0499 |
Service Description: |
Filters for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0500 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Filters for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0500 |
Service Description: |
Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0501 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0501 |
Service Description: |
Mobility cart for pneumatic ventricular assist device, replacement 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: |
Q0502 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Mobility cart for pneumatic ventricular assist device, replacement only |
Q0502 |
Service Description: |
Battery for pneumatic ventricular assist device, replacement only, each |
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: |
Q0503 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Battery for pneumatic ventricular assist device, replacement only, each |
Q0503 |
Service Description: |
Power adapter for pneumatic ventricular assist device, replacement only, vehicle type |
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: |
Q0504 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Power adapter for pneumatic ventricular assist device, replacement only, vehicle type |
Q0504 |
Service Description: |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement 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: |
Q0506 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Battery, lithium-hyphenion, for use with electric or electric/pneumatic ventricular assist device, replacement only |
Q0506 |
Service Description: |
Miscellaneous supply or accessory for use with an external ventricular assist device |
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: |
Q0507 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with an external ventricular assist device |
Q0507 |
Service Description: |
Miscellaneous supply or accessory for use with an implanted ventricular assist device |
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: |
Q0508 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with an implanted ventricular assist device |
Q0508 |
Service Description: |
Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A |
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: |
Q0509 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ventricular Assist Device (VAD) |
Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A |
Q0509 |
Service Description: |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
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: |
Q2041 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Yescarta (axicabtagene ciloleucel) |
Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco |
Q2041 |
Service Description: |
Tisagenlecleucel car-pos t |
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: |
Q2042 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Kymriah (tisagenleclencel) |
Tisagenlecleucel car-pos t |
Q2042 |
Service Description: |
Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion |
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: |
Q2043 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Provenge® (sipuleucel-T) |
Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion |
Q2043 |
Service Description: |
Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
Q2053 |
Service Code Type: |
HCPCS |
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: |
|
|
Tecartus (brexucabtagene autoleucel) |
Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells |
Q2053 |
Service Description: |
Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells |
Prior Authorization required: Preferred: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: INN: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Prior Authorization required: OON: |
Yes |
Effective Date for this Tier: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
Q2054 |
Service Code Type: |
HCPCS |
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: |
|
|
Breyanzi - lisocabtagene maraleucel |
Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells |
Q2054 |
Service Description: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
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: |
Q4081 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Q4081 |
Service Description: |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
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: |
Q4081 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Procrit® (epoetin alpha) |
Injection, epoetin alfa, 100 units (for esrd on dialysis) |
Q4081 |
Service Description: |
Biobrane Biosynthetic Dressing |
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: |
Q4100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Biobrane Biosynthetic Dressing |
Q4100 |
Service Description: |
Epicel |
Prior Authorization required: Preferred: |
No |
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: |
Q4100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epicel |
Q4100 |
Service Description: |
Skin substitute, not otherwise specified |
Prior Authorization required: Preferred: |
No |
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: |
Q4100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Skin substitute, not otherwise specified |
Q4100 |
Service Description: |
Apligraf, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4101 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Apligraf, per square centimeter |
Q4101 |
Service Description: |
Oasis wound matrix, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4102 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Oasis wound matrix, per square centimeter |
Q4102 |
Service Description: |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4104 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra bilayer matrix wound dressing (bmwd), per square centimeter |
Q4104 |
Service Description: |
Integra dermal regeneration template (drt), per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4105 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra dermal regeneration template (drt), per square centimeter |
Q4105 |
Service Description: |
Dermagraft, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4106 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermagraft, per square centimeter |
Q4106 |
Service Description: |
Graftjacket, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4107 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket, per square centimeter |
Q4107 |
Service Description: |
Integra matrix, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4108 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Integra matrix, per square centimeter |
Q4108 |
Service Description: |
Primatrix, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4110 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Primatrix, per square centimeter |
Q4110 |
Service Description: |
Graftjacket xpress, injectable, 1cc |
Prior Authorization required: Preferred: |
No |
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: |
Q4113 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Graftjacket xpress, injectable, 1cc |
Q4113 |
Service Description: |
Alloderm, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4116 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Alloderm, per square centimeter |
Q4116 |
Service Description: |
Matristem wound matrix, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4119 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Matristem wound matrix, per square centimeter |
Q4119 |
Service Description: |
Theraskin, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4121 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Theraskin, per square centimeter |
Q4121 |
Service Description: |
Dermacell, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4122 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Dermacell, per square centimeter |
Q4122 |
Service Description: |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4128 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Flex hd, allopatch hd, or matrix hd, per square centimeter |
Q4128 |
Service Description: |
Strattice tm, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4130 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Strattice tm, per square centimeter |
Q4130 |
Service Description: |
Grafix prime, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4133 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Grafix prime, per square centimeter |
Q4133 |
Service Description: |
Epifix, injectable, 1 mg |
Prior Authorization required: Preferred: |
No |
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: |
Q4145 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, injectable, 1 mg |
Q4145 |
Service Description: |
Transcyte, per sq centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4182 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Transcyte, per sq centimeter |
Q4182 |
Service Description: |
Epifix, per square centimeter |
Prior Authorization required: Preferred: |
No |
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: |
Q4186 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Epifix, per square centimeter |
Q4186 |
Service Description: |
PURAPLY AM PER SQ CM |
Prior Authorization required: Preferred: |
No |
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: |
Q4196 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
PURAPLY AM PER SQ CM |
Q4196 |
Service Description: |
Vim, per square centimeter |
Prior Authorization required: Preferred: |
No |
Effective Date for this Tier: |
1/1/2022 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: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4251 |
Service Code Type: |
HCPCS |
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: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Vim, per square centimeter |
Q4251 |
Service Description: |
Vendaje, per square centimeter |
Prior Authorization required: Preferred: |
No |
Effective Date for this Tier: |
1/1/2022 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: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4252 |
Service Code Type: |
HCPCS |
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: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Vendaje, per square centimeter |
Q4252 |
Service Description: |
Zenith amniotic membrane, per square centimeter |
Prior Authorization required: Preferred: |
No |
Effective Date for this Tier: |
1/1/2022 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: |
1/1/2022 12:00:00 AM |
Restricted to Preferred Facilities: |
|
Service Code: |
Q4253 |
Service Code Type: |
HCPCS |
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: |
|
|
Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft) |
Zenith amniotic membrane, per square centimeter |
Q4253 |
Service Description: |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
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: |
Q5101 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
White Blood Cell Stimulating Factors (Neulasta®, Neupogen®, Leukine®, Granix® and Zarxio®) |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Q5101 |
Service Description: |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
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: |
Q5101 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Zarxio (filgrastim- sndz) |
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram |
Q5101 |
Service Description: |
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
Q5103 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Inflectra (infliximab-dyyb) |
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg |
Q5103 |
Service Description: |
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
Q5104 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Renflexis (infliximab-abda) |
Injection, infliximab-abda, biosimilar, (renflexis), 10 mg |
Q5104 |
Service Description: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
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: |
Q5106 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Erythropoietin Stimulating Agents |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Q5106 |
Service Description: |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
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: |
Q5106 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Retacrit (epoetin alfa-epbx) |
Injection, epoetin alfa, biosimilar, (retacrit) (for non-esrd use), 1000 units |
Q5106 |
Service Description: |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
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: |
Q5108 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fulphilia (pegfilgrastim-jmdb) |
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
Q5108 |
Service Description: |
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
Q5109 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ixifi (infliximab-qbtx) |
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg |
Q5109 |
Service Description: |
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram |
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: |
Q5110 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Nivestym (filgrastim-aafi) |
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram |
Q5110 |
Service Description: |
Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg |
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: |
Q5114 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ogivri (trastuzumab-dkst) |
Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg |
Q5114 |
Service Description: |
Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg |
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: |
Q5115 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Truxima (rituximab-abbs) |
Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg |
Q5115 |
Service Description: |
Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg |
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: |
Q5119 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ruxience (injection, rituximab-pvvr, biosimilar) |
Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg |
Q5119 |
Service Description: |
Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg |
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: |
Q5120 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Ziextenzo (injection, pegfilgrastim-bmez, biosimilar) |
Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg |
Q5120 |
Service Description: |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
Prior Authorization required: Preferred: |
Yes |
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: |
Q5121 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Avsola (injection, infliximab-axxq, biosimilar) |
Injection, infliximab-axxq, biosimilar, (avsola), 10 mg |
Q5121 |
Service Description: |
Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg |
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: |
Q9991 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sublocade (buprenorphine ER injection for subcutaneous use ) |
Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg |
Q9991 |
Service Description: |
Injection, buprenorphine extended-release (sublocade), greater than 100 mg |
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: |
Q9992 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Sublocade (buprenorphine ER injection for subcutaneous use ) |
Injection, buprenorphine extended-release (sublocade), greater than 100 mg |
Q9992 |
Service Description: |
Sterile dilutant for epoprostenol, 50ml |
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: |
S0155 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Flolan® (epoprostenol) |
Sterile dilutant for epoprostenol, 50ml |
S0155 |
Service Description: |
Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by hcg, ultrasound to conf |
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: |
S0199 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Termination of Pregnancy (Abortion) |
Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by hcg, ultrasound to conf |
S0199 |
Service Description: |
PART HOSITALIZATN SRVC<24 HR-DIEM |
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: |
S0201 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
PART HOSITALIZATN SRVC<24 HR-DIEM |
S0201 |
Service Description: |
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss |
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: |
S0618 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss |
S0618 |
Service Description: |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
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: |
S1040 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Cranial Orthotics – helmets/remolding bands for Infants |
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
S1040 |
Service Description: |
Transplantation of small intestine and liver allografts |
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: |
S2053 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Transplantation of small intestine and liver allografts |
S2053 |
Service Description: |
Transplantation of multivisceral organs |
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: |
S2054 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Transplantation of multivisceral organs |
S2054 |
Service Description: |
Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; 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: |
S2055 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor |
S2055 |
Service Description: |
Lobar lung transplantation |
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: |
S2060 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Lobar lung transplantation |
S2060 |
Service Description: |
Donor lobectomy (lung) for transplantation, 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: |
S2061 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Donor lobectomy (lung) for transplantation, living donor |
S2061 |
Service Description: |
Simultaneous pancreas kidney transplantation |
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: |
S2065 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Simultaneous pancreas kidney transplantation |
S2065 |
Service Description: |
Islet cell tissue transplant from pancreas; 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: |
S2102 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Islet cell tissue transplant from pancreas; allogeneic |
S2102 |
Service Description: |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte 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: |
S2112 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Autologous cultured chondrocyte (MACI) |
Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) |
S2112 |
Service Description: |
Cord blood harvesting for 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: |
S2140 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Cord blood harvesting for transplantation, allogeneic |
S2140 |
Service Description: |
Cord blood-derived stem-cell 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: |
S2142 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Cord blood-derived stem-cell transplantation, allogeneic |
S2142 |
Service Description: |
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m |
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: |
S2150 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Transplant evaluation services (pre-transplant services) and surgical tranplantation of organs, bone marrow or stem cells (Solid Organ) |
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m |
S2150 |
Service Description: |
Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear |
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: |
S2230 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear |
S2230 |
Service Description: |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
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: |
S2400 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero |
S2400 |
Service Description: |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
Prior Authorization required: Preferred: |
Yes |
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: |
S2401 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, urinary tract obstruction in the fetus, procedure performed in utero |
S2401 |
Service Description: |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
Prior Authorization required: Preferred: |
Yes |
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: |
S2402 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero |
S2402 |
Service Description: |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
Prior Authorization required: Preferred: |
Yes |
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: |
S2403 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero |
S2403 |
Service Description: |
Repair, myelomeningocele in the fetus, procedure performed in utero |
Prior Authorization required: Preferred: |
Yes |
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: |
S2404 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, myelomeningocele in the fetus, procedure performed in utero |
S2404 |
Service Description: |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
Prior Authorization required: Preferred: |
Yes |
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: |
S2405 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
S2405 |
Service Description: |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
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: |
S2405 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero |
S2405 |
Service Description: |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
Prior Authorization required: Preferred: |
Yes |
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: |
S2409 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified |
S2409 |
Service Description: |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
Prior Authorization required: Preferred: |
Yes |
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: |
S2411 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Fetal Surgery (surgery on the unborn child) |
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome |
S2411 |
Service Description: |
Genetic Testing - Other Cancer |
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: |
S3840 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3840 |
Service Description: |
Genetic Testing - Other Cancer |
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: |
S3841 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3841 |
Service Description: |
Genetic Testing - Other Cancer |
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: |
S3842 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other Cancer |
Genetic Testing - Other Cancer |
S3842 |
Service Description: |
Genetic testing for alpha-thalassemia |
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: |
S3845 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
Genetic testing for alpha-thalassemia |
S3845 |
Service Description: |
Genetic testing for hemoglobin e beta-thalassemia |
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: |
S3846 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
Genetic testing for hemoglobin e beta-thalassemia |
S3846 |
Service Description: |
Genetic testing for sickle cell anemia |
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: |
S3850 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Severe Anemias |
Genetic testing for sickle cell anemia |
S3850 |
Service Description: |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
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: |
S3861 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected Brugada Syndrome |
S3861 |
Service Description: |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
Prior Authorization required: Preferred: |
Yes |
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: |
S3865 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy |
S3865 |
Service Description: |
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family (Effective 4/1/09) |
Prior Authorization required: Preferred: |
Yes |
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: |
S3866 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Cardiac |
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family (Effective 4/1/09) |
S3866 |
Service Description: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
Prior Authorization required: Preferred: |
Yes |
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: |
S3870 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Comparative Genomic Hybridization (CGH) or Chromosomal Microarray Analysis (CMA) for Evaluation of Developmental Delay |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
S3870 |
Service Description: |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
Prior Authorization required: Preferred: |
Yes |
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: |
S3870 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Genetic Testing - Other |
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability |
S3870 |
Service Description: |
Magnetic resonance cholangiopancreatography (mrcp) |
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: |
S8037 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance cholangiopancreatography (mrcp) |
S8037 |
Service Description: |
Magnetic resonance imaging (mri), low-field |
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: |
S8042 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Magnetic Resonance Imaging (MRI) (Outpatient/Nonemergency) |
Magnetic resonance imaging (mri), low-field |
S8042 |
Service Description: |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
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: |
S8092 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
CT (CAT) Scan (Outpatient/Nonemergency) |
Electron beam computed tomography (also known as ultrafast ct, cine ct) |
S8092 |
Service Description: |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
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: |
S9475 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
Ambulatory setting substance abuse treatment or detoxification services, per diem |
S9475 |
Service Description: |
INTENSIVE OP PSYC SERVICES PER DIEM |
Prior Authorization required: Preferred: |
No |
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: |
S9480 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Behavioral Health (Mental Health) and Substance Abuse: IOP treatment programs or Outpatient treatment of Opioid dependence |
INTENSIVE OP PSYC SERVICES PER DIEM |
S9480 |
Service Description: |
Private duty/independent nursing service(s), licensed, up to 15 minutes |
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: |
T1000 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
Prior authorization is only required for Hospice when it relates to inpatient services. |
|
Hospice |
Private duty/independent nursing service(s), licensed, up to 15 minutes |
T1000 |
Service Description: |
Hospice inpatient respite care; per diem |
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: |
T2044 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hospice |
Hospice inpatient respite care; per diem |
T2044 |
Service Description: |
Hospice general inpatient care; per diem |
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: |
T2045 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
Any |
Monetary Restrictions: |
No Restriction |
Frequency Restriction for Coverage: |
No Restriction |
Comments: |
|
|
Hospice |
Hospice general inpatient care; per diem |
T2045 |
Service Description: |
Ear protector evaluation |
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: |
V5008 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Ear protector evaluation |
V5008 |
Service Description: |
Assessment for hearing aid |
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: |
V5010 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Assessment for hearing aid |
V5010 |
Service Description: |
Fitting orientation/checking of hearing aid |
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: |
V5011 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Fitting orientation/checking of hearing aid |
V5011 |
Service Description: |
Repair/modification of a hearing aid |
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: |
V5014 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Repair/modification of a hearing aid |
V5014 |
Service Description: |
Conformity evaluation |
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: |
V5020 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Conformity evaluation |
V5020 |
Service Description: |
Hearing aid, monaural, body worn, air conduction |
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: |
V5030 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, monaural, body worn, air conduction |
V5030 |
Service Description: |
Hearing aid, monaural, body worn, bone conduction |
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: |
V5040 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, monaural, body worn, bone conduction |
V5040 |
Service Description: |
Hearing aid monaural, in the ear |
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: |
V5050 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid monaural, in the ear |
V5050 |
Service Description: |
Hearing aid monaural (BTE) |
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: |
V5060 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid monaural (BTE) |
V5060 |
Service Description: |
Glasses, air conduction |
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: |
V5070 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Glasses, air conduction |
V5070 |
Service Description: |
Glasses, bone conduction |
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: |
V5080 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Glasses, bone conduction |
V5080 |
Service Description: |
Dispensing fee, unspecified hearing aid |
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: |
V5090 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, unspecified hearing aid |
V5090 |
Service Description: |
Semi-implantable middle ear hearing prosthesis |
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: |
V5095 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Semi-implantable middle ear hearing prosthesis |
V5095 |
Service Description: |
Hearing aid, bilateral, body worn |
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: |
V5100 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, bilateral, body worn |
V5100 |
Service Description: |
Dispensing fee, bilateral, in the ear |
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: |
V5110 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, bilateral, in the ear |
V5110 |
Service Description: |
Binaural, body |
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: |
V5120 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Binaural, body |
V5120 |
Service Description: |
Hearing aid binaural, in the ear |
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: |
V5130 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid binaural, in the ear |
V5130 |
Service Description: |
Hearing aid binaural, BTE |
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: |
V5140 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid binaural, BTE |
V5140 |
Service Description: |
Binaural, glasses |
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: |
V5150 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Binaural, glasses |
V5150 |
Service Description: |
Dispensing fee, binaural, BTE |
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: |
V5160 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, binaural, BTE |
V5160 |
Service Description: |
Hearing aid, contralateral routing device, monaural, in the ear (ite) |
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: |
V5171 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, in the ear (ite) |
V5171 |
Service Description: |
Hearing aid, contralateral routing device, monaural, in the canal (itc) |
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: |
V5172 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, in the canal (itc) |
V5172 |
Service Description: |
Hearing aid, contralateral routing device, monaural, behind the ear (bte) |
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: |
V5181 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing device, monaural, behind the ear (bte) |
V5181 |
Service Description: |
Hearing aid, contralateral routing, monaural, glasses |
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: |
V5190 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing, monaural, glasses |
V5190 |
Service Description: |
Dispensing fee, contralateral, monaural |
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: |
V5200 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, contralateral, monaural |
V5200 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/ite |
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: |
V5211 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/ite |
V5211 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/itc |
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: |
V5212 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/itc |
V5212 |
Service Description: |
Hearing aid, contralateral routing system, binaural, ite/bte |
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: |
V5213 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, ite/bte |
V5213 |
Service Description: |
Hearing aid, contralateral routing system, binaural, itc/itc |
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: |
V5214 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, itc/itc |
V5214 |
Service Description: |
Hearing aid, contralateral routing system, binaural, itc/bte |
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: |
V5215 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, itc/bte |
V5215 |
Service Description: |
Hearing aid, contralateral routing system, binaural, bte/bte |
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: |
V5221 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, bte/bte |
V5221 |
Service Description: |
Hearing aid, contralateral routing system, binaural, glasses |
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: |
V5230 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, contralateral routing system, binaural, glasses |
V5230 |
Service Description: |
Dispensing fee, contralateral routing system, binaural |
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: |
V5240 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, contralateral routing system, binaural |
V5240 |
Service Description: |
Dispensing fee, monaural hearing aid, any type |
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: |
V5241 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Dispensing fee, monaural hearing aid, any type |
V5241 |
Service Description: |
Hearing aid, analog, monaural, cic (completely in the ear canal) |
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: |
V5242 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, monaural, cic (completely in the ear canal) |
V5242 |
Service Description: |
Hearing aid, analog, monaural, itc (in the canal) |
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: |
V5243 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, monaural, itc (in the canal) |
V5243 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, cic |
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: |
V5244 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, cic |
V5244 |
Service Description: |
Hearing aid, digitally programmable, analog, monaural, itc |
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: |
V5245 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, analog, monaural, itc |
V5245 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, ite (in the ear) |
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: |
V5246 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, ite (in the ear) |
V5246 |
Service Description: |
Hearing aid, digitally programmable analog, monaural, BTE |
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: |
V5247 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, monaural, BTE |
V5247 |
Service Description: |
Hearing aid, analog, binaural, cic |
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: |
V5248 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, binaural, cic |
V5248 |
Service Description: |
Hearing aid, analog, binaural, itc |
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: |
V5249 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, analog, binaural, itc |
V5249 |
Service Description: |
Hearing aid, digitally programmable analog, binaural, cic |
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: |
V5250 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, binaural, cic |
V5250 |
Service Description: |
Hearing aid, digitally programmable analog, binaural, itc |
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: |
V5251 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable analog, binaural, itc |
V5251 |
Service Description: |
Hearing aid, digitally programmable, binaural, ite |
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: |
V5252 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, binaural, ite |
V5252 |
Service Description: |
Hearing aid, digitally programmable, binaural, BTE |
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: |
V5253 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digitally programmable, binaural, BTE |
V5253 |
Service Description: |
Hearing aid, digital, monaural, cic |
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: |
V5254 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, cic |
V5254 |
Service Description: |
Hearing aid, digital, monaural, itc |
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: |
V5255 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, itc |
V5255 |
Service Description: |
Hearing aid, digital, monaural, ite |
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: |
V5256 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, ite |
V5256 |
Service Description: |
Hearing aid, digital, monaural, BTE |
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: |
V5257 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, monaural, BTE |
V5257 |
Service Description: |
Hearing aid, digital, binaural, cic |
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: |
V5258 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, cic |
V5258 |
Service Description: |
Hearing aid, digital, binaural, itc |
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: |
V5259 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, itc |
V5259 |
Service Description: |
Hearing aid, digital, binaural, ite |
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: |
V5260 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, ite |
V5260 |
Service Description: |
Hearing aid, digital, binaural, BTE |
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: |
V5261 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, digital, binaural, BTE |
V5261 |
Service Description: |
Hearing aid, disposable, any type, monaural |
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: |
V5262 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, disposable, any type, monaural |
V5262 |
Service Description: |
Hearing aid, disposable, any type, binaural |
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: |
V5263 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, disposable, any type, binaural |
V5263 |
Service Description: |
Ear mold/insert, not disposable, any type |
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: |
V5264 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Ear mold/insert, not disposable, any type |
V5264 |
Service Description: |
Ear mold/insert, disposable, any type |
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: |
V5265 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Ear mold/insert, disposable, any type |
V5265 |
Service Description: |
Battery for use in hearing device |
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: |
V5266 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Battery for use in hearing device |
V5266 |
Service Description: |
Hearing aid supplies/accessories |
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: |
V5267 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid supplies/accessories |
V5267 |
Service Description: |
Ear impression, each |
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: |
V5275 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Ear impression, each |
V5275 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM SYS MONAURL ANY TYPE |
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: |
V5281 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM SYS MONAURL ANY TYPE |
V5281 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM SYS BINAURL ANY TYPE |
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: |
V5282 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM SYS BINAURL ANY TYPE |
V5282 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM NCK LOOP INDUCT RECV |
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: |
V5283 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM NCK LOOP INDUCT RECV |
V5283 |
Service Description: |
ASSIST LIST DEVICE PERS FM/DM EAR LEVEL RECEIVER |
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: |
V5284 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVICE PERS FM/DM EAR LEVEL RECEIVER |
V5284 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM DIR AUDIO INPUT RECV |
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: |
V5285 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM DIR AUDIO INPUT RECV |
V5285 |
Service Description: |
ASSIST LISTEN DEVC PERS BLUE TOOTH FM/DM RECEIVR |
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: |
V5286 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC PERS BLUE TOOTH FM/DM RECEIVR |
V5286 |
Service Description: |
ASSISTIVE LISTENING DEVC PERS FM/DM RECEIVER NOS |
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: |
V5287 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSISTIVE LISTENING DEVC PERS FM/DM RECEIVER NOS |
V5287 |
Service Description: |
ASSIST LISTEN DEVC PERS FM/DM TRANSMITTER ALD |
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: |
V5288 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC PERS FM/DM TRANSMITTER ALD |
V5288 |
Service Description: |
ASSIST LIST DEVC PERS FM/DM ADPTR/BOOT CPLG RECV |
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: |
V5289 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LIST DEVC PERS FM/DM ADPTR/BOOT CPLG RECV |
V5289 |
Service Description: |
ASSIST LISTEN DEVC TRANSMITT MICROPHONE ANY TYPE |
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: |
V5290 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
ASSIST LISTEN DEVC TRANSMITT MICROPHONE ANY TYPE |
V5290 |
Service Description: |
Hearing aid, not otherwise classified |
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: |
V5298 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing aid, not otherwise classified |
V5298 |
Service Description: |
Hearing service miscellaneous |
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: |
V5299 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Hearing service miscellaneous |
V5299 |
Service Description: |
Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) |
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: |
V5336 |
Service Code Type: |
HCPCS |
Effective Date: |
1/1/2021 12:00:00 AM |
Age Range for Coverage: |
birth through 18 |
Monetary Restrictions: |
Coverage limit is $3,000 per ear |
Frequency Restriction for Coverage: |
Coverage limited to once per ear, every 36 months |
Comments: |
|
|
Pediatric Hearing Aids |
Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) |
V5336 |