Added codes
Effective
October 1, 2021
AIM Specialty Health® Genetic Testing
Now reviewed by AIM® Specialty Health and
requires prior authorization.
0258U, 0260U, 0262U, 0264U
Amniotic Membrane and Amniotic Fluid, 7.01.583
Now requires review for investigative.
Q4251, Q4252, Q4253
Antibody-Drug Conjugates, 5.01.582
Now requires review for medical necessity.
C9084
Chimeric Antigen Receptor Therapy for Leukemia and
Lymphoma, 8.01.63
Now requires review for medical necessity
and prior authorization.
Q2054
Chimeric Antigen Receptor Therapy for Leukemia and
Lymphoma, 8.01.63
Now requires review for medical necessity.
C9081
Cryoablation of Tumors Located on the Kidney, Lung,
Breast, Pancreas or Bone, 7.01.92
Now requires review for investigative.
19105, 0581T
Cutaneous T-Cell Lymphomas (CTCL): Systemic Therapies,
5.01.532
Now requires review for medical necessity
and prior authorization.
J9318, J9319
Electrical Stimulation Devices, 1.01.507
Now requires review for medical necessity
and prior authorization.
K1023
Epidermal Growth Factor Receptor (EGFR) Inhibitors,
5.01.603
Now requires review for medical necessity.
C9083
Gender Reassignment Surgery, 7.01.557
Now requires review for medical necessity
and prior authorization.
57335
Immune Checkpoint Inhibitors, 5.01.591
Now requires review for medical necessity.
C9082
Lumbar Spinal Fusion, 7.01.542
Now requires review for medical necessity.
C8131
Magnetic Resonance Imaging-Guided Focused Ultrasound,
7.01.109
Now requires review for medical necessity.
C9734
Miscellaneous Oncology Drugs, 5.01.540
Now requires review for medical necessity
and prior authorization.
J1448, J9247, J9281
Nerve Repair for Peripheral Nerve Injuries Using
Synthetic Conduits or Allografts, 7.01.584
Now requires review for investigative and
prior authorization.
64910, 64912, 64913
Nerve Repair for Peripheral Nerve Injuries Using
Synthetic Conduits or Allografts, 7.01.584
Now requires review for investigative.
C9352, C9353, C9355, C9361
Pharmacologic Treatment of Duchenne Muscular Dystrophy,
5.01.570
Now requires review for medical necessity
and prior authorization.
J1426
Pharmacologic Treatment of High Cholesterol, 5.01.558
Now requires review for medical necessity
and prior authorization.
J1305
Radioembolization for Primary and Metastatic Tumors of
the Liver, 8.01.43
Now requires review for medical necessity.
C2616
Revised codes
Effective October 1, 2021
Diagnosis and Treatment of Sacroiliac Joint Pain,
6.01.527
Now requires review for investigative and
prior authorization.
27280
Removed codes
Effective October 1, 2021
Amniotic
Membrane and Amniotic Fluid, 7.01.583
No longer requires review for investigative.
Q4228, Q4236
Chimeric
Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63
No longer requires review for investigative.
C9076
Cutaneous
T-Cell Lymphomas (CTCL): Systemic Therapies, 5.01.532
No longer requires review for medical
necessity.
C9065
Cutaneous
T-Cell Lymphomas (CTCL): Systemic Therapies, 5.01.532
No longer requires review for medical
necessity and prior authorization.
J9315
Diagnosis
and Treatment of Sacroiliac Joint Pain, 6.01.527
No longer requires review for investigative.
64451
In Vitro
Chemoresistance and Chemosensitivity Assays, 2.03.01
No longer requires review for investigative.
Policy archived.
81535, 81536
Miscellaneous
Oncology Drugs, 5.01.540
No longer requires review for medical
necessity and prior authorization.
J9280
Miscellaneous
Oncology Drugs, 5.01.540
No longer requires review for medical
necessity.
C9078, C9080
Pharmacologic
Treatment of Duchenne Muscular Dystrophy, 5.01.570
No longer requires review for medical
necessity.
C9075
Pharmacologic
Treatment of High Cholesterol, 5.01.558
No longer requires review for medical
necessity.
C9079