Added codes
Effective July 2, 2020
Electrostimulation
and Electromagnetic Therapy for Treating Wounds, 2.01.57
Now requires review for investigative.
E0769, G0281, G0282, G0295, G0329
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
Now requires review for medical necessity.
43266
Effective July 1, 2020
AIM Specialty Health® Genetic Testing
Now requires review for medical necessity and prior authorization.
0172U, 0173U, 0175U, 0177U, 0179U
Drugs for Rare Diseases, 5.01.576
Now requires review for medical necessity and prior authorization.
J0791, J0223
Electrical Stimulation Devices,
1.01.507
Now requires review for medical necessity and prior authorization.
E0761
Erythyroid Maturation Agents, 5.01.614
Now requires review for medical necessity and prior authorization.
J0896
Granulocyte Colony-Stimulating Factor
(G-CSF) Use in Adult Patients), 5.01.551
Now requires review for medical necessity and prior authorization.
Q5120
Herceptin (trastuzumab) and Other
HERS Inhibitors, 5.01.514
Now requires review for medical necessity and prior authorization.
J9358
Immune Globulin Therapy, 8.01.503
Now requires review for medical necessity and prior authorization.
J1558
Irreversible Electroporation
(NanoKnife® System), 7.01.572
Now requires review for investigative.
0600T, 0601T
Miscellaneous Oncology Drugs, 5.01.540
Now requires review for medical necessity and prior authorization.
J9177
Pharmacologic Treatment of Duchenne
Muscular Dystrophy, 5.01.570
Now requires review for medical necessity and prior authorization.
J1429
Pharmacotherapy of Arthropathies,
5.01.550
Now requires review for medical necessity and prior authorization.
Q5121
Pharmacotherapy of Spinal Muscular
Atrophy (SMA), 5.01.574
Now requires review for medical necessity and prior authorization.
J3399
Rituximab: Non-oncologic and
Miscellaneous Uses, 5.01.556
Now requires review for medical necessity and prior authorization.
Q5119
Removed codes
Effective July 2, 2020
Autologous Chondrocyte Implantation for
Focal Articular Cartilage Lesions, 7.01.569
No longer requires review for medical necessity and prior authorization.
S2112
Cardiac Hemodynamic Monitoring for the
Management of Heart Failure in the Outpatient Setting, 2.02.24
No longer requires review for investigative.
93701
Chimeric Antigen Receptor Therapy for
Hematologic Malignancies, 8.01.63
No longer requires review for medical necessity and prior authorization.
0537T, 0538T, 0539T, 0540T
Coronary Angiography for Known
Suspected Coronary Artery Disease, 2.02.507
No longer requires review for medical necessity and prior authorization. This
policy is now covered under InterQual® criteria.
93460, 93461
Cryosurgical Ablation of Miscellaneous
Solid Tumors Other Than Liver, Prostate or Dermatologic Tumors, 7.01.92
No longer requires review for investigative.
19105
Deep Brain Stimulation, 7.01.63
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
61868
Diagnosis and Treatment of Sacroiliac
Joint Pain, 6.01.23
No longer requires review for medical necessity and prior authorization.
27280
Diagnosis and Treatment of Sacroiliac
Joint Pain, 6.01.23
No longer requires review for investigative.
64625
Hospital Beds and Accessories, 1.01.520
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
E0265, E0266, E0296, E0297, E0300, E0912
In Vitro Chemoresistance and
Chemosensitivity Assays, 2.03.01
No longer requires review for investigative and prior authorization.
0564T
Lipid Apheresis, 8.02.04
No longer requires review for investigative and prior authorization.
0342T
Lipid Apheresis, 8.02.04
No longer requires review for medical necessity and prior authorization.
S2120
Oscillatory Devices for the Treatment
of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
E0481
Patient Lifts, Seat Lifts and Standing
Devices, 1.01.519
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
E0642
Percutaneous and Vertebroplasty and
Sacroplasty, 2.01.57
No longer requires review for investigational and prior authorization.
0200T, 0201T
Postsurgical Outpatient Use of Limb
Compression Devices for Venous Thromboembolism Prophylaxis, 1.01.28
No longer requires review for medical necessity and prior authorization.
E0675
Power Operated Vehicle (Scooters)
(excluding motorized wheelchairs), 1.01.527
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
E1230, K0899
Quantitative Assay for Measurement of
HER2 Total Protein Expression and HER2 Dimers, 2.04.76
No longer requires review for investigative and prior authorization.
0009U
Recombinant and Autologous Platelet Derived
Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.16
No longer requires review for investigative.
G0460, S9055
Surgical Treatment of Snoring and
Obstructive Sleep Apnea Syndrome, 7.01.101
No longer requires review for investigative.
41512, 41530
Surgical Treatment of Snoring and
Obstructive Sleep Apnea Syndrome, 7.01.101
No longer requires review for investigative and prior authorization.
S2080
Surgical Treatment of Snoring and
Obstructive Sleep Apnea Syndrome, 7.01.101
No longer requires review for medical necessity and prior authorization.
21685, 42950
Total Artificial Hearts and Implantable
Ventricular Assist, 7.03.11
No longer requires review for medical necessity and prior authorization.
33981, 33982, 33983
Total Artificial Hearts and Implantable
Ventricular Assist, 7.03.11
No longer requires review for investigative.
33990, 33991, 33992, 33993
Wheelchairs (Manual or Motorized),
1.01.501
No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.
E0950, E0955, E1012, E1014, E1031, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221,
E1222, E1223, E1224, E1225, E1226, E1229, E1240, E1250, E1260, E1270, E1285, E1290, E1295, E2227, E2228, E2230, E2291, E2292, E2293, E2294, E2295, E2300, E2310, E2311, E2331, E2341, E2342, E2343, E2351, E2398, E2603, E2604, E2605, E2606, E2607, E2608,
E2610, E2613, E2614, E2615, E2616, E2620, E2621, E2622, E2623, E2624, E2625, K0003, K0004, K0009, K0010, K0011, K0012, K0014, K0830, K0831, K0898, K0900