Added codes
Effective February 4, 2022
The following codes will require review for medical necessity and prior authorization for services on or after February 4, 2022
American Society of
Addiction Medicine (ASAM), 10.01.532
H0031, H0032, H2014, H2019, S5108, S5109, S5110 and S5111
Effective January 7, 2022
Hysterectomy
for Non-Malignant Conditions, 7.01.548
Now requires review for medical necessity and prior authorization.
58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573
Hysterectomy
for Non-Malignant Conditions, 7.01.548
Now requires review for medical necessity and prior authorization, including site of service.
58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550, 58552, 58553, 58554
Effective January 1, 2022
Amniotic
Membrane and Amniotic Fluid, 7.01.583
Now requires review for investigational.
A2001, Q4199
Amyloid
Antibodies for the Treatment of Alzheimer’s Disease, 5.01.626
Now requires review for medical necessity and prior authorization.
J0172
Bioengineered
Skin and Soft Tissue Substitute, 7.01.113
Now requires review for investigational.
A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010
CGRP
Inhibitors for Migraine Prophylaxis, 5.01.584
Now requires review for medical necessity and prior authorization.
J3031
Chimeric
Antigen Receptor Therapy for Multiple Myeloma, 8.01.66
Now requires review for medical necessity and prior authorization.
Q2055
Cryoablation
for Chronic Rhinitis, 7.01.168
Now requires review for investigational.
30117, C9771
Drugs
for Rare Diseases, 5.01.576
Now requires review for medical necessity.
C9085
Epidermal
Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
Now requires review for medical necessity and prior authorization.
J9061
Gender
Transition/Affirmation Surgery, 7.01.557
Now requires review for medical necessity and prior authorization.
11960, 15788, 15789, 15792, 15793, 21087, 21210, 40500, 40510, 40520, 40525, 40527, 53430, 54520
Gender
Transition/Affirmation Surgery, 7.01.557
Will require review for WA members when submitted for gender transition/affirmation surgery unless otherwise specified by contract.
15775, 15776, 17380, 54400, 54401, 54405, C1813, C2622
Gonadotropin
Releasing Hormone (GnRH) Analogs, 5.01.625
Now requires review for medical necessity and prior authorization.
J1952
Immune
Checkpoint Inhibitors, 5.01.591
Now requires review for medical necessity and prior authorization.
J9272
Implantable
Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03
Now requires review for medical necessity and prior authorization.
69716, 69719
Lumbar
Spinal Fusion in Adults, 7.01.542
Now requires review for medical necessity and prior authorization.
63052, 63053
Miscellaneous
Oncology Drugs, 5.01.540
Now requires review for medical necessity and prior authorization.
J9021
Non-covered
Experimental/Investigational Services, 10.01.533
Now requires review for investigational.
0295U, 0672T, 0674T, 0675T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0686T, 0687T, 0688T, 0689T, 0690T, 0691T, 0692T, 0693T, 0694T, 0695T, 0696T, 0697T, 0698T, 0700T, 0701T, 0704T, 0705T, 0706T, 0707T, 0708T, 0709T, 0710T,
0711T, 0712T, 0713T, K1027, 33267, 33268, 33269, 61736, 61737
Percutaneous
Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty,
Biacuplasty, and Intraosseous Basivertebral Nerve Ablation, 7.01.72
Now requires review for investigational.
64628, 64629
Peroral
Endoscopic Myotomy for Treatment of Esophageal Achalasia, 2.01.91
Now requires review for investigational.
43497
Pharmacotherapy
of Miscellaneous Autoimmune Diseases, 5.01.564
Now requires review for medical necessity.
C9086
Prescription
Digital Therapeutics for Substance Use Disorder, 5.01.35
Now requires review for investigational.
0702T, 0703T
Radiofrequency
Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors, 7.01.95
Now requires review for investigational.
0673T
Surgical
Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101
Now requires review for medical necessity and prior authorization.
64582, 64583, 64584
Transcatheter
Aortic Valve Implantation for Aortic Stenosis, 7.01.585
Now requires review for investigational.
33370, C1884
Use
of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551
Now requires review for medical necessity and prior authorization.
J2506
AIM®
Specialty Health Genetic Testing
Now reviewed by AIM® Specialty Health and requires prior authorization.
0285U, 0286U, 0287U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 81349, 81523
Revised codes
Effective January 7, 2022
Cervical
Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
Currently requires review for medical necessity, now requires review for site of service.
22551, 22554, 22600, 63020, 63045
Lumbar
Spinal Fusion in Adults, 7.01.542
Currently requires review for medical necessity, now requires review for site of service.
22533, 22558, 22612, 22630, 22633, 63052, 63053
Removed codes
Effective January 1, 2022
Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.66
No longer requires review. Code terminated.
C9081
Epidermal
Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
No longer requires review. Code terminated.
C9083
Immune
Checkpoint Inhibitors, 5.01.591
No longer requires review. Code terminated.
C9082
Implantable
Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03
No longer requires review. Code terminated.
69715, 69718
Non-covered
Experimental/Investigational Services, 10.01.533
No longer requires review. Code terminated.
C9752, C9753
Surgical
Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101
No longer requires review. Code terminated.
0466T, 0467T
Use
of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551
No longer requires review. Code terminated.
J2505
Wilderness
Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522
Now requires review for medical necessity and prior authorization.
T2036, T2037
AIM®
Specialty Health Genetic Testing
No longer requires review. Code terminated.
0208U