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Home / Providers / Prior Auth List 2022
View Procedure or Service: Service Description: Service Code:

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

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

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

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

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

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

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

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

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

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

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Inpatient Facility Admission - Planned

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

Hospice

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

Hospice

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

Inpatient Facility Admission - Planned

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

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

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

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

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

Surgical Reconstruction

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Bioengineered Skin Equivalents (including but not limited to Dermagraft and Apligraf (Graftskin) - a type of skin graft)

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Surgery - Integumentary

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

Blepharoplasty (plastic surgery of the eyelids)

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

Blepharoplasty (plastic surgery of the eyelids)

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

Blepharoplasty (plastic surgery of the eyelids)

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

Blepharoplasty (plastic surgery of the eyelids)

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

Surgery - Integumentary

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgery - Integumentary

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Surgical Reconstruction

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

Xiaflex® (collagenase clostridium histolyticum)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Surgery - Musculoskeletal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Pectus Excavatum or Carinatum (surgical correction of chest deformity)

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Surgery - Musculoskeletal

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Spinal Fusion (Elective)

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

Surgery - Musculoskeletal

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

Surgery - Shoulder - Center Of Excellence

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

Surgery - Shoulder - Center Of Excellence

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

Surgery - Shoulder - Center Of Excellence

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

Surgery - Shoulder - Center Of Excellence

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

Sacroiliac Joint Injection

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Sacroiliac Joint Fusion

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Autologous cultured chondrocyte (MACI)

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Musculoskeletal

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

Surgery - Hip/Knee - Center Of Excellence

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Extracorporeal Shock Wave Treatment (ESWT) for Musculoskeletal Indications

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - Musculoskeletal

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

Surgery - General

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

Surgery - General

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Rhinoplasty as a standalone procedure or Rhinoplasty, with or without septal repair, in conjunction with other planned medically necessary surgeries.

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

Rhinoplasty including major septal repair

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

Surgery - General

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

Rhinoplasty including major septal repair

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

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

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

Rhinoplasty including major septal repair

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

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

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgery - General

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

Surgical Reconstruction

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

Bronchial Thermoplasty

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

Bronchial Thermoplasty

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

Surgical Reconstruction

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

Lung Volume Reduction Surgery

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

Stereotactic Radiosurgery (including but not limited to Cyberknife, GammaKnife, LINAC, Neuromate, Nerhkoordinaten Manipulator (MKM))

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart)

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

Transmyocardial Laser Revascularization (TMLR) (when performed as a stand-alone procedure–process to increase blood supply to the heart)

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

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

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

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

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

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

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

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

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

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

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

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

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Ventricular Assist Device (VAD)

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Intrathecal Infusion Pump

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

Varicose Vein Treatments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Magnetic Esophageal Sphincter Augmentation (LINX)

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

Magnetic Esophageal Sphincter Augmentation (LINX)

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Gastric Electrical Stimulation

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

Gastric Electrical Stimulation

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Gastric Electrical Stimulation

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

Surgery - Weight Loss - Center Of Excellence

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

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

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

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

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

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

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

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

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

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

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

Chemodenervation-Botox® (Botulinum toxin Type A)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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