07-26-2025 Healthcare Service Codes Preauthorization Search Results 8:01:01 AM

[1 to 5392 of 5392] BACK TO SEARCH   Code Description Preauthorization Required Effective Date End Date Notes Primary Criteria Secondary Criteria   40843 VESTIBULOPLASTY; POSTERIOR, BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     41874 ALVEOLOPLASTY, EACH QUADRANT (SPECIFY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40652 REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40654 REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40700 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR COMPLETE, UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40702 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 1 OF 2 STAGES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40720 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY RECREATION OF DEFECT AND RECLOSURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40761 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; WITH CROSS LIP PEDICLE FLAP (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND INSERTING OF PEDICLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40799 UNLISTED PROCEDURE, LIPS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40530 RESECTION OF LIP, MORE THAN ONE-FOURTH, WITHOUT RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40842 VESTIBULOPLASTY; POSTERIOR, UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40527 EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH CROSS LIP FLAP (ABBE-ESTLANDER) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40844 VESTIBULOPLASTY; ENTIRE ARCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40845 VESTIBULOPLASTY; COMPLEX (INCLUDING RIDGE EXTENSION, MUSCLE REPOSITIONING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40899 UNLISTED PROCEDURE, VESTIBULE OF MOUTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     41512 TONGUE BASE SUSPENSION, PERMANENT SUTURE TECHNIQUE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   41530 SUBMUCOSAL ABLATION OF THE TONGUE BASE, RADIOFREQUENCY, 1 OR MORE SITES, PER SESSION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   41828 EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH QUADRANT (SPECIFY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     41830 ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR SEQUESTRECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38209 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; THAWING OF PREVIOUSLY FROZEN HARVEST, WITH WASHING, PER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40840 VESTIBULOPLASTY; ANTERIOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38232 BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4182 TRANSCYTE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   38211 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; TUMOR CELL DEPLETION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38212 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; RED BLOOD CELL REMOVAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38213 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; PLATELET DEPLETION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38214 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; PLASMA (VOLUME) DEPLETION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38215 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; CELL CONCENTRATION IN PLASMA, MONONUCLEAR, OR BUFFY COAT LAYER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38225 CHIMERIC ANTIGEN RECEPTOR T-CELL (CAR-T) THERAPY; HARVESTING OF BLOOD-DERIVED T LYMPHOCYTES FOR DEVELOPMENT OF GENETICALLY MODIFIED AUTOLOGOUS CAR-T CELLS, PER DAY Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     38226 CHIMERIC ANTIGEN RECEPTOR T-CELL (CAR-T) THERAPY; PREPARATION OF BLOOD-DERIVED T LYMPHOCYTES FOR TRANSPORTATION (EG, CRYOPRESERVATION, STORAGE) Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     40650 REPAIR LIP, FULL THICKNESS; VERMILION ONLY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38228 CHIMERIC ANTIGEN RECEPTOR T-CELL (CAR-T) THERAPY; CAR-T CELL ADMINISTRATION, AUTOLOGOUS Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     41899 UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38240 HEMATOPOIETIC PROGENITOR CELL (HPC); ALLOGENEIC TRANSPLANTATION PER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38241 HEMATOPOIETIC PROGENITOR CELL (HPC); AUTOLOGOUS TRANSPLANTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38242 ALLOGENEIC LYMPHOCYTE INFUSIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38243 HEMATOPOIETIC PROGENITOR CELL (HPC); HPC BOOST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38308 LYMPHANGIOTOMY OR OTHER OPERATIONS ON LYMPHATIC CHANNELS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   40510 EXCISION OF LIP; TRANSVERSE WEDGE EXCISION WITH PRIMARY CLOSURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40520 EXCISION OF LIP; V-EXCISION WITH PRIMARY DIRECT LINEAR CLOSURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     40525 EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH LOCAL FLAP (EG, ESTLANDER OR FAN) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38227 CHIMERIC ANTIGEN RECEPTOR T-CELL (CAR-T) THERAPY; RECEIPT AND PREPARATION OF CAR-T CELLS FOR ADMINISTRATION Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     47136 LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     41872 GINGIVOPLASTY, EACH QUADRANT (SPECIFY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     44133 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; PARTIAL, FROM LIVING DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     44135 INTESTINAL ALLOTRANSPLANTATION; FROM CADAVER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     44136 INTESTINAL ALLOTRANSPLANTATION; FROM LIVING DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     44137 REMOVAL OF TRANSPLANTED INTESTINAL ALLOGRAFT, COMPLETE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     44799 UNLISTED PROCEDURE, SMALL INTESTINE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     46220 EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     46230 EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     43999 UNLISTED PROCEDURE, STOMACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47135 LIVER ALLOTRANSPLANTATION, ORTHOTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     43845 GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   47140 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING DONOR; LEFT LATERAL SEGMENT ONLY (SEGMENTS II AND III) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47141 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING DONOR; TOTAL LEFT LOBECTOMY (SEGMENTS II, III AND IV) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47142 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING DONOR; TOTAL RIGHT LOBECTOMY (SEGMENTS V, VI, VII AND VIII) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47143 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMMON BILE DUCT FOR IMPLANTATION; WITHOUT TRISEGMENT OR LOBE SPLIT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47144 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMMON BILE DUCT FOR IMPLANTATION; WITH TRISEGMENT SPLIT OF WHOLE LIVER GRAFT INTO 2 PARTIAL LIVER GRAFTS (IE, LEFT LATERAL SEGMENT [SEGMENTS II AND III] AND RIGHT TRISEGMENT [SEGMENTS I AND IV THROUGH VIII]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47145 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMMON BILE DUCT FOR IMPLANTATION; WITH LOBE SPLIT OF WHOLE LIVER GRAFT INTO 2 PARTIAL LIVER GRAFTS (IE, LEFT LOBE [SEGMENTS II, III, AND IV] AND RIGHT LOBE [SEGMENTS I AND V THROUGH VIII]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47146 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER GRAFT PRIOR TO ALLOTRANSPLANTATION; VENOUS ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47147 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER GRAFT PRIOR TO ALLOTRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     46707 REPAIR OF ANORECTAL FISTULA WITH PLUG (EG, PORCINE SMALL INTESTINE SUBMUCOSA [SIS]) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   43631 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTRODUODENOSTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   42200 PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42205 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; SOFT TISSUE ONLY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42210 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; WITH BONE GRAFT TO ALVEOLAR RIDGE (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42215 PALATOPLASTY FOR CLEFT PALATE; MAJOR REVISION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42220 PALATOPLASTY FOR CLEFT PALATE; SECONDARY LENGTHENING PROCEDURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42225 PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     42260 REPAIR OF NASOLABIAL FISTULA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     43284 LAPAROSCOPY, SURGICAL, ESOPHAGEAL SPHINCTER AUGMENTATION PROCEDURE, PLACEMENT OF SPHINCTER AUGMENTATION DEVICE (IE, MAGNETIC BAND), INCLUDING CRUROPLASTY WHEN PERFORMED Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   44132 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; FROM CADAVER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     43622 GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   38208 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; THAWING OF PREVIOUSLY FROZEN HARVEST, WITHOUT WASHING, PER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     43632 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTROJEJUNOSTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   43633 GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   43634 GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL POUCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   43647 LAPAROSCOPY, SURGICAL; IMPLANTATION OR REPLACEMENT OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   43648 LAPAROSCOPY, SURGICAL; REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   43659 UNLISTED LAPAROSCOPY PROCEDURE, STOMACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     43621 GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   V5259 HEARING AID, DIGITAL, BINAURAL, ITC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5271 ASSISTIVE LISTENING DEVICE, TELEVISION CAPTION DECODER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5250 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, CIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5251 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, ITC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5252 HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, ITE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5253 HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, BTE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5254 HEARING AID, DIGITAL, MONAURAL, CIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5255 HEARING AID, DIGITAL, MONAURAL, ITC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5256 HEARING AID, DIGITAL, MONAURAL, ITE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5248 HEARING AID, ANALOG, BINAURAL, CIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5258 HEARING AID, DIGITAL, BINAURAL, CIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5247 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5260 HEARING AID, DIGITAL, BINAURAL, ITE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5261 HEARING AID, DIGITAL, BINAURAL, BTE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5262 HEARING AID, DISPOSABLE, ANY TYPE, MONAURAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5263 HEARING AID, DISPOSABLE, ANY TYPE, BINAURAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5267 HEARING AID OR ASSISTIVE LISTENING DEVICE/SUPPLIES/ACCESSORIES, NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5268 ASSISTIVE LISTENING DEVICE, TELEPHONE AMPLIFIER, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5269 ASSISTIVE LISTENING DEVICE, ALERTING, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38210 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; SPECIFIC CELL DEPLETION WITHIN HARVEST, T-CELL DEPLETION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5257 HEARING AID, DIGITAL, MONAURAL, BTE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5190 HEARING AID, CONTRALATERAL ROUTING, MONAURAL, GLASSES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63706 REPAIR OF MYELOMENINGOCELE; LARGER THAN 5 CM DIAMETER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4184 CELLESTA OR CELLESTA DUO, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4185 CELLESTA FLOWABLE AMNION (25 MG PER CC); PER 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4187 EPICORD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4188 AMNIOARMOR, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4189 ARTACENT AC, 1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4190 ARTACENT AC, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4191 RESTORIGIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   V5249 HEARING AID, ANALOG, BINAURAL, ITC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5180 HEARING AID, CROS, BEHIND THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5272 ASSISTIVE LISTENING DEVICE, TDD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5210 HEARING AID, BICROS, IN THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5220 HEARING AID, BICROS, BEHIND THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5230 HEARING AID, CONTRALATERAL ROUTING SYSTEM, BINAURAL, GLASSES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5242 HEARING AID, ANALOG, MONAURAL, CIC (COMPLETELY IN THE EAR CANAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5243 HEARING AID, ANALOG, MONAURAL, ITC (IN THE CANAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5244 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, CIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5245 HEARING AID, DIGITALLY PROGRAMMABLE, ANALOG, MONAURAL, ITC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5246 HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4192 RESTORIGIN, 1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5270 ASSISTIVE LISTENING DEVICE, TELEVISION AMPLIFIER, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37719 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37761 LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36479 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37766 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37799 UNLISTED PROCEDURE, VASCULAR SURGERY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37917 REPAIR OF ECTROPION; EXTENSIVE (E.G. TARSAL STRIP OPERATIONS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38204 MANAGEMENT OF RECIPIENT HEMATOPOIETIC PROGENITOR CELL DONOR SEARCH AND CELL ACQUISITION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38205 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION, PER COLLECTION; ALLOGENEIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38206 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION, PER COLLECTION; AUTOLOGOUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     38207 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; CRYOPRESERVATION AND STORAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37765 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5289 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM ADAPTER/BOOT COUPLING DEVICE FOR RECEIVER, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5273 ASSISTIVE LISTENING DEVICE, FOR USE WITH COCHLEAR IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5274 ASSISTIVE LISTENING DEVICE, NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5281 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM SYSTEM, MONAURAL, (1 RECEIVER, TRANSMITTER, MICROPHONE), ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5282 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM SYSTEM, BINAURAL, (2 RECEIVERS, TRANSMITTER, MICROPHONE), ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5283 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM NECK, LOOP INDUCTION RECEIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5284 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM, EAR LEVEL RECEIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5285 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM, DIRECT AUDIO INPUT RECEIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5286 ASSISTIVE LISTENING DEVICE, PERSONAL BLUE TOOTH FM/DM RECEIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     37500 VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5288 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM TRANSMITTER ASSISTIVE LISTENING DEVICE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47399 UNLISTED PROCEDURE, LIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36465 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 (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36466 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 (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN), SAME LEG Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36470 INJECTION OF SCLEROSANT; SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36471 INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36473 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   36474 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) Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     36476 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5287 ASSISTIVE LISTENING DEVICE, PERSONAL FM/DM RECEIVER, NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63030 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63267 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63001 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63003 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63005 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63011 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63012 LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS WITH DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LUMBAR (GILL TYPE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63015 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63016 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62365 REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63020 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62362 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     63198 INCISE SPINAL COLUMN & CORD, NECK Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63199 INCISE SPINAL COLUMN & CORD, THORAX Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63200 LAMINECTOMY, WITH RELEASE OF TETHERED SPINAL CORD, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63250 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63251 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63252 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACOLUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63265 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47381 ABLATION, OPEN, OF 1 OR MORE LIVER TUMOR(S); CRYOSURGICAL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   63017 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62280 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; SUBARACHNOID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   62282 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   62284 INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62287 DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, ANY METHOD UTILIZING NEEDLE BASED TECHNIQUE TO REMOVE DISC MATERIAL UNDER FLUOROSCOPIC IMAGING OR OTHER FORM OF INDIRECT VISUALIZATION, WITH DISCOGRAPHY AND/OR EPIDURAL INJECTION(S) AT THE TREATED LEVEL(S), WHEN PERFORMED, SINGLE OR MULTIPLE LEVELS, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE Yes 8/15/2018     InterQual® Evidence-Based Criteria & Guidelines     62321 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62380 ENDOSCOPIC DECOMPRESSION OF SPINAL CORD, NERVE ROOT(S), INCLUDING LAMINOTOMY, PARTIAL FACETECTOMY, FORAMINOTOMY, DISCECTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, 1 INTERSPACE, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62323 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63268 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62325 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62326 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62327 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62350 IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62351 IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62355 REMOVAL OF PREVIOUSLY IMPLANTED INTRATHECAL OR EPIDURAL CATHETER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62360 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62361 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62322 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE Yes 8/15/2018     InterQual® Evidence-Based Criteria & Guidelines     63661 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63266 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63305 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY TRANSTHORACIC APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63306 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY THORACOLUMBAR APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63307 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63308 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODES FOR SINGLE SEGMENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63600 CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, PERCUTANEOUS, ANY MODALITY (INCLUDING STIMULATION AND/OR RECORDING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63610 STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, SEPARATE PROCEDURE NOT FOLLOWED BY OTHER SURGERY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63615 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION OF LESION, SPINAL CORD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63303 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63655 LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63302 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY THORACOLUMBAR APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63662 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63663 REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63664 REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63685 INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63688 REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63700 REPAIR OF MENINGOCELE; LESS THAN 5 CM DIAMETER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63702 REPAIR OF MENINGOCELE; LARGER THAN 5 CM DIAMETER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22633 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63650 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63282 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, EXTRAMEDULLARY, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63270 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63271 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63272 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63273 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63275 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63276 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63277 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63278 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63304 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63281 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, EXTRAMEDULLARY, THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62269 BIOPSY OF SPINAL CORD, PERCUTANEOUS NEEDLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63283 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63285 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, INTRAMEDULLARY, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63286 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, INTRAMEDULLARY, THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63287 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, INTRAMEDULLARY, THORACOLUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63290 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; COMBINED EXTRADURAL-INTRADURAL LESION, ANY LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63295 OSTEOPLASTIC RECONSTRUCTION OF DORSAL SPINAL ELEMENTS, FOLLOWING PRIMARY INTRASPINAL PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63300 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63301 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY TRANSTHORACIC APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63280 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, EXTRAMEDULLARY, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     53431 URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA AND/OR LOWER BLADDER FOR INCONTINENCE (EG, TENAGO, LEADBETTER PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62272 SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER); Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50547 LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50548 LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     51020 CYSTOTOMY OR CYSTOSTOMY, WITH FULGURATION AND/OR INSERTION OF RADIOACTIVE MATERIAL Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   51715 ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     52284 CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   53400 URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (EG, JOHANNSEN TYPE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     53405 URETHROPLASTY; SECOND STAGE (FORMATION OF URETHRA), INCLUDING URINARY DIVERSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     50380 RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     53520 CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE (SEPARATE PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     53854 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY RADIOFREQUENCY GENERATED WATER VAPOR THERMOTHERAPY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   54120 AMPUTATION OF PENIS; PARTIAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     54125 AMPUTATION OF PENIS; COMPLETE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE; Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   54235 INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) (EG, PAPAVERINE, PHENTOLAMINE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     54300 PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     54304 PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR FIRST STAGE HYPOSPADIAS REPAIR WITH OR WITHOUT TRANSPLANTATION OF PREPUCE AND/OR SKIN FLAPS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     53410 URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     50320 DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); OPEN, FROM LIVING DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4181 AMNIO WOUND, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   48160 PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH AUTOLOGOUS TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLET CELLS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48550 DONOR PANCREATECTOMY (INCLUDING COLD PRESERVATION), WITH OR WITHOUT DUODENAL SEGMENT FOR TRANSPLANTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48551 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR PANCREAS ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES, SPLENECTOMY, DUODENOTOMY, LIGATION OF BILE DUCT, LIGATION OF MESENTERIC VESSELS, AND Y-GRAFT ARTERIAL ANASTOMOSES FROM ILIAC ARTERY TO SUPERIOR MESENTERIC ARTERY AND TO SPLENIC ARTERY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48552 BACKBENCH RECONSTRUCTION OF CADAVER DONOR PANCREAS ALLOGRAFT PRIOR TO TRANSPLANTATION, VENOUS ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48556 REMOVAL OF TRANSPLANTED PANCREATIC ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     48999 UNLISTED PROCEDURE, PANCREAS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50546 LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50300 DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); FROM CADAVER DONOR, UNILATERAL OR BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     54417 REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     50323 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR RENAL ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION AND REMOVAL OF PERINEPHRIC FAT, DIAPHRAGMATIC AND RETROPERITONEAL ATTACHMENTS, EXCISION OF ADRENAL GLAND, AND PREPARATION OF URETER(S), RENAL VEIN(S), AND RENAL ARTERY(S), LIGATING BRANCHES, AS NECESSARY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50325 BACKBENCH STANDARD PREPARATION OF LIVING DONOR RENAL ALLOGRAFT (OPEN OR LAPAROSCOPIC) PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION AND REMOVAL OF PERINEPHRIC FAT AND PREPARATION OF URETER(S), RENAL VEIN(S), AND RENAL ARTERY(S), LIGATING BRANCHES, AS NECESSARY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50327 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50328 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL ALLOGRAFT PRIOR TO TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50329 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL ALLOGRAFT PRIOR TO TRANSPLANTATION; URETERAL ANASTOMOSIS, EACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITHOUT RECIPIENT NEPHRECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITH RECIPIENT NEPHRECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     49999 UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     61583 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; INTRADURAL, INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OR RESECTION OF FRONTAL LOBE, OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59851 INDUCED ABORTION, BY 1 OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH DILATION AND CURETTAGE AND/OR EVACUATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59852 INDUCED ABORTION, BY 1 OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAILED INTRA-AMNIOTIC INJECTION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59855 INDUCED ABORTION, BY 1 OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59856 INDUCED ABORTION, BY 1 OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH DILATION AND CURETTAGE AND/OR EVACUATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59857 INDUCED ABORTION, BY 1 OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAILED MEDICAL EVACUATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     60512 PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     61330 DECOMPRESSION OF ORBIT ONLY, TRANSCRANIAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     61580 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING LATERAL RHINOTOMY, ETHMOIDECTOMY, SPHENOIDECTOMY, WITHOUT MAXILLECTOMY OR ORBITAL EXENTERATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     54336 1-STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     61582 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OF FRONTAL LOBE(S), OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     59840 INDUCED ABORTION, BY DILATION AND CURETTAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     61889 INSERTION OF SKULL-MOUNTED CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, INCLUDING CRANIECTOMY OR CRANIOTOMY, WHEN PERFORMED, WITH DIRECT OR INDUCTIVE COUPLING, WITH CONNECTION TO DEPTH AND/OR CORTICAL STRIP ELECTRODE ARRAY(S) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     61891 REVISION OR REPLACEMENT OF SKULL-MOUNTED CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER WITH CONNECTION TO DEPTH AND/OR CORTICAL STRIP ELECTRODE ARRAY(S) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     61892 REMOVAL OF SKULL-MOUNTED CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER WITH CRANIOPLASTY, WHEN PERFORMED Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     62263 PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   62264 PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   62267 PERCUTANEOUS ASPIRATION WITHIN THE NUCLEUS PULPOSUS, INTERVERTEBRAL DISC, OR PARAVERTEBRAL TISSUE FOR DIAGNOSTIC PURPOSES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     62268 PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     47383 ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, CRYOABLATION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   61581 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING LATERAL RHINOTOMY, ORBITAL EXENTERATION, ETHMOIDECTOMY, SPHENOIDECTOMY AND/OR MAXILLECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     57106 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     54520 ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     55150 RESECTION OF SCROTUM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     55175 SCROTOPLASTY; SIMPLE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     55180 SCROTOPLASTY; COMPLICATED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     55706 BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   59850 INDUCED ABORTION, BY 1 OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     56625 VULVECTOMY SIMPLE; COMPLETE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     59841 INDUCED ABORTION, BY DILATION AND EVACUATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     57107 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     57109 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     57110 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   57111 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     57282 COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     57292 CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   58674 LAPAROSCOPY, SURGICAL, ABLATION OF UTERINE FIBROID(S) INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     54400 INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document)     55874 TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   28299 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     29868 ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR LATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27703 ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27715 OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING OR SHORTENING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28285 CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28286 CORRECTION, COCK-UP FIFTH TOE, WITH PLASTIC SKIN CLOSURE (EG, RUIZ-MORA TYPE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28292 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28295 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28296 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27700 ARTHROPLASTY, ANKLE; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28298 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27488 REMOVAL OF PROSTHESIS, INCLUDING TOTAL KNEE PROSTHESIS, METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER, KNEE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28344 RECONSTRUCTION, TOE(S); POLYDACTYLY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28345 RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH OR WITHOUT SKIN GRAFT(S), EACH WEB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     28890 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 Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   28899 UNLISTED PROCEDURE, FOOT OR TOES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     29800 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     29804 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     29866 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF THE AUTOGRAFT[S]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27278 ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS, WITH IMAGE GUIDANCE, INCLUDING PLACEMENT OF INTRA-ARTICULAR IMPLANT(S) (EG, BONE ALLOGRAFT[S], SYNTHETIC DEVICE[S]), WITHOUT PLACEMENT OF TRANSFIXATION DEVICE Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     28297 CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27443 ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; WITH DEBRIDEMENT AND PARTIAL SYNOVECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4183 SURGIGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   27280 ARTHRODESIS, SACROILIAC JOINT, OPEN, INCLUDES OBTAINING BONE GRAFT, INCLUDING INSTRUMENTATION, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27415 OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27416 OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   27437 ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27438 ARTHROPLASTY, PATELLA; WITH PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27440 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27702 ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27442 ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     30120 EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR RHINOPHYMA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27445 ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG, WALLDIUS TYPE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27446 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27447 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27465 OSTEOPLASTY, FEMUR; SHORTENING (EXCLUDING 64876) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27466 OSTEOPLASTY, FEMUR; LENGTHENING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27468 OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING AND SHORTENING WITH FEMORAL SEGMENT TRANSFER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27486 REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27487 REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27441 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH DEBRIDEMENT AND PARTIAL SYNOVECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33928 REMOVAL AND REPLACEMENT OF TOTAL REPLACEMENT HEART SYSTEM (ARTIFICIAL HEART) Yes 8/15/2018     InterQual® Evidence-Based Criteria & Guidelines     29867 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33277 INSERTION OF PHRENIC NERVE STIMULATOR TRANSVENOUS SENSING LEAD (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33278 REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; SYSTEM, INCLUDING PULSE GENERATOR AND LEAD(S) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33279 REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; TRANSVENOUS STIMULATION OR SENSING LEAD(S) ONLY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33280 REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; PULSE GENERATOR ONLY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33281 REPOSITIONING OF PHRENIC NERVE STIMULATOR TRANSVENOUS LEAD(S) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33287 REMOVAL AND REPLACEMENT OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; PULSE GENERATOR Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33288 REMOVAL AND REPLACEMENT OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; TRANSVENOUS STIMULATION OR SENSING LEAD(S) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     33266 ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   33927 IMPLANTATION OF A TOTAL REPLACEMENT HEART SYSTEM (ARTIFICIAL HEART) WITH RECIPIENT CARDIECTOMY Yes 8/15/2018     InterQual® Evidence-Based Criteria & Guidelines     33265 ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED (EG, MODIFIED MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   33929 REMOVAL OF A TOTAL REPLACEMENT HEART SYSTEM (ARTIFICIAL HEART) FOR HEART TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 8/15/2018     InterQual® Evidence-Based Criteria & Guidelines     33930 DONOR CARDIECTOMY-PNEUMONECTOMY (INCLUDING COLD PRESERVATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33933 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR HEART/LUNG ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE AORTA, SUPERIOR VENA CAVA, INFERIOR VENA CAVA, AND TRACHEA FOR IMPLANTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33935 HEART-LUNG TRANSPLANT WITH RECIPIENT CARDIECTOMY-PNEUMONECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33940 DONOR CARDIECTOMY (INCLUDING COLD PRESERVATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33944 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR HEART ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE AORTA, SUPERIOR VENA CAVA, INFERIOR VENA CAVA, PULMONARY ARTERY, AND LEFT ATRIUM FOR IMPLANTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33945 HEART TRANSPLANT, WITH OR WITHOUT RECIPIENT CARDIECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33990 INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LEFT HEART, ARTERIAL ACCESS ONLY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   33548 SURGICAL VENTRICULAR RESTORATION PROCEDURE, INCLUDES PROSTHETIC PATCH, WHEN PERFORMED (EG, VENTRICULAR REMODELING, SVR, SAVER, DOR PROCEDURES) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   31660 BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 1 LOBE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   30130 EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     30140 SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     30150 RHINECTOMY; PARTIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     30160 RHINECTOMY; TOTAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     30469 REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   30801 ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   30802 ABLATION, SOFT TISSUE OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   30999 UNLISTED PROCEDURE, NOSE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33276 INSERTION OF PHRENIC NERVE STIMULATOR SYSTEM (PULSE GENERATOR AND STIMULATING LEAD[S]), INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND PULSE GENERATOR INITIAL ANALYSIS WITH DIAGNOSTIC MODE ACTIVATION, WHEN PERFORMED Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     31243 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY CRYOABLATION, POSTERIOR NASAL NERVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   27138 REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     31661 BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 2 OR MORE LOBES Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   32850 DONOR PNEUMONECTOMY(S) (INCLUDING COLD PRESERVATION), FROM CADAVER DONOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32851 LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOPULMONARY BYPASS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32852 LUNG TRANSPLANT, SINGLE; WITH CARDIOPULMONARY BYPASS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32853 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); WITHOUT CARDIOPULMONARY BYPASS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32854 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); WITH CARDIOPULMONARY BYPASS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32856 BACKBENCH STANDARD PREPARATION OF CADAVER DONOR LUNG ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE PULMONARY VENOUS/ATRIAL CUFF, PULMONARY ARTERY, AND BRONCHUS; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     32999 UNLISTED PROCEDURE, LUNGS AND PLEURA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     31242 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DESTRUCTION BY RADIOFREQUENCY ABLATION, POSTERIOR NASAL NERVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22860 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SECOND INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     22890 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; 1 OR MORE ADDITIONAL LEVELS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22849 REINSERTION OF SPINAL FIXATION DEVICE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22850 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22853 INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22854 INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO VERTEBRAL CORPECTOMY(IES) (VERTEBRAL BODY RESECTION, PARTIAL OR COMPLETE) DEFECT, IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22855 REMOVAL OF ANTERIOR INSTRUMENTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22856 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22857 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22847 ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22859 INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22846 ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22861 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22862 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22864 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22865 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22867 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22868 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22869 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT OPEN DECOMPRESSION OR FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, LUMBAR; SINGLE LEVEL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   27279 ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXING DEVICE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22858 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22836 ANTERIOR THORACIC VERTEBRAL BODY TETHERING, INCLUDING THORACOSCOPY, WHEN PERFORMED; UP TO 7 VERTEBRAL SEGMENTS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97550 CAREGIVER TRAINING IN STRATEGIES AND TECHNIQUES TO FACILITATE THE PATIENT'S FUNCTIONAL PERFORMANCE IN THE HOME OR COMMUNITY (EG, ACTIVITIES OF DAILY LIVING [ADLS], INSTRUMENTAL ADLS [IADLS], TRANSFERS, MOBILITY, COMMUNICATION, SWALLOWING, FEEDING, PROBLEM SOLVING, SAFETY PRACTICES) (WITHOUT THE PATIENT PRESENT), FACE TO FACE; INITIAL 30 MINUTES Yes 9/1/2024   For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). Authorization required for all visits pertaining to Speech Therapy. InterQual® Evidence-Based Criteria & Guidelines     22800 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; UP TO 6 VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22802 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 7 TO 12 VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22804 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 13 OR MORE VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22808 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22810 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 4 TO 7 VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22812 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 8 OR MORE VERTEBRAL SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22818 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); SINGLE OR 2 SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22848 PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22830 EXPLORATION OF SPINAL FUSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22899 UNLISTED PROCEDURE, SPINE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22837 ANTERIOR THORACIC VERTEBRAL BODY TETHERING, INCLUDING THORACOSCOPY, WHEN PERFORMED; 8 OR MORE VERTEBRAL SEGMENTS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22838 REVISION (EG, AUGMENTATION, DIVISION OF TETHER), REPLACEMENT, OR REMOVAL OF THORACIC VERTEBRAL BODY TETHERING, INCLUDING THORACOSCOPY, WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22841 INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22842 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22843 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22844 POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 13 OR MORE VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22845 ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22819 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); 3 OR MORE SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     26485 TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITHOUT FREE TENDON GRAFT, EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22870 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT OPEN DECOMPRESSION OR FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, LUMBAR; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   25444 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25445 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25446 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS AND PARTIAL OR ENTIRE CARPUS (TOTAL WRIST) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25447 ARTHROPLASTY, INTERPOSITION, INTERCARPAL OR CARPOMETACARPAL JOINTS (E.G. TENDON) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25449 REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, WRIST JOINT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25450 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS OR ULNA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25455 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS AND ULNA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25442 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL ULNA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     26483 TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25441 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     26489 TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27080 COCCYGECTOMY, PRIMARY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27125 HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27130 ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27132 CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27134 REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     27137 REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     26480 TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     24470 HEMIEPIPHYSEAL ARREST (EG, CUBITUS VARUS OR VALGUS, DISTAL HUMERUS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22999 UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     23440 RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     23470 ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     23472 ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     23473 REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     23474 REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     24363 ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     24370 REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR ULNAR COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25443 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID CARPAL (NAVICULAR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     24420 OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENING) (EXCLUDING 64876) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33993 REPOSITIONING OF PERCUTANEOUS RIGHT OR LEFT HEART VENTRICULAR ASSIST DEVICE WITH IMAGING GUIDANCE AT SEPARATE AND DISTINCT SESSION FROM INSERTION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   25310 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25312 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; WITH TENDON GRAFT(S) (INCLUDES OBTAINING GRAFT), EACH TENDON Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25332 ARTHROPLASTY, WRIST, WITH OR WITHOUT INTERPOSITION, WITH OR WITHOUT EXTERNAL OR INTERNAL FIXATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25390 OSTEOPLASTY, RADIUS OR ULNA; SHORTENING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25391 OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25392 OSTEOPLASTY, RADIUS AND ULNA; SHORTENING (EXCLUDING 64876) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25393 OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUTOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     25394 OSTEOPLASTY, CARPAL BONE, SHORTENING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     24371 REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND ULNAR COMPONENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J9150 INJECTION, DAUNORUBICIN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L3649 ORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     J9075 INJECTION, CYCLOPHOSPHAMIDE, NOT OTHERWISE SPECIFIED, 5 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9076 INJECTION, CYCLOPHOSPHAMIDE (BAXTER), 5 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9098 INJECTION, CYTARABINE LIPOSOME, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9100 INJECTION, CYTARABINE, 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9119 INJECTION, CEMIPLIMAB-RWLC, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9120 INJECTION, DACTINOMYCIN, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9130 DACARBAZINE, 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9073 INJECTION, CYCLOPHOSPHAMIDE (INGENUS), 5 MG Yes 11/26/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9145 INJECTION, DARATUMUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9072 INJECTION, CYCLOPHOSPHAMIDE (AVYXA), 5 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9151 INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9155 INJECTION, DEGARELIX, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9161 INJECTION, DENILEUKIN DIFTITOX-CXDL, 1 MCG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     33991 INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LEFT HEART, BOTH ARTERIAL AND VENOUS ACCESS, WITH TRANSSEPTAL PUNCTURE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J9144 INJECTION, DARATUMUMAB, 10 MG AND HYALURONIDASE-FIHJ Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1229 WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1230 POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9074 INJECTION, CYCLOPHOSPHAMIDE (SANDOZ), 5 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L3650 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     J9056 INJECTION, BENDAMUSTINE HYDROCHLORIDE (VIVIMUSTA), 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9058 INJECTION, BENDAMUSTINE HYDROCHLORIDE (APOTEX), 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9059 INJECTION, BENDAMUSTINE HYDROCHLORIDE (BAXTER), 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9060 INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9061 INJECTION, AMIVANTAMAB-VMJW, 2 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9063 INJECTION, MIRVETUXIMAB SORAVTANSINE-GYNX, 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9065 INJECTION, CLADRIBINE, PER 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9070 CYCLOPHOSPHAMIDE, 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q4171 INTERFYL, 1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT (RIVETON), BOTH SHOES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4161 BIO-CONNEKT WOUND MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4162 WOUNDEX FLOW, BIOSKIN FLOW, 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4163 WOUNDEX, BIOSKIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4164 HELICOLL, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4165 KERAMATRIX OR KERASORB, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4166 CYTAL, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4167 TRUSKIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4159 AFFINITY, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4170 CYGNUS, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4158 KERECIS OMEGA3, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4173 PALINGEN OR PALINGEN XPLUS, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4174 PALINGEN OR PROMATRX, 0.36 MG PER 0.25 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4175 MIRODERM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4176 NEOPATCH OR THERION, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4177 FLOWERAMNIOFLO, 0.1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4178 FLOWERAMNIOPATCH, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4179 FLOWERDERM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4180 REVITA, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4169 ARTACENT WOUND, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L3740 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3660 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND WEBBING, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3670 SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3671 SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3674 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3675 SHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OR EQUAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3677 SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3702 ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3710 ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4160 NUSHIELD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L3730 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     E1224 WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L3760 ELBOW ORTHOSIS (EO), WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED, ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4151 AMNIOBAND OR GUARDIAN, PER SQUARE CENTIMETER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4152 DERMAPURE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4153 DERMAVEST AND PLURIVEST, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4154 BIOVANCE, PER SQUARE CENTIMETER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4155 NEOXFLO OR CLARIXFLO, 1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4156 NEOX 100 OR CLARIX 100, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4157 REVITALON, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L3720 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     63091 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E1226 WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 DEGREES), EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     63077 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63078 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63081 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63082 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63085 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSTHORACIC APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); THORACIC, SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63086 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSTHORACIC APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); THORACIC, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63087 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63075 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63090 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63066 COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), THORACIC; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63101 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); THORACIC, SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63102 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); LUMBAR, SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63103 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); THORACIC OR LUMBAR, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63170 LAMINECTOMY WITH MYELOTOMY (EG, BISCHOF OR DREZ TYPE), CERVICAL, THORACIC, OR THORACOLUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63172 LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO SUBARACHNOID SPACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63173 LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO PERITONEAL OR PLEURAL SPACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63180 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; 1 OR 2 SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63182 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; MORE THAN 2 SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63088 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63048 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63707 REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK, NOT REQUIRING LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     33999 UNLISTED PROCEDURE, CARDIAC SURGERY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63035 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63040 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63042 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63043 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL CERVICAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63044 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63045 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63076 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63047 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63191 LAMINECTOMY WITH SECTION OF SPINAL ACCESSORY NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63050 LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63051 LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES [EG, WIRE, SUTURE, MINI-PLATES], WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63052 LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63053 LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63055 TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63056 TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63057 TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63064 COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), THORACIC; SINGLE SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63046 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E1180 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1110 SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEG REST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1130 STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1140 WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1150 WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1160 WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     63185 LAMINECTOMY WITH RHIZOTOMY; 1 OR 2 SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E1172 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) WITHOUT FOOTRESTS OR LEGREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1090 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOT RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1190 AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1195 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1200 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1220 WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED, (INDICATE BRAND NAME, MODEL NUMBER, IF ANY) AND JUSTIFICATION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1221 WHEELCHAIR WITH FIXED ARM, FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1222 WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1223 WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     33992 REMOVAL OF PERCUTANEOUS LEFT HEART VENTRICULAR ASSIST DEVICE, ARTERIAL OR ARTERIAL AND VENOUS CANNULA(S), AT SEPARATE AND DISTINCT SESSION FROM INSERTION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, WITHOUT FOOTRESTS OR LEGREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1060 FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1225 WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     63194 INCISE SPINAL COLUMN & CORD, NECK Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63195 INCISE SPINAL COLUMN & CORD, THORAX Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63196 INCISE SPINAL COLUMN & CORD, NECK Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63197 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 1 STAGE, THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E1036 MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, EXTRA-WIDE, WITH INTEGRATED SEAT, OPERATED BY CAREGIVER, PATIENT WEIGHT CAPACITY GREATER THAN 300 LBS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1037 TRANSPORT CHAIR, PEDIATRIC SIZE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1050 FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1092 WIDE HEAVY DUTY WHEEL CHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH), SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1070 FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1083 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG REST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1084 HEMI-WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1085 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOT RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1086 HEMI-WHEELCHAIR DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE FOOTRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1087 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1088 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEG RESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1089 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     63190 LAMINECTOMY WITH RHIZOTOMY; MORE THAN 2 SEGMENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     81363 HBB (HEMOGLOBIN, SUBUNIT BETA) (EG, SICKLE CELL ANEMIA, BETA THALASSEMIA, HEMOGLOBINOPATHY); DUPLICATION/DELETION VARIANT(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81407 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 8 (EG, ANALYSIS OF 26-50 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF >50 EXONS, SEQUENCE ANALYSIS OF MULTIPLE GENES ON ONE PLATFORM) ABCC8 (ATP-BINDING CASSETTE, SUB-FAMILY C [CFTR/MRP], MEMBER 8) (EG, FAMILIAL HYPERINSULINISM), FULL GENE SEQUENCE AGL (AMYLO-ALPHA-1, 6-GLUCOSIDASE, 4-ALPHA-GLUCANOTRANSFERASE) (EG, GLYCOGEN STORAGE DISEASE TYPE III), FULL GENE SEQUENCE AHI1 (ABELSON HELPER INTEGRATION SITE 1) (EG, JOUB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81343 PPP2R2B (PROTEIN PHOSPHATASE 2 REGULATORY SUBUNIT BBETA) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81344 TBP (TATA BOX BINDING PROTEIN) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81346 TYMS (THYMIDYLATE SYNTHETASE) (EG, 5-FLUOROURACIL/5-FU DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, TANDEM REPEAT VARIANT) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81349 CYTOGENOMIC (GENOME-WIDE) ANALYSIS FOR CONSTITUTIONAL CHROMOSOMAL ABNORMALITIES; INTERROGATION OF GENOMIC REGIONS FOR COPY NUMBER AND LOSS-OF-HETEROZYGOSITY VARIANTS, LOW-PASS SEQUENCING ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81350 UGT1A1 (UDP GLUCURONOSYLTRANSFERASE 1 FAMILY, POLYPEPTIDE A1) (EG, DRUG METABOLISM, HEREDITARY UNCONJUGATED HYPERBILIRUBINEMIA [GILBERT SYNDROME]) GENE ANALYSIS, COMMON VARIANTS (EG, *28, *36, *37) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81353 TP53 (TUMOR PROTEIN 53) (EG, LI-FRAUMENI SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, -1639G>A, C.173+1000C>T) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81341 TRB@ (T CELL ANTIGEN RECEPTOR, BETA) (EG, LEUKEMIA AND LYMPHOMA), GENE REARRANGEMENT ANALYSIS TO DETECT ABNORMAL CLONAL POPULATION(S); USING DIRECT PROBE METHODOLOGY (EG, SOUTHERN BLOT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81362 HBB (HEMOGLOBIN, SUBUNIT BETA) (EG, SICKLE CELL ANEMIA, BETA THALASSEMIA, HEMOGLOBINOPATHY); KNOWN FAMILIAL VARIANT(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81340 TRB@ (T CELL ANTIGEN RECEPTOR, BETA) (EG, LEUKEMIA AND LYMPHOMA), GENE REARRANGEMENT ANALYSIS TO DETECT ABNORMAL CLONAL POPULATION(S); USING AMPLIFICATION METHODOLOGY (EG, POLYMERASE CHAIN REACTION) Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81364 HBB (HEMOGLOBIN, SUBUNIT BETA) (EG, SICKLE CELL ANEMIA, BETA THALASSEMIA, HEMOGLOBINOPATHY); FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81400 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 1 (EG, IDENTIFICATION OF SINGLE GERMLINE VARIANT [EG, SNP] BY TECHNIQUES SUCH AS RESTRICTION ENZYME DIGESTION OR MELT CURVE ANALYSIS) ACADM (ACYL-COA DEHYDROGENASE, C-4 TO C-12 STRAIGHT CHAIN, MCAD) (EG, MEDIUM CHAIN ACYL DEHYDROGENASE DEFICIENCY), K304E VARIANT ACE (ANGIOTENSIN CONVERTING ENZYME) (EG, HEREDITARY BLOOD PRESSURE REGULATION), INSERTION/DELETION VARIANT AGTR1 (ANGIOTENSIN II RECEPTOR, TYPE 1) (EG, ESSENTIAL HYPERTENSION), 1166A>C VARIANT BCKDHA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81401 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 2 (EG, 2-10 SNPS, 1 METHYLATED VARIANT, OR 1 SOMATIC VARIANT [TYPICALLY USING NONSEQUENCING TARGET VARIANT ANALYSIS], OR DETECTION OF A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT) ABCC8 (ATP-BINDING CASSETTE, SUB-FAMILY C [CFTR/MRP], MEMBER 8) (EG, FAMILIAL HYPERINSULINISM), COMMON VARIANTS (EG, C.3898-9G>A [C.3992-9G>A], F1388DEL) ABL1 (ABL PROTO-ONCOGENE 1, NON-RECEPTOR TYROSINE KINASE) (EG, ACQUIRED IMATINIB RESISTANCE), T315I VARIANT ACADM (ACYL-COA DEHYDRO Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81402 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 3 (EG, >10 SNPS, 2-10 METHYLATED VARIANTS, OR 2-10 SOMATIC VARIANTS [TYPICALLY USING NON-SEQUENCING TARGET VARIANT ANALYSIS], IMMUNOGLOBULIN AND T-CELL RECEPTOR GENE REARRANGEMENTS, DUPLICATION/DELETION VARIANTS OF 1 EXON, LOSS OF HETEROZYGOSITY [LOH], UNIPARENTAL DISOMY [UPD]) CHROMOSOME 1P-/19Q- (EG, GLIAL TUMORS), DELETION ANALYSIS CHROMOSOME 18Q- (EG, D18S55, D18S58, D18S61, D18S64, AND D18S69) (EG, COLON CANCER), ALLELIC IMBALANCE ASSESSMENT (IE, LOSS OF Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4 (EG, ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, ANALYSIS OF >10 AMPLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 2-5 EXONS) ANG (ANGIOGENIN, RIBONUCLEASE, RNASE A FAMILY, 5) (EG, AMYOTROPHIC LATERAL SCLEROSIS), FULL GENE SEQUENCE ARX (ARISTALESS RELATED HOMEOBOX) (EG, X-LINKED LISSENCEPHALY WITH AMBIGUOUS GENITALIA, X-LINKED INTELLECTUAL DISABILITY), DUPLICATION/DELETION ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81404 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 5 (EG, ANALYSIS OF 2-5 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 6-10 EXONS, OR CHARACTERIZATION OF A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT BY SOUTHERN BLOT ANALYSIS) ACADS (ACYL-COA DEHYDROGENASE, C-2 TO C-3 SHORT CHAIN) (EG, SHORT CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY), TARGETED SEQUENCE ANALYSIS (EG, EXONS 5 AND 6) AQP2 (AQUAPORIN 2 [COLLECTING DUCT]) (EG, NEPHROGENIC DIABETES INSIPIDUS), FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81405 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 6 (EG, ANALYSIS OF 6-10 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 11-25 EXONS, REGIONALLY TARGETED CYTOGENOMIC ARRAY ANALYSIS) ABCD1 (ATP-BINDING CASSETTE, SUB-FAMILY D [ALD], MEMBER 1) (EG, ADRENOLEUKODYSTROPHY), FULL GENE SEQUENCE ACADS (ACYL-COA DEHYDROGENASE, C-2 TO C-3 SHORT CHAIN) (EG, SHORT CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY), FULL GENE SEQUENCE ACTA2 (ACTIN, ALPHA 2, SMOOTH MUSCLE, AORTA) (EG, THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81310 NPM1 (NUCLEOPHOSMIN) (EG, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, EXON 12 VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81361 HBB (HEMOGLOBIN, SUBUNIT BETA) (EG, SICKLE CELL ANEMIA, BETA THALASSEMIA, HEMOGLOBINOPATHY); COMMON VARIANT(S) (EG, HBS, HBC, HBE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81322 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME, PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81200 ASPA (ASPARTOACYLASE) (EG, CANAVAN DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, E285A, Y231X) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81312 PABPN1 (POLY[A] BINDING PROTEIN NUCLEAR 1) (EG, OCULOPHARYNGEAL MUSCULAR DYSTROPHY) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81313 PCA3/KLK3 (PROSTATE CANCER ANTIGEN 3 [NON-PROTEIN CODING]/KALLIKREIN-RELATED PEPTIDASE 3 [PROSTATE SPECIFIC ANTIGEN]) RATIO (EG, PROSTATE CANCER) Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81314 PDGFRA (PLATELET-DERIVED GROWTH FACTOR RECEPTOR, ALPHA POLYPEPTIDE) (EG, GASTROINTESTINAL STROMAL TUMOR [GIST]), GENE ANALYSIS, TARGETED SEQUENCE ANALYSIS (EG, EXONS 12, 18) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81315 PML/RARALPHA, (T(15;17)), (PROMYELOCYTIC LEUKEMIA/RETINOIC ACID RECEPTOR ALPHA) (EG, PROMYELOCYTIC LEUKEMIA) TRANSLOCATION ANALYSIS; COMMON BREAKPOINTS (EG, INTRON 3 AND INTRON 6), QUALITATIVE OR QUANTITATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81316 PML/RARALPHA, (T(15;17)), (PROMYELOCYTIC LEUKEMIA/RETINOIC ACID RECEPTOR ALPHA) (EG, PROMYELOCYTIC LEUKEMIA) TRANSLOCATION ANALYSIS; SINGLE BREAKPOINT (EG, INTRON 3, INTRON 6 OR EXON 6), QUALITATIVE OR QUANTITATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81317 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81318 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81342 TRG@ (T CELL ANTIGEN RECEPTOR, GAMMA) (EG, LEUKEMIA AND LYMPHOMA), GENE REARRANGEMENT ANALYSIS, EVALUATION TO DETECT ABNORMAL CLONAL POPULATION(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81321 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME, PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81408 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 9 (EG, ANALYSIS OF >50 EXONS IN A SINGLE GENE BY DNA SEQUENCE ANALYSIS) ABCA4 (ATP-BINDING CASSETTE, SUB-FAMILY A [ABC1], MEMBER 4) (EG, STARGARDT DISEASE, AGE-RELATED MACULAR DEGENERATION), FULL GENE SEQUENCE ATM (ATAXIA TELANGIECTASIA MUTATED) (EG, ATAXIA TELANGIECTASIA), FULL GENE SEQUENCE CDH23 (CADHERIN-RELATED 23) (EG, USHER SYNDROME, TYPE 1), FULL GENE SEQUENCE CEP290 (CENTROSOMAL PROTEIN 290KDA) (EG, JOUBERT SYNDROME), FULL GENE SEQUENCE COL1A1 (COLLA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81323 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME, PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81324 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH, HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE ANALYSIS; DUPLICATION/DELETION ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81325 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH, HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81326 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH, HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81329 SMN1 (SURVIVAL OF MOTOR NEURON 1, TELOMERIC) (EG, SPINAL MUSCULAR ATROPHY) GENE ANALYSIS; DOSAGE/DELETION ANALYSIS (EG, CARRIER TESTING), INCLUDES SMN2 (SURVIVAL OF MOTOR NEURON 2, CENTROMERIC) ANALYSIS, IF PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81330 SMPD1 (SPHINGOMYELIN PHOSPHODIESTERASE 1, ACID LYSOSOMAL) (EG, NIEMANN-PICK DISEASE, TYPE A) GENE ANALYSIS, COMMON VARIANTS (EG, R496L, L302P, FSP330) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81331 SNRPN/UBE3A (SMALL NUCLEAR RIBONUCLEOPROTEIN POLYPEPTIDE N AND UBIQUITIN PROTEIN LIGASE E3A) (EG, PRADER-WILLI SYNDROME AND/OR ANGELMAN SYNDROME), METHYLATION ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81332 SERPINA1 (SERPIN PEPTIDASE INHIBITOR, CLADE A, ALPHA-1 ANTIPROTEINASE, ANTITRYPSIN, MEMBER 1) (EG, ALPHA-1-ANTITRYPSIN DEFICIENCY), GENE ANALYSIS, COMMON VARIANTS (EG, *S AND *Z) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81319 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81449 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, 5-50 GENES, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED; RNA ANALYSIS Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS OF 11-25 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 26-50 EXONS) ACADVL (ACYL-COA DEHYDROGENASE, VERY LONG CHAIN) (EG, VERY LONG CHAIN ACYL-COENZYME A DEHYDROGENASE DEFICIENCY), FULL GENE SEQUENCE ACTN4 (ACTININ, ALPHA 4) (EG, FOCAL SEGMENTAL GLOMERULOSCLEROSIS), FULL GENE SEQUENCE AFG3L2 (AFG3 ATPASE FAMILY GENE 3-LIKE 2 [S. CEREVISIAE]) (EG, SPINOCEREBELLAR ATAXIA), FULL GENE SEQUENCE AIRE (AUTOIMMU Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81437 HEREDITARY NEUROENDOCRINE TUMOR-RELATED DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA), GENOMIC SEQUENCE ANALYSIS PANEL, 5 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81438 HEREDITARY NEUROENDOCRINE TUMOR DISORDERS (EG, MEDULLARY THYROID CARCINOMA, PARATHYROID CARCINOMA, MALIGNANT PHEOCHROMOCYTOMA OR PARAGANGLIOMA); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR SDHB, SDHC, SDHD, AND VHL Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81439 HEREDITARY CARDIOMYOPATHY (EG, HYPERTROPHIC CARDIOMYOPATHY, DILATED CARDIOMYOPATHY, ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 5 CARDIOMYOPATHY-RELATED GENES (EG, DSG2, MYBPC3, MYH7, PKP2, TTN) Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81440 NUCLEAR ENCODED MITOCHONDRIAL GENES (EG, NEUROLOGIC OR MYOPATHIC PHENOTYPES), GENOMIC SEQUENCE PANEL, MUST INCLUDE ANALYSIS OF AT LEAST 100 GENES, INCLUDING BCS1L, C10ORF2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, AND TYMP Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81441 INHERITED BONE MARROW FAILURE SYNDROMES (IBMFS) (EG, FANCONI ANEMIA, DYSKERATOSIS CONGENITA, DIAMOND-BLACKFAN ANEMIA, SHWACHMAN-DIAMOND SYNDROME, GATA2 DEFICIENCY SYNDROME, CONGENITAL AMEGAKARYOCYTIC THROMBOCYTOPENIA) SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 30 GENES, INCLUDING BRCA2, BRIP1, DKC1, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, GATA1, GATA2, MPL, NHP2, NOP10, PALB2, RAD51C, RPL11, RPL35A, RPL5, RPS10, RPS19, RPS24, RPS26, RPS7, SBDS, TERT, AND Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81442 NOONAN SPECTRUM DISORDERS (EG, NOONAN SYNDROME, CARDIO-FACIO-CUTANEOUS SYNDROME, COSTELLO SYNDROME, LEOPARD SYNDROME, NOONAN-LIKE SYNDROME), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 12 GENES, INCLUDING BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, AND SOS1 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81443 GENETIC TESTING FOR SEVERE INHERITED CONDITIONS (EG, CYSTIC FIBROSIS, ASHKENAZI JEWISH-ASSOCIATED DISORDERS [EG, BLOOM SYNDROME, CANAVAN DISEASE, FANCONI ANEMIA TYPE C, MUCOLIPIDOSIS TYPE VI, GAUCHER DISEASE, TAY-SACHS DISEASE], BETA HEMOGLOBINOPATHIES, PHENYLKETONURIA, GALACTOSEMIA), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 15 GENES (EG, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81435 HEREDITARY COLON CANCER-RELATED DISORDERS (EG, LYNCH SYNDROME, PTEN HAMARTOMA SYNDROME, COWDEN SYNDROME, FAMILIAL ADENOMATOSIS POLYPOSIS), GENOMIC SEQUENCE ANALYSIS PANEL, 5 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81448 HEREDITARY PERIPHERAL NEUROPATHIES (EG, CHARCOT-MARIE-TOOTH, SPASTIC PARAPLEGIA), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 5 PERIPHERAL NEUROPATHY-RELATED GENES (EG, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81434 HEREDITARY RETINAL DISORDERS (EG, RETINITIS PIGMENTOSA, LEBER CONGENITAL AMAUROSIS, CONE-ROD DYSTROPHY), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 15 GENES, INCLUDING ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, AND USH2A Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81450 HEMATOLYMPHOID NEOPLASM OR DISORDER, GENOMIC SEQUENCE ANALYSIS PANEL, 5-50 GENES, INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81451 HEMATOLYMPHOID NEOPLASM OR DISORDER, GENOMIC SEQUENCE ANALYSIS PANEL, 5-50 GENES, INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED; RNA ANALYSIS Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81455 SOLID ORGAN OR HEMATOLYMPHOID NEOPLASM OR DISORDER, 51 OR GREATER GENES, GENOMIC SEQUENCE ANALYSIS PANEL, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81456 SOLID ORGAN OR HEMATOLYMPHOID NEOPLASM OR DISORDER, 51 OR GREATER GENES, GENOMIC SEQUENCE ANALYSIS PANEL, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED; RNA ANALYSIS Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81457 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS, MICROSATELLITE INSTABILITY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     81458 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS, COPY NUMBER VARIANTS AND MICROSATELLITE INSTABILITY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     81459 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS, COPY NUMBER VARIANTS, MICROSATELLITE INSTABILITY, TUMOR MUTATION BURDEN, AND REARRANGEMENTS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     81460 WHOLE MITOCHONDRIAL GENOME (EG, LEIGH SYNDROME, MITOCHONDRIAL ENCEPHALOMYOPATHY, LACTIC ACIDOSIS, AND STROKE-LIKE EPISODES [MELAS], MYOCLONIC EPILEPSY WITH RAGGED-RED FIBERS [MERFF], NEUROPATHY, ATAXIA, AND RETINITIS PIGMENTOSA [NARP], LEBER HEREDITARY OPTIC NEUROPATHY [LHON]), GENOMIC SEQUENCE, MUST INCLUDE SEQUENCE ANALYSIS OF ENTIRE MITOCHONDRIAL GENOME WITH HETEROPLASMY DETECTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81445 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, 5-50 GENES, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS OR REARRANGEMENTS, IF PERFORMED; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81420 FETAL CHROMOSOMAL ANEUPLOIDY (EG, TRISOMY 21, MONOSOMY X) GENOMIC SEQUENCE ANALYSIS PANEL, CIRCULATING CELL-FREE FETAL DNA IN MATERNAL BLOOD, MUST INCLUDE ANALYSIS OF CHROMOSOMES 13, 18, AND 21 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81410 AORTIC DYSFUNCTION OR DILATION (EG, MARFAN SYNDROME, LOEYS DIETZ SYNDROME, EHLER DANLOS SYNDROME TYPE IV, ARTERIAL TORTUOSITY SYNDROME); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 9 GENES, INCLUDING FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, AND MYLK Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81411 AORTIC DYSFUNCTION OR DILATION (EG, MARFAN SYNDROME, LOEYS DIETZ SYNDROME, EHLER DANLOS SYNDROME TYPE IV, ARTERIAL TORTUOSITY SYNDROME); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR TGFBR1, TGFBR2, MYH11, AND COL3A1 Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81412 ASHKENAZI JEWISH ASSOCIATED DISORDERS (EG, BLOOM SYNDROME, CANAVAN DISEASE, CYSTIC FIBROSIS, FAMILIAL DYSAUTONOMIA, FANCONI ANEMIA GROUP C, GAUCHER DISEASE, TAY-SACHS DISEASE), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 9 GENES, INCLUDING ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, AND SMPD1 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81413 CARDIAC ION CHANNELOPATHIES (EG, BRUGADA SYNDROME, LONG QT SYNDROME, SHORT QT SYNDROME, CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 10 GENES, INCLUDING ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, AND SCN5A Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81414 CARDIAC ION CHANNELOPATHIES (EG, BRUGADA SYNDROME, LONG QT SYNDROME, SHORT QT SYNDROME, CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA); DUPLICATION/DELETION GENE ANALYSIS PANEL, MUST INCLUDE ANALYSIS OF AT LEAST 2 GENES, INCLUDING KCNH2 AND KCNQ1 Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81415 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81416 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS, EACH COMPARATOR EXOME (EG, PARENTS, SIBLINGS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81417 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); RE-EVALUATION OF PREVIOUSLY OBTAINED EXOME SEQUENCE (EG, UPDATED KNOWLEDGE OR UNRELATED CONDITION/SYNDROME) Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81436 HEREDITARY COLON CANCER DISORDERS (EG, LYNCH SYNDROME, PTEN HAMARTOMA SYNDROME, COWDEN SYNDROME, FAMILIAL ADENOMATOSIS POLYPOSIS); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSIS OF AT LEAST 5 GENES, INCLUDING MLH1, MSH2, EPCAM, SMAD4, AND STK11 Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81419 EPILEPSY GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, AND ZEB2 Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81304 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81422 FETAL CHROMOSOMAL MICRODELETION(S) GENOMIC SEQUENCE ANALYSIS (EG, DIGEORGE SYNDROME, CRI-DU-CHAT SYNDROME), CIRCULATING CELL-FREE FETAL DNA IN MATERNAL BLOOD Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81425 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81426 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS, EACH COMPARATOR GENOME (EG, PARENTS, SIBLINGS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81427 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); RE-EVALUATION OF PREVIOUSLY OBTAINED GENOME SEQUENCE (EG, UPDATED KNOWLEDGE OR UNRELATED CONDITION/SYNDROME) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81430 HEARING LOSS (EG, NONSYNDROMIC HEARING LOSS, USHER SYNDROME, PENDRED SYNDROME); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 60 GENES, INCLUDING CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, AND WFS1 Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81431 HEARING LOSS (EG, NONSYNDROMIC HEARING LOSS, USHER SYNDROME, PENDRED SYNDROME); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE COPY NUMBER ANALYSES FOR STRC AND DFNB1 DELETIONS IN GJB2 AND GJB6 GENES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81432 HEREDITARY BREAST CANCER-RELATED DISORDERS (EG, HEREDITARY BREAST CANCER, HEREDITARY OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCER, HEREDITARY PANCREATIC CANCER, HEREDITARY PROSTATE CANCER), GENOMIC SEQUENCE ANALYSIS PANEL, 5 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER VARIANTS Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81433 HEREDITARY BREAST CANCER-RELATED DISORDERS (EG, HEREDITARY BREAST CANCER, HEREDITARY OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCER); DUPLICATION/DELETION ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR BRCA1, BRCA2, MLH1, MSH2, AND STK11 Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81418 DRUG METABOLISM (EG, PHARMACOGENOMICS) GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE TESTING OF AT LEAST 6 GENES, INCLUDING CYP2C19, CYP2D6, AND CYP2D6 DUPLICATION/DELETION ANALYSIS Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     81237 EZH2 (ENHANCER OF ZESTE 2 POLYCOMB REPRESSIVE COMPLEX 2 SUBUNIT) (EG, DIFFUSE LARGE B-CELL LYMPHOMA) GENE ANALYSIS, COMMON VARIANT(S) (EG, CODON 646) Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81246 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE DOMAIN (TKD) VARIANTS (EG, D835, I836) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81228 CYTOGENOMIC (GENOME-WIDE) ANALYSIS FOR CONSTITUTIONAL CHROMOSOMAL ABNORMALITIES; INTERROGATION OF GENOMIC REGIONS FOR COPY NUMBER VARIANTS, COMPARATIVE GENOMIC HYBRIDIZATION [CGH] MICROARRAY ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81229 CYTOGENOMIC (GENOME-WIDE) ANALYSIS FOR CONSTITUTIONAL CHROMOSOMAL ABNORMALITIES; INTERROGATION OF GENOMIC REGIONS FOR COPY NUMBER AND SINGLE NUCLEOTIDE POLYMORPHISM (SNP) VARIANTS, COMPARATIVE GENOMIC HYBRIDIZATION (CGH) MICROARRAY ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81230 CYP3A4 (CYTOCHROME P450 FAMILY 3 SUBFAMILY A MEMBER 4) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, *2, *22) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81231 CYP3A5 (CYTOCHROME P450 FAMILY 3 SUBFAMILY A MEMBER 5) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *7) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81232 DPYD (DIHYDROPYRIMIDINE DEHYDROGENASE) (EG, 5-FLUOROURACIL/5-FU AND CAPECITABINE DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, *2A, *4, *5, *6) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81233 BTK (BRUTON'S TYROSINE KINASE) (EG, CHRONIC LYMPHOCYTIC LEUKEMIA) GENE ANALYSIS, COMMON VARIANTS (EG, C481S, C481R, C481F) Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81236 EZH2 (ENHANCER OF ZESTE 2 POLYCOMB REPRESSIVE COMPLEX 2 SUBUNIT) (EG, MYELODYSPLASTIC SYNDROME, MYELOPROLIFERATIVE NEOPLASMS) GENE ANALYSIS, FULL GENE SEQUENCE Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81224 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; INTRON 8 POLY-T ANALYSIS (EG, MALE INFERTILITY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81238 F9 (COAGULATION FACTOR IX) (EG, HEMOPHILIA B), FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81239 DMPK (DM1 PROTEIN KINASE) (EG, MYOTONIC DYSTROPHY TYPE 1) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE) Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81240 F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81241 F5 (COAGULATION FACTOR V) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, LEIDEN VARIANT Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81242 FANCC (FANCONI ANEMIA, COMPLEMENTATION GROUP C) (EG, FANCONI ANEMIA, TYPE C) GENE ANALYSIS, COMMON VARIANT (EG, IVS4+4A>T) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81243 FMR1 (FRAGILE X MESSENGER RIBONUCLEOPROTEIN 1) (EG, FRAGILE X SYNDROME, X-LINKED INTELLECTUAL DISABILITY [XLID]) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81244 FMR1 (FRAGILE X MESSENGER RIBONUCLEOPROTEIN 1) (EG, FRAGILE X SYNDROME, X-LINKED INTELLECTUAL DISABILITY [XLID]) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE AND PROMOTER METHYLATION STATUS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81311 NRAS (NEUROBLASTOMA RAS VIRAL [V-RAS] ONCOGENE HOMOLOG) (EG, COLORECTAL CARCINOMA), GENE ANALYSIS, VARIANTS IN EXON 2 (EG, CODONS 12 AND 13) AND EXON 3 (EG, CODON 61) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81234 DMPK (DM1 PROTEIN KINASE) (EG, MYOTONIC DYSTROPHY TYPE 1) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EXPANDED) ALLELES Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81215 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63704 REPAIR OF MYELOMENINGOCELE; LESS THAN 5 CM DIAMETER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81202 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81203 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81205 BCKDHB (BRANCHED-CHAIN KETO ACID DEHYDROGENASE E1, BETA POLYPEPTIDE) (EG, MAPLE SYRUP URINE DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, R183P, G278S, E422X) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81206 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81207 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MINOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81208 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; OTHER BREAKPOINT, QUALITATIVE OR QUANTITATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81209 BLM (BLOOM SYNDROME, RECQ HELICASE-LIKE) (EG, BLOOM SYNDROME) GENE ANALYSIS, 2281DEL6INS7 VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81212 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED), BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; 185DELAG, 5385INSC, 6174DELT VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81250 G6PC (GLUCOSE-6-PHOSPHATASE, CATALYTIC SUBUNIT) (EG, GLYCOGEN STORAGE DISEASE, TYPE 1A, VON GIERKE DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, R83C, Q347X) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81216 BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81217 BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81218 CEBPA (CCAAT/ENHANCER BINDING PROTEIN [C/EBP], ALPHA) (EG, ACUTE MYELOID LEUKEMIA), GENE ANALYSIS, FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81219 CALR (CALRETICULIN) (EG, MYELOPROLIFERATIVE DISORDERS), GENE ANALYSIS, COMMON VARIANTS IN EXON 9 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81220 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; COMMON VARIANTS (EG, ACMG/ACOG GUIDELINES) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81221 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81222 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81223 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; FULL GENE SEQUENCE Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     81210 BRAF (B-RAF PROTO-ONCOGENE, SERINE/THREONINE KINASE) (EG, COLON CANCER, MELANOMA), GENE ANALYSIS, V600 VARIANT(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81295 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81245 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE MYELOID LEUKEMIA), GENE ANALYSIS; INTERNAL TANDEM DUPLICATION (ITD) VARIANTS (IE, EXONS 14, 15) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81286 FXN (FRATAXIN) (EG, FRIEDREICH ATAXIA) GENE ANALYSIS; FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81287 MGMT (O-6-METHYLGUANINE-DNA METHYLTRANSFERASE) (EG, GLIOBLASTOMA MULTIFORME) PROMOTER METHYLATION ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81288 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; PROMOTER METHYLATION ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81289 FXN (FRATAXIN) (EG, FRIEDREICH ATAXIA) GENE ANALYSIS; KNOWN FAMILIAL VARIANT(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81290 MCOLN1 (MUCOLIPIN 1) (EG, MUCOLIPIDOSIS, TYPE IV) GENE ANALYSIS, COMMON VARIANTS (EG, IVS3-2A>G, DEL6.4KB) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81291 MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDUCTASE) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, COMMON VARIANTS (EG, 677T, 1298C) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81292 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81284 FXN (FRATAXIN) (EG, FRIEDREICH ATAXIA) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81294 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81279 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARGETED SEQUENCE ANALYSIS (EG, EXONS 12 AND 13) Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81296 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81297 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81298 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81299 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81300 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81301 MICROSATELLITE INSTABILITY ANALYSIS (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) OF MARKERS FOR MISMATCH REPAIR DEFICIENCY (EG, BAT25, BAT26), INCLUDES COMPARISON OF NEOPLASTIC AND NORMAL TISSUE, IF PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81302 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81303 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81293 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81265 COMPARATIVE ANALYSIS USING SHORT TANDEM REPEAT (STR) MARKERS; PATIENT AND COMPARATIVE SPECIMEN (EG, PRE-TRANSPLANT RECIPIENT AND DONOR GERMLINE TESTING, POST-TRANSPLANT NON-HEMATOPOIETIC RECIPIENT GERMLINE [EG, BUCCAL SWAB OR OTHER GERMLINE TISSUE SAMPLE] AND DONOR TESTING, TWIN ZYGOSITY TESTING, OR MATERNAL CELL CONTAMINATION OF FETAL CELLS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81251 GBA (GLUCOSIDASE, BETA, ACID) (EG, GAUCHER DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, N370S, 84GG, L444P, IVS2+1G>A) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81252 GJB2 (GAP JUNCTION PROTEIN, BETA 2, 26KDA, CONNEXIN 26) (EG, NONSYNDROMIC HEARING LOSS) GENE ANALYSIS; FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81253 GJB2 (GAP JUNCTION PROTEIN, BETA 2, 26KDA, CONNEXIN 26) (EG, NONSYNDROMIC HEARING LOSS) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81254 GJB6 (GAP JUNCTION PROTEIN, BETA 6, 30KDA, CONNEXIN 30) (EG, NONSYNDROMIC HEARING LOSS) GENE ANALYSIS, COMMON VARIANTS (EG, 309KB [DEL(GJB6-D13S1830)] AND 232KB [DEL(GJB6-D13S1854)]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81255 HEXA (HEXOSAMINIDASE A [ALPHA POLYPEPTIDE]) (EG, TAY-SACHS DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, 1278INSTATC, 1421+1G>C, G269S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81256 HFE (HEMOCHROMATOSIS) (EG, HEREDITARY HEMOCHROMATOSIS) GENE ANALYSIS, COMMON VARIANTS (EG, C282Y, H63D) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81257 HBA1/HBA2 (ALPHA GLOBIN 1 AND ALPHA GLOBIN 2) (EG, ALPHA THALASSEMIA, HB BART HYDROPS FETALIS SYNDROME, HBH DISEASE), GENE ANALYSIS; COMMON DELETIONS OR VARIANT (EG, SOUTHEAST ASIAN, THAI, FILIPINO, MEDITERRANEAN, ALPHA3.7, ALPHA4.2, ALPHA20.5, CONSTANT SPRING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81258 HBA1/HBA2 (ALPHA GLOBIN 1 AND ALPHA GLOBIN 2) (EG, ALPHA THALASSEMIA, HB BART HYDROPS FETALIS SYNDROME, HBH DISEASE), GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81285 FXN (FRATAXIN) (EG, FRIEDREICH ATAXIA) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81260 IKBKAP (INHIBITOR OF KAPPA LIGHT POLYPEPTIDE GENE ENHANCER IN B-CELLS, KINASE COMPLEX-ASSOCIATED PROTEIN) (EG, FAMILIAL DYSAUTONOMIA) GENE ANALYSIS, COMMON VARIANTS (EG, 2507+6T>C, R696P) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81464 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, CELL-FREE NUCLEIC ACID (EG, PLASMA), INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS, COPY NUMBER VARIANTS, MICROSATELLITE INSTABILITY, TUMOR MUTATION BURDEN, AND REARRANGEMENTS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     81266 COMPARATIVE ANALYSIS USING SHORT TANDEM REPEAT (STR) MARKERS; EACH ADDITIONAL SPECIMEN (EG, ADDITIONAL CORD BLOOD DONOR, ADDITIONAL FETAL SAMPLES FROM DIFFERENT CULTURES, OR ADDITIONAL ZYGOSITY IN MULTIPLE BIRTH PREGNANCIES) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81267 CHIMERISM (ENGRAFTMENT) ANALYSIS, POST TRANSPLANTATION SPECIMEN (EG, HEMATOPOIETIC STEM CELL), INCLUDES COMPARISON TO PREVIOUSLY PERFORMED BASELINE ANALYSES; WITHOUT CELL SELECTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81268 CHIMERISM (ENGRAFTMENT) ANALYSIS, POST TRANSPLANTATION SPECIMEN (EG, HEMATOPOIETIC STEM CELL), INCLUDES COMPARISON TO PREVIOUSLY PERFORMED BASELINE ANALYSES; WITH CELL SELECTION (EG, CD3, CD33), EACH CELL TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81269 HBA1/HBA2 (ALPHA GLOBIN 1 AND ALPHA GLOBIN 2) (EG, ALPHA THALASSEMIA, HB BART HYDROPS FETALIS SYNDROME, HBH DISEASE), GENE ANALYSIS; DUPLICATION/DELETION VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) GENE ANALYSIS, P.VAL617PHE (V617F) VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81271 HTT (HUNTINGTIN) (EG, HUNTINGTON DISEASE) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81274 HTT (HUNTINGTIN) (EG, HUNTINGTON DISEASE) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG, EXPANDED SIZE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81276 KRAS (KIRSTEN RAT SARCOMA VIRAL ONCOGENE HOMOLOG) (EG, CARCINOMA) GENE ANALYSIS; ADDITIONAL VARIANT(S) (EG, CODON 61, CODON 146) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81259 HBA1/HBA2 (ALPHA GLOBIN 1 AND ALPHA GLOBIN 2) (EG, ALPHA THALASSEMIA, HB BART HYDROPS FETALIS SYNDROME, HBH DISEASE), GENE ANALYSIS; FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     96138 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY TECHNICIAN, TWO OR MORE TESTS, ANY METHOD; FIRST 30 MINUTES Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     96922 EXCIMER LASER TREATMENT FOR PSORIASIS; OVER 500 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     95810 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     95811 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BILEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     95905 MOTOR AND/OR SENSORY NERVE CONDUCTION, USING PRECONFIGURED ELECTRODE ARRAY(S), AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH LIMB, INCLUDES F-WAVE STUDY WHEN PERFORMED, WITH INTERPRETATION AND REPORT Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96002 DYNAMIC SURFACE ELECTROMYOGRAPHY, DURING WALKING OR OTHER FUNCTIONAL ACTIVITIES, 1-12 MUSCLES Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96130 PSYCHOLOGICAL TESTING EVALUATION SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING INTEGRATION OF PATIENT DATA, INTERPRETATION OF STANDARDIZED TEST RESULTS AND CLINICAL DATA, CLINICAL DECISION MAKING, TREATMENT PLANNING AND REPORT, AND INTERACTIVE FEEDBACK TO THE PATIENT, FAMILY MEMBER(S) OR CAREGIVER(S), WHEN PERFORMED; FIRST HOUR Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     96131 PSYCHOLOGICAL TESTING EVALUATION SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING INTEGRATION OF PATIENT DATA, INTERPRETATION OF STANDARDIZED TEST RESULTS AND CLINICAL DATA, CLINICAL DECISION MAKING, TREATMENT PLANNING AND REPORT, AND INTERACTIVE FEEDBACK TO THE PATIENT, FAMILY MEMBER(S) OR CAREGIVER(S), WHEN PERFORMED; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     96133 NEUROPSYCHOLOGICAL TESTING EVALUATION SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING INTEGRATION OF PATIENT DATA, INTERPRETATION OF STANDARDIZED TEST RESULTS AND CLINICAL DATA, CLINICAL DECISION MAKING, TREATMENT PLANNING AND REPORT, AND INTERACTIVE FEEDBACK TO THE PATIENT, FAMILY MEMBER(S) OR CAREGIVER(S), WHEN PERFORMED; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 8/15/2023     InterQual® Evidence-Based Criteria & Guidelines     95807 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     96137 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, TWO OR MORE TESTS, ANY METHOD; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     95803 ACTIGRAPHY TESTING, RECORDING, ANALYSIS, INTERPRETATION, AND REPORT (MINIMUM OF 72 HOURS TO 14 CONSECUTIVE DAYS OF RECORDING) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96139 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY TECHNICIAN, TWO OR MORE TESTS, ANY METHOD; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     96567 PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO DESTROY PREMALIGNANT LESIONS OF THE SKIN AND ADJACENT MUCOSA WITH APPLICATION AND ILLUMINATION/ACTIVATION OF PHOTOSENSITIVE DRUG(S), PER DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     96900 ACTINOTHERAPY (ULTRAVIOLET LIGHT) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96910 PHOTOCHEMOTHERAPY; TAR AND ULTRAVIOLET B (GOECKERMAN TREATMENT) OR PETROLATUM AND ULTRAVIOLET B Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96912 PHOTOCHEMOTHERAPY; PSORALENS AND ULTRAVIOLET A (PUVA) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96913 PHOTOCHEMOTHERAPY (GOECKERMAN AND/OR PUVA) FOR SEVERE PHOTORESPONSIVE DERMATOSES REQUIRING AT LEAST 4-8 HOURS OF CARE UNDER DIRECT SUPERVISION OF THE PHYSICIAN (INCLUDES APPLICATION OF MEDICATION AND DRESSINGS) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   96920 EXCIMER LASER TREATMENT FOR PSORIASIS; TOTAL AREA LESS THAN 250 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81462 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, CELL-FREE NUCLEIC ACID (EG, PLASMA), INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS, COPY NUMBER VARIANTS AND REARRANGEMENTS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     96136 PSYCHOLOGICAL OR NEUROPSYCHOLOGICAL TEST ADMINISTRATION AND SCORING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, TWO OR MORE TESTS, ANY METHOD; FIRST 30 MINUTES Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     93264 REMOTE MONITORING OF A WIRELESS PULMONARY ARTERY PRESSURE SENSOR FOR UP TO 30 DAYS, INCLUDING AT LEAST WEEKLY DOWNLOADS OF PULMONARY ARTERY PRESSURE RECORDINGS, INTERPRETATION(S), TREND ANALYSIS, AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   92132 COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (EG, OPTICAL COHERENCE TOMOGRAPHY [OCT]), ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   92137 COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (EG, OPTICAL COHERENCE TOMOGRAPHY [OCT]), POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA, INCLUDING OCT ANGIOGRAPHY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL Yes 7/27/2020     InterQual® Evidence-Based Criteria & Guidelines     92508 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS Yes 7/27/2020     InterQual® Evidence-Based Criteria & Guidelines     92524 BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE Yes 7/27/2020     InterQual® Evidence-Based Criteria & Guidelines     92526 TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING Yes 7/27/2020     InterQual® Evidence-Based Criteria & Guidelines     92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY SENSORY ORGANIZATION TEST (CDP-SOT), 6 CONDITIONS (IE, EYES OPEN, EYES CLOSED, VISUAL SWAY, PLATFORM SWAY, EYES CLOSED PLATFORM SWAY, PLATFORM AND VISUAL SWAY), INCLUDING INTERPRETATION AND REPORT; Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   92549 COMPUTERIZED DYNAMIC POSTUROGRAPHY SENSORY ORGANIZATION TEST (CDP-SOT), 6 CONDITIONS (IE, EYES OPEN, EYES CLOSED, VISUAL SWAY, PLATFORM SWAY, EYES CLOSED PLATFORM SWAY, PLATFORM AND VISUAL SWAY), INCLUDING INTERPRETATION AND REPORT; WITH MOTOR CONTROL TEST (MCT) AND ADAPTATION TEST (ADT) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   95808 POLYSOMNOGRAPHY; ANY AGE, SLEEP STAGING WITH 1-3 ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     93050 ARTERIAL PRESSURE WAVEFORM ANALYSIS FOR ASSESSMENT OF CENTRAL ARTERIAL PRESSURES, INCLUDES OBTAINING WAVEFORM(S), DIGITIZATION AND APPLICATION OF NONLINEAR MATHEMATICAL TRANSFORMATIONS TO DETERMINE CENTRAL ARTERIAL PRESSURES AND AUGMENTATION INDEX, WITH INTERPRETATION AND REPORT, UPPER EXTREMITY ARTERY, NON-INVASIVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97010 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; HOT OR COLD PACKS Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     93701 BIOIMPEDANCE-DERIVED PHYSIOLOGIC CARDIOVASCULAR ANALYSIS Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   93702 BIOIMPEDANCE SPECTROSCOPY (BIS), EXTRACELLULAR FLUID ANALYSIS FOR LYMPHEDEMA ASSESSMENT(S) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   93740 TEMPERATURE GRADIENT STUDIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   94014 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF TIME; INCLUDES REINFORCED EDUCATION, TRANSMISSION OF SPIROMETRIC TRACING, DATA CAPTURE, ANALYSIS OF TRANSMITTED DATA, PERIODIC RECALIBRATION AND REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   94015 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF TIME; RECORDING (INCLUDES HOOK-UP, REINFORCED EDUCATION, DATA TRANSMISSION, DATA CAPTURE, TREND ANALYSIS, AND PERIODIC RECALIBRATION) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   94016 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF TIME; REVIEW AND INTERPRETATION ONLY BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   95782 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     95783 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BI-LEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     92972 PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97157 MULTIPLE-FAMILY GROUP ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITHOUT THE PATIENT PRESENT), FACE-TO-FACE WITH MULTIPLE SETS OF GUARDIANS/CAREGIVERS, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   96921 EXCIMER LASER TREATMENT FOR PSORIASIS; 250 SQ CM TO 500 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97151 BEHAVIOR IDENTIFICATION ASSESSMENT, ADMINISTERED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, EACH 15 MINUTES OF THE PHYSICIAN'S OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL'S TIME FACE-TO-FACE WITH PATIENT AND/OR GUARDIAN(S)/CAREGIVER(S) ADMINISTERING ASSESSMENTS AND DISCUSSING FINDINGS AND RECOMMENDATIONS, AND NON-FACE-TO-FACE ANALYZING PAST DATA, SCORING/INTERPRETING THE ASSESSMENT, AND PREPARING THE REPORT/TREATMENT PLAN Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97152 BEHAVIOR IDENTIFICATION-SUPPORTING ASSESSMENT, ADMINISTERED BY ONE TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97153 ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97154 GROUP ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH TWO OR MORE PATIENTS, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97129 THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES Yes 1/1/2022   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97156 FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITH OR WITHOUT THE PATIENT PRESENT), FACE-TO-FACE WITH GUARDIAN(S)/CAREGIVER(S), EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97124 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97158 GROUP ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH MULTIPLE PATIENTS, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97533 SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97535 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97537 COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR WORK ENVIRONMENT/MODIFICATION ANALYSIS, WORK TASK ANALYSIS, USE OF ASSISTIVE TECHNOLOGY DEVICE/ADAPTIVE EQUIPMENT), DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97542 WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97545 WORK HARDENING/CONDITIONING; INITIAL 2 HOURS Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     0317U ONCOLOGY (LUNG CANCER), FOUR-PROBE FISH (3Q29, 3P22.1, 10Q22.3, 10CEN) ASSAY, WHOLE BLOOD, PREDICTIVE ALGORITHM-GENERATED EVALUATION REPORTED AS DECREASED OR INCREASED RISK FOR LUNG CANCER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97155 ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, WHICH MAY INCLUDE SIMULTANEOUS DIRECTION OF TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES Yes 4/15/2020     Sendero Health Plans Medical Policy, "Applied Behavioral Analysis for the treatment of Autism Spectrum Disorder" InterQual® Evidence-Based Criteria & Guidelines   97034 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97012 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; TRACTION, MECHANICAL Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97014 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97016 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; VASOPNEUMATIC DEVICES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97018 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; PARAFFIN BATH Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97022 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; WHIRLPOOL Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97024 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; DIATHERMY (EG, MICROWAVE) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97026 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; INFRARED Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97028 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRAVIOLET Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97130 THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97033 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     90871 ECT (MULTIPLE SEIZURES) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     97035 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97036 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; HUBBARD TANK, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97037 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; LOW-LEVEL LASER THERAPY (IE, NONTHERMAL AND NON-ABLATIVE) FOR POST-OPERATIVE PAIN REDUCTION Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97039 UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT ATTENDANCE) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97113 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH THERAPEUTIC EXERCISES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     82715 FAT DIFFERENTIAL, FECES, QUANTITATIVE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   91299 UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81554 PULMONARY DISEASE (IDIOPATHIC PULMONARY FIBROSIS [IPF]), MRNA, GENE EXPRESSION ANALYSIS OF 190 GENES, UTILIZING TRANSBRONCHIAL BIOPSIES, DIAGNOSTIC ALGORITHM REPORTED AS CATEGORICAL RESULT (EG, POSITIVE OR NEGATIVE FOR HIGH PROBABILITY OF USUAL INTERSTITIAL PNEUMONIA [UIP]) Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81558 TRANSPLANTATION MEDICINE (ALLOGRAFT REJECTION, KIDNEY), MRNA, GENE EXPRESSION PROFILING BY QUANTITATIVE POLYMERASE CHAIN REACTION (QPCR) OF 139 GENES, UTILIZING WHOLE BLOOD, ALGORITHM REPORTED AS A BINARY CATEGORIZATION AS TRANSPLANT EXCELLENCE, WHICH INDICATES IMMUNE QUIESCENCE, OR NOT TRANSPLANT EXCELLENCE, INDICATING SUBCLINICAL REJECTION Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     81560 TRANSPLANTATION MEDICINE (ALLOGRAFT REJECTION, PEDIATRIC LIVER AND SMALL BOWEL), MEASUREMENT OF DONOR AND THIRD-PARTY-INDUCED CD154+T-CYTOTOXIC MEMORY CELLS, UTILIZING WHOLE PERIPHERAL BLOOD, ALGORITHM REPORTED AS A REJECTION RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81595 CARDIOLOGY (HEART TRANSPLANT), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF 20 GENES (11 CONTENT AND 9 HOUSEKEEPING), UTILIZING SUBFRACTION OF PERIPHERAL BLOOD, ALGORITHM REPORTED AS A REJECTION RISK SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81599 UNLISTED MULTIANALYTE ASSAY WITH ALGORITHMIC ANALYSIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     82233 BETA-AMYLOID; 1-40 (ABETA 40) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   82234 BETA-AMYLOID; 1-42 (ABETA 42) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81551 ONCOLOGY (PROSTATE), PROMOTER METHYLATION PROFILING BY REAL-TIME PCR OF 3 GENES (GSTP1, APC, RASSF1), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS A LIKELIHOOD OF PROSTATE CANCER DETECTION ON REPEAT BIOPSY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   82710 FAT OR LIPIDS, FECES; QUANTITATIVE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81546 ONCOLOGY (THYROID), MRNA, GENE EXPRESSION ANALYSIS OF 10,196 GENES, UTILIZING FINE NEEDLE ASPIRATE, ALGORITHM REPORTED AS A CATEGORICAL RESULT (EG, BENIGN OR SUSPICIOUS) Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     82725 FATTY ACIDS, NONESTERIFIED Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   83006 GROWTH STIMULATION EXPRESSED GENE 2 (ST2, INTERLEUKIN 1 RECEPTOR LIKE-1) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   83719 LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   83722 LIPOPROTEIN, DIRECT MEASUREMENT; SMALL DENSE LDL CHOLESTEROL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   83884 NEUROFILAMENT LIGHT CHAIN (NFL) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   83987 PH; EXHALED BREATH CONDENSATE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   84393 TAU, PHOSPHORYLATED (EG, PTAU 181, PTAU 217), EACH Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   84394 TAU, TOTAL (TTAU) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   82656 ELASTASE, PANCREATIC (EL-1), FECAL; QUALITATIVE OR SEMI-QUANTITATIVE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81506 ENDOCRINOLOGY (TYPE 2 DIABETES), BIOCHEMICAL ASSAYS OF SEVEN ANALYTES (GLUCOSE, HBA1C, INSULIN, HS-CRP, ADIPONECTIN, FERRITIN, INTERLEUKIN 2-RECEPTOR ALPHA), UTILIZING SERUM OR PLASMA, ALGORITHM REPORTING A RISK SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81195 CYTOGENOMIC (GENOME-WIDE) ANALYSIS, HEMATOLOGIC MALIGNANCY, STRUCTURAL VARIANTS AND COPY NUMBER VARIANTS, OPTICAL GENOME MAPPING (OGM) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81465 WHOLE MITOCHONDRIAL GENOME LARGE DELETION ANALYSIS PANEL (EG, KEARNS-SAYRE SYNDROME, CHRONIC PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA), INCLUDING HETEROPLASMY DETECTION, IF PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81470 X-LINKED INTELLECTUAL DISABILITY (XLID) (EG, SYNDROMIC AND NON-SYNDROMIC XLID); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 60 GENES, INCLUDING ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, AND SLC16A2 Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81471 X-LINKED INTELLECTUAL DISABILITY (XLID) (EG, SYNDROMIC AND NON-SYNDROMIC XLID); DUPLICATION/DELETION GENE ANALYSIS, MUST INCLUDE ANALYSIS OF AT LEAST 60 GENES, INCLUDING ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, AND SLC16A2 Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81490 AUTOIMMUNE (RHEUMATOID ARTHRITIS), ANALYSIS OF 12 BIOMARKERS USING IMMUNOASSAYS, UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS A DISEASE ACTIVITY SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81493 CORONARY ARTERY DISEASE, MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 23 GENES, UTILIZING WHOLE PERIPHERAL BLOOD, ALGORITHM REPORTED AS A RISK SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81500 ONCOLOGY (OVARIAN), BIOCHEMICAL ASSAYS OF TWO PROTEINS (CA-125 AND HE4), UTILIZING SERUM, WITH MENOPAUSAL STATUS, ALGORITHM REPORTED AS A RISK SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81552 ONCOLOGY (UVEAL MELANOMA), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 15 GENES (12 CONTENT AND 3 HOUSEKEEPING), UTILIZING FINE NEEDLE ASPIRATE OR FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS RISK OF METASTASIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81504 ONCOLOGY (TISSUE OF ORIGIN), MICROARRAY GENE EXPRESSION PROFILING OF > 2000 GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS TISSUE SIMILARITY SCORES Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86036 ANTINEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA); SCREEN, EACH ANTIBODY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81523 ONCOLOGY (BREAST), MRNA, NEXT-GENERATION SEQUENCING GENE EXPRESSION PROFILING OF 70 CONTENT GENES AND 31 HOUSEKEEPING GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS INDEX RELATED TO RISK TO DISTANT METASTASIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81525 ONCOLOGY (COLON), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 12 GENES (7 CONTENT AND 5 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS A RECURRENCE SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81535 ONCOLOGY (GYNECOLOGIC), LIVE TUMOR CELL CULTURE AND CHEMOTHERAPEUTIC RESPONSE BY DAPI STAIN AND MORPHOLOGY, PREDICTIVE ALGORITHM REPORTED AS A DRUG RESPONSE SCORE; FIRST SINGLE DRUG OR DRUG COMBINATION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81536 ONCOLOGY (GYNECOLOGIC), LIVE TUMOR CELL CULTURE AND CHEMOTHERAPEUTIC RESPONSE BY DAPI STAIN AND MORPHOLOGY, PREDICTIVE ALGORITHM REPORTED AS A DRUG RESPONSE SCORE; EACH ADDITIONAL SINGLE DRUG OR DRUG COMBINATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81538 ONCOLOGY (LUNG), MASS SPECTROMETRIC 8-PROTEIN SIGNATURE, INCLUDING AMYLOID A, UTILIZING SERUM, PROGNOSTIC AND PREDICTIVE ALGORITHM REPORTED AS GOOD VERSUS POOR OVERALL SURVIVAL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81539 ONCOLOGY (HIGH-GRADE PROSTATE CANCER), BIOCHEMICAL ASSAY OF FOUR PROTEINS (TOTAL PSA, FREE PSA, INTACT PSA, AND HUMAN KALLIKREIN-2 [HK2]), UTILIZING PLASMA OR SERUM, PROGNOSTIC ALGORITHM REPORTED AS A PROBABILITY SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   81541 ONCOLOGY (PROSTATE), MRNA GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 46 GENES (31 CONTENT AND 15 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS A DISEASE-SPECIFIC MORTALITY RISK SCORE Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81542 ONCOLOGY (PROSTATE), MRNA, MICROARRAY GENE EXPRESSION PROFILING OF 22 CONTENT GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS METASTASIS RISK SCORE Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81503 ONCOLOGY (OVARIAN), BIOCHEMICAL ASSAYS OF FIVE PROTEINS (CA-125, APOLIPOPROTEIN A1, BETA-2 MICROGLOBULIN, TRANSFERRIN, AND PRE-ALBUMIN), UTILIZING SERUM, ALGORITHM REPORTED AS A RISK SCORE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   88285 CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88264 CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88267 CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYOTYPE, WITH BANDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88269 CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT CELLS FROM 6-12 COLONIES, 1 KARYOTYPE, WITH BANDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88272 MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 3-5 CELLS (EG, FOR DERIVATIVES AND MARKERS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88273 MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 10-30 CELLS (EG, FOR MICRODELETIONS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88274 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 25-99 CELLS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, ANALYZE 100-300 CELLS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     84443 THYROID STIMULATING HORMONE (TSH) Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   88283 CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING TECHNIQUE (EG, NOR, C-BANDING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88261 CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88289 CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88291 CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION AND REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88299 UNLISTED CYTOGENETIC STUDY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88375 OPTICAL ENDOMICROSCOPIC IMAGE(S), INTERPRETATION AND REPORT, REAL-TIME OR REFERRED, EACH ENDOSCOPIC SESSION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   89160 MEAT FIBERS, FECES Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   90378 RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     90870 ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY MONITORING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81463 SOLID ORGAN NEOPLASM, GENOMIC SEQUENCE ANALYSIS PANEL, CELL-FREE NUCLEIC ACID (EG, PLASMA), INTERROGATION FOR SEQUENCE VARIANTS; DNA ANALYSIS, COPY NUMBER VARIANTS, AND MICROSATELLITE INSTABILITY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     88280 CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     87336 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ENTAMOEBA HISTOLYTICA DISPAR GROUP Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   91112 GASTROINTESTINAL TRANSIT AND PRESSURE MEASUREMENT, STOMACH THROUGH COLON, WIRELESS CAPSULE, WITH INTERPRETATION AND REPORT Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86037 ANTINEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA); TITER, EACH ANTIBODY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86051 AQUAPORIN-4 (NEUROMYELITIS OPTICA [NMO]) ANTIBODY; ENZYME-LINKED IMMUNOSORBENT IMMUNOASSAY (ELISA) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86052 AQUAPORIN-4 (NEUROMYELITIS OPTICA [NMO]) ANTIBODY; CELL-BASED IMMUNOFLUORESCENCE ASSAY (CBA), EACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86053 AQUAPORIN-4 (NEUROMYELITIS OPTICA [NMO]) ANTIBODY; FLOW CYTOMETRY (IE, FLUORESCENCE-ACTIVATED CELL SORTING [FACS]), EACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86231 ENDOMYSIAL ANTIBODY (EMA), EACH IMMUNOGLOBULIN (IG) CLASS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86258 GLIADIN (DEAMIDATED) (DGP) ANTIBODY, EACH IMMUNOGLOBULIN (IG) CLASS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86352 CELLULAR FUNCTION ASSAY INVOLVING STIMULATION (EG, MITOGEN OR ANTIGEN) AND DETECTION OF BIOMARKER (EG, ATP) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   88263 CHROMOSOME ANALYSIS; COUNT 45 CELLS FOR MOSAICISM, 2 KARYOTYPES, WITH BANDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     86596 VOLTAGE-GATED CALCIUM CHANNEL ANTIBODY, EACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   88262 CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     87513 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HELICOBACTER PYLORI (H. PYLORI), CLARITHROMYCIN RESISTANCE, AMPLIFIED PROBE TECHNIQUE Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   87525 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROBE TECHNIQUE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   87526 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PROBE TECHNIQUE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   87527 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICATION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   87594 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); PNEUMOCYSTIS JIROVECII, AMPLIFIED PROBE TECHNIQUE Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   88245 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER CHROMATID EXCHANGE (SCE), 20-25 CELLS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88248 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE BREAKAGE, SCORE 50-100 CELLS, COUNT 20 CELLS, 2 KARYOTYPES (EG, FOR ATAXIA TELANGIECTASIA, FANCONI ANEMIA, FRAGILE X) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     88249 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, CLASTOGEN STRESS (EG, DIEPOXYBUTANE, MITOMYCIN C, IONIZING RADIATION, UV RADIATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     86015 ACTIN (SMOOTH MUSCLE) ANTIBODY (ASMA), EACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   86364 TISSUE TRANSGLUTAMINASE, EACH IMMUNOGLOBULIN (IG) CLASS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   67909 REDUCTION OF OVERCORRECTION OF PTOSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67961 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67880 CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67882 CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67805 EXCISION OF CHALAZION; MULTIPLE, DIFFERENT LIDS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67801 EXCISION OF CHALAZION; MULTIPLE, SAME LID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67912 CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LID LOAD (EG, GOLD WEIGHT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67914 REPAIR OF ECTROPION; SUTURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67921 REPAIR OF ENTROPION; SUTURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65755 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81201 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64680 DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64681 DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; SUPERIOR HYPOGASTRIC PLEXUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64999 UNLISTED PROCEDURE, NERVOUS SYSTEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65710 KERATOPLASTY (CORNEAL TRANSPLANT); ANTERIOR LAMELLAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67808 EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65750 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67966 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65756 KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65757 BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT PRIOR TO TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65767 EPIKERATOPLASTY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65855 TRABECULOPLASTY BY LASER SURGERY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     66683 IMPLANTATION OF IRIS PROSTHESIS, INCLUDING SUTURE FIXATION AND REPAIR OR REMOVAL OF IRIS, WHEN PERFORMED Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   67414 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67445 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH REMOVAL OF BONE FOR DECOMPRESSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67800 EXCISION OF CHALAZION; SINGLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     65730 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA OR PSEUDOPHAKIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70481 COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67950 CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69728 REMOVAL, ENTIRE OSSEOINTEGRATED IMPLANT, SKULL; WITH MAGNETIC TRANSCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR, OUTSIDE THE MASTOID AND INVOLVING A BONY DEFECT GREATER THAN OR EQUAL TO 100 SQ MM SURFACE AREA OF BONE DEEP TO THE OUTER CRANIAL CORTEX Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     69729 IMPLANTATION, OSSEOINTEGRATED IMPLANT, SKULL; WITH MAGNETIC TRANSCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR, OUTSIDE OF THE MASTOID AND RESULTING IN REMOVAL OF GREATER THAN OR EQUAL TO 100 SQ MM SURFACE AREA OF BONE DEEP TO THE OUTER CRANIAL CORTEX Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     69730 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, SKULL; WITH MAGNETIC TRANSCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR, OUTSIDE THE MASTOID AND INVOLVING A BONY DEFECT GREATER THAN OR EQUAL TO 100 SQ MM SURFACE AREA OF BONE DEEP TO THE OUTER CRANIAL CORTEX Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     69930 COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     70336 MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70460 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69661 STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; WITH FOOTPLATE DRILL OUT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70480 COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69660 STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70482 COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70486 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70487 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70488 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70490 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70491 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70492 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70496 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69632 TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67971 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67973 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, 1 STAGE OR FIRST STAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67974 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, UPPER, 1 STAGE OR FIRST STAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67975 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     67999 UNLISTED PROCEDURE, EYELIDS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     68841 INSERTION OF DRUG-ELUTING IMPLANT, INCLUDING PUNCTAL DILATION WHEN PERFORMED, INTO LACRIMAL CANALICULUS, EACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   69310 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, FOR STENOSIS DUE TO INJURY, INFECTION) (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69320 RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL ATRESIA, SINGLE STAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69662 REVISION OF STAPEDECTOMY OR STAPEDOTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69631 TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64632 DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   69633 TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL OSSICULAR REPLACEMENT PROSTHESIS [TORP]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69635 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69636 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69637 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL OSSICULAR REPLACEMENT PROSTHESIS [TORP]) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69641 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69642 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69643 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69644 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     69620 MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR AREA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64466 THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64484 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64447 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64448 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64449 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64450 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64451 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64454 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64455 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64445 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64463 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; CONTINUOUS INFUSION BY CATHETER (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64435 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64467 THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64468 THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64469 THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64473 LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64474 LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY CONTINUOUS INFUSION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     64479 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64480 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64462 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SECOND AND ANY ADDITIONAL INJECTION SITE(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64416 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63709 REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR PSEUDOMENINGOCELE, WITH LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63710 DURAL GRAFT, SPINAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63740 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, OR OTHER; INCLUDING LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63741 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, OR OTHER; PERCUTANEOUS, NOT REQUIRING LAMINECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63744 REPLACEMENT, IRRIGATION OR REVISION OF LUMBOSUBARACHNOID SHUNT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     63746 REMOVAL OF ENTIRE LUMBOSUBARACHNOID SHUNT SYSTEM WITHOUT REPLACEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64400 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64405 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64446 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64415 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64486 TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64417 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64418 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64420 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64421 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64424 DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64425 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64430 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64431 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64408 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; VAGUS NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64610 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64483 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64581 OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64582 OPEN IMPLANTATION OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY, PULSE GENERATOR, AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     64583 REVISION OR REPLACEMENT OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     64585 REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64596 INSERTION OR REPLACEMENT OF PERCUTANEOUS ELECTRODE ARRAY, PERIPHERAL NERVE, WITH INTEGRATED NEUROSTIMULATOR, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED; INITIAL ELECTRODE ARRAY Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     64597 INSERTION OR REPLACEMENT OF PERCUTANEOUS ELECTRODE ARRAY, PERIPHERAL NERVE, WITH INTEGRATED NEUROSTIMULATOR, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED; EACH ADDITIONAL ELECTRODE ARRAY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     64598 REVISION OR REMOVAL OF NEUROSTIMULATOR ELECTRODE ARRAY, PERIPHERAL NERVE, WITH INTEGRATED NEUROSTIMULATOR Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     64575 OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64605 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64569 REVISION OR REPLACEMENT OF CRANIAL NERVE (EG, VAGUS NERVE) NEUROSTIMULATOR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64620 DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64622 DESTROY PARAVERT NERV LUMB/SAC SNGL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64623 DESTROY PARAVERT NRV, LUMB/SAC, ADD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64624 DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64625 RADIOFREQUENCY ABLATION, NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64628 THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; FIRST 2 VERTEBRAL BODIES, LUMBAR OR SACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64629 THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; EACH ADDITIONAL VERTEBRAL BODY, LUMBAR OR SACRAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64630 DESTRUCTION BY NEUROLYTIC AGENT; PUDENDAL NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64600 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SUPRAORBITAL, INFRAORBITAL, MENTAL, OR INFERIOR ALVEOLAR BRANCH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64487 TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY CONTINUOUS INFUSION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64488 TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64489 TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64580 OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; NEUROMUSCULAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64510 INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70542 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64530 INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64553 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; CRANIAL NERVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64555 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64561 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64565 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; NEUROMUSCULAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64566 POSTERIOR TIBIAL NEUROSTIMULATION, PERCUTANEOUS NEEDLE ELECTRODE, SINGLE TREATMENT, INCLUDES PROGRAMMING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64568 OPEN IMPLANTATION OF CRANIAL NERVE (EG, VAGUS NERVE) NEUROSTIMULATOR ELECTRODE ARRAY AND PULSE GENERATOR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77059 MAGNETIC RESONANCE IMAGING, BREAST,WITHOUT AND/OR WITH CONTRAST MATERIAL(S); BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78452 MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77012 COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77013 COMPUTED TOMOGRAPHY GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77021 MAGNETIC RESONANCE IMAGING GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY, NEEDLE ASPIRATION, INJECTION, OR PLACEMENT OF LOCALIZATION DEVICE) RADIOLOGICAL SUPERVISION AND INTERPRETATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77022 MAGNETIC RESONANCE IMAGING GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77046 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77047 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT CONTRAST MATERIAL; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77048 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND WITH CONTRAST MATERIAL(S), INCLUDING COMPUTER-AIDED DETECTION (CAD REAL-TIME LESION DETECTION, CHARACTERIZATION AND PHARMACOKINETIC ANALYSIS), WHEN PERFORMED; UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     76498 UNLISTED MAGNETIC RESONANCE PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77058 MAGNETIC RESONANCE IMAGING, BREAST,WITHOUT AND/OR WITH CONTRAST MATERIAL(S); UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     76497 UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77078 COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES, AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77084 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD SUPPLY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78071 PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION, WHEN PERFORMED); WITH TOMOGRAPHIC (SPECT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78072 PARATHYROID PLANAR IMAGING (INCLUDING SUBTRACTION, WHEN PERFORMED); WITH TOMOGRAPHIC (SPECT), AND CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ANATOMICAL LOCALIZATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78205 LIVER IMAGING (SPECT); Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78206 LIVER IMAGING (SPECT); WITH VASCULAR FLOW Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78320 BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70498 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77049 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND WITH CONTRAST MATERIAL(S), INCLUDING COMPUTER-AIDED DETECTION (CAD REAL-TIME LESION DETECTION, CHARACTERIZATION AND PHARMACOKINETIC ANALYSIS), WHEN PERFORMED; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75572 COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74185 MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74261 COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74262 COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITH CONTRAST MATERIAL(S) INCLUDING NON-CONTRAST IMAGES, IF PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74712 MAGNETIC RESONANCE (EG, PROTON) IMAGING, FETAL, INCLUDING PLACENTAL AND MATERNAL PELVIC IMAGING WHEN PERFORMED; SINGLE OR FIRST GESTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74713 MAGNETIC RESONANCE (EG, PROTON) IMAGING, FETAL, INCLUDING PLACENTAL AND MATERNAL PELVIC IMAGING WHEN PERFORMED; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75557 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75559 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75561 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     77011 COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75565 CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED), SINGLE STUDY; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75573 COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY IN THE SETTING OF CONGENITAL HEART DISEASE (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF LEFT VENTRICULAR [LV] CARDIAC FUNCTION, RIGHT VENTRICULAR [RV] STRUCTURE AND FUNCTION AND EVALUATION OF VASCULAR STRUCTURES, IF PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75574 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART, CORONARY ARTERIES AND BYPASS GRAFTS (WHEN PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING (INCLUDING EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     75635 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     76120 CINERADIOGRAPHY/VIDEORADIOGRAPHY, EXCEPT WHERE SPECIFICALLY INCLUDED Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   76125 CINERADIOGRAPHY/VIDEORADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   76380 COMPUTED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     76390 MAGNETIC RESONANCE SPECTROSCOPY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   76391 MAGNETIC RESONANCE (EG, VIBRATION) ELASTOGRAPHY Yes 8/15/2023     InterQual® Evidence-Based Criteria & Guidelines     75563 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81183 ATXN10 (ATAXIN 10) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78451 MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81166 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL DUPLICATION/DELETION ANALYSIS (IE, DETECTION OF LARGE GENE REARRANGEMENTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81167 BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL DUPLICATION/DELETION ANALYSIS (IE, DETECTION OF LARGE GENE REARRANGEMENTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81170 ABL1 (ABL PROTO-ONCOGENE 1, NON-RECEPTOR TYROSINE KINASE) (EG, ACQUIRED IMATINIB TYROSINE KINASE INHIBITOR RESISTANCE), GENE ANALYSIS, VARIANTS IN THE KINASE DOMAIN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81177 ATN1 (ATROPHIN 1) (EG, DENTATORUBRAL-PALLIDOLUYSIAN ATROPHY) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81178 ATXN1 (ATAXIN 1) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81179 ATXN2 (ATAXIN 2) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81180 ATXN3 (ATAXIN 3) (EG, SPINOCEREBELLAR ATAXIA, MACHADO-JOSEPH DISEASE) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81164 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED), BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL DUPLICATION/DELETION ANALYSIS (IE, DETECTION OF LARGE GENE REARRANGEMENTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81182 ATXN8OS (ATXN8 OPPOSITE STRAND [NON-PROTEIN CODING]) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81163 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED), BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81184 CACNA1A (CALCIUM VOLTAGE-GATED CHANNEL SUBUNIT ALPHA1 A) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81185 CACNA1A (CALCIUM VOLTAGE-GATED CHANNEL SUBUNIT ALPHA1 A) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS; FULL GENE SEQUENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81186 CACNA1A (CALCIUM VOLTAGE-GATED CHANNEL SUBUNIT ALPHA1 A) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS; KNOWN FAMILIAL VARIANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81187 CNBP (CCHC-TYPE ZINC FINGER NUCLEIC ACID BINDING PROTEIN) (EG, MYOTONIC DYSTROPHY TYPE 2) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81191 NTRK1 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 1) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81192 NTRK2 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 2) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81193 NTRK3 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 3) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81194 NTRK (NEUROTROPHIC RECEPTOR TYROSINE KINASE 1, 2, AND 3) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     81181 ATXN7 (ATAXIN 7) (EG, SPINOCEREBELLAR ATAXIA) GENE ANALYSIS, EVALUATION TO DETECT ABNORMAL (EG, EXPANDED) ALLELES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78807 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; TOMOGRAPHIC (SPECT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78469 MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78491 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78492 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION STUDY (INCLUDING VENTRICULAR WALL MOTION[S] AND/OR EJECTION FRACTION[S], WHEN PERFORMED); MULTIPLE STUDIES AT REST AND STRESS (EXERCISE OR PHARMACOLOGIC) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78494 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTITATIVE PROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78608 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78609 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION EVALUATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78647 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); TOMOGRAPHIC (SPECT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78710 KIDNEY IMAGING MORPHOLOGY; TOMOGRAPHIC (SPECT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81165 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78804 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR, INFLAMMATORY PROCESS OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S) (INCLUDES VASCULAR FLOW AND BLOOD POOL IMAGING, WHEN PERFORMED); PLANAR, WHOLE BODY, REQUIRING 2 OR MORE DAYS IMAGING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74181 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78811 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78812 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID-THIGH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78813 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78814 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81161 DMD (DYSTROPHIN) (EG, DUCHENNE/BECKER MUSCULAR DYSTROPHY) DELETION ANALYSIS, AND DUPLICATION ANALYSIS, IF PERFORMED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     81162 BRCA1 (BRCA1, DNA REPAIR ASSOCIATED), BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND FULL DUPLICATION/DELETION ANALYSIS (IE, DETECTION OF LARGE GENE REARRANGEMENTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     78803 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR, INFLAMMATORY PROCESS OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S) (INCLUDES VASCULAR FLOW AND BLOOD POOL IMAGING, WHEN PERFORMED); TOMOGRAPHIC (SPECT), SINGLE AREA (EG, HEAD, NECK, CHEST, PELVIS) OR ACQUISITION, SINGLE DAY IMAGING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72131 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74183 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71555 MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72125 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72126 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72127 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72128 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72130 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71271 COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2021     InterQual® Evidence-Based Criteria & Guidelines     72132 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72133 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72141 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72142 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72146 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72147 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72148 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72149 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72129 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22632 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70543 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70545 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70546 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70547 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70548 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71550 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72158 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70554 MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70555 MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70557 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70558 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70559 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71250 COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71260 COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     71270 COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74150 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73701 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73702 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73706 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73718 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73719 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73720 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73721 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73722 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72156 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73223 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74160 COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74170 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74174 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74175 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74176 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74177 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     70540 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73723 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73200 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     74182 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72159 MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72191 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72192 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72193 COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72194 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72195 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72196 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73700 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72198 MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73225 MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73201 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73202 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73206 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73218 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73219 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73220 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73221 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     73222 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72157 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E0162 SITZ BATH CHAIR See Note N/A   Noncovered healthcare service       E0188 SYNTHETIC SHEEPSKIN PAD See Note N/A   Noncovered healthcare service       C9784 GASTRIC RESTRICTIVE PROCEDURE, ENDOSCOPIC SLEEVE GASTROPLASTY, WITH ESOPHAGOGASTRODUODENOSCOPY AND INTRALUMINAL TUBE INSERTION, IF PERFORMED, INCLUDING ALL SYSTEM AND TISSUE ANCHORING COMPONENTS See Note N/A   Noncovered healthcare service       C9785 ENDOSCOPIC OUTLET REDUCTION, GASTRIC POUCH APPLICATION, WITH ENDOSCOPY AND INTRALUMINAL TUBE INSERTION, IF PERFORMED, INCLUDING ALL SYSTEM AND TISSUE ANCHORING COMPONENTS See Note N/A   Noncovered healthcare service       D5919 FACIAL PROSTHESIS See Note N/A   Noncovered healthcare service       D5925 FACIAL AUGMENTATION IMPLANT PROSTHESIS See Note N/A   Noncovered healthcare service       D7210 DENTAL SERVICES See Note N/A   Noncovered healthcare service       D8060 COSMETIC, RECONSTRUCTIVE OR PLASTIC SURGERY See Note N/A   Noncovered healthcare service       D8080 COSMETIC, RECONSTRUCTIVE OR PLASTIC SURGERY See Note N/A   Noncovered healthcare service       A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH See Note N/A   Noncovered healthcare service       E0161 SITZ BATH/EQUIPMENT W/FAUCET See Note N/A   Noncovered healthcare service       A9281 REACHING/GRABBING DEVICE, ANY TYPE, ANY LENGTH, EACH See Note N/A   Noncovered healthcare service       E0163 COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS See Note N/A   Noncovered healthcare service       E0165 COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS See Note N/A   Noncovered healthcare service       E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY See Note N/A   Noncovered healthcare service       E0168 HEAVYDUTY/WIDE COMMODE CHAIR See Note N/A   Noncovered healthcare service       E0170 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE See Note N/A   Noncovered healthcare service       E0171 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE See Note N/A   Noncovered healthcare service       E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE See Note N/A   Noncovered healthcare service       A4236 REPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOODGLUCOSE MONITOR OWNED BY PATIENT, EACH See Note N/A   Noncovered healthcare service       E0160 SITZ TYPE BATH OR EQUIPMENT See Note N/A   Noncovered healthcare service       A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH See Note N/A   Noncovered healthcare service       90758 ZAIRE EBOLAVIRUS VACCINE, LIVE, FOR INTRAMUSCULAR USE See Note N/A   Noncovered healthcare service       A4639 INFRARED HT SYS REPLCMNT PAD See Note N/A   Noncovered healthcare service       A4651 CALIBRATED MICROCAP TUBE See Note N/A   Noncovered healthcare service       A4927 GLOVES, NON-STERILE, PER 100 See Note N/A   Noncovered healthcare service       A6000 WOUND WARMING WOUND COVER See Note N/A   Noncovered healthcare service       A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH See Note N/A   Noncovered healthcare service       A6531 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH See Note N/A   Noncovered healthcare service       A6532 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH See Note N/A   Noncovered healthcare service       A9300 EXERCISE EQUIPMENT See Note N/A   Noncovered healthcare service       A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH See Note N/A   Noncovered healthcare service       E0189 LAMBSWOOL SHEEPSKIN PAD See Note N/A   Noncovered healthcare service       A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT See Note N/A   Noncovered healthcare service       A9150 MISC/EXPE NON-PRESCRIPT DRUG See Note N/A   Noncovered healthcare service       A9152 SINGLE VITAMIN/MINERAL/TRACE ELEMENT, ORAL, PER DOSE, NOT OTHERWISE SPECIFIED See Note N/A   Noncovered healthcare service       A9153 MULTIPLE VITAMINS, W/ OR W/OUT MINERALS AND TRACE ELEMENTS, ORAL, PER DOSE,NOT OTHERWISE SPECIFIED See Note N/A   Noncovered healthcare service       A9155 ARTIFICIAL SALIVA, 30 ML See Note N/A   Noncovered healthcare service       A9270 NON-COVERED ITEM OR SERVICE See Note N/A   Noncovered healthcare service       A9273 HOT WATER BOTTLE, ICE CAP OR COLLAR, HEAT AND/OR COLD WRAP, ANY TYPE See Note N/A   Noncovered healthcare service       A9280 ALERT DEVICE, NOC See Note N/A   Noncovered healthcare service       A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH See Note N/A   Noncovered healthcare service       E0705 TRANSFER BOARD OR DEVICE, ANY TYPE, EACH See Note N/A   Noncovered healthcare service       E0175 COMMODE CHAIR FOOT REST See Note N/A   Noncovered healthcare service       E0248 TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET W/ OR W/OUT COMMODE OPENING See Note N/A   Noncovered healthcare service       E0271 MATTRESS INNERSPRING See Note N/A   Noncovered healthcare service       E0272 MATTRESS FOAM RUBBER See Note N/A   Noncovered healthcare service       E0273 BED BOARD See Note N/A   Noncovered healthcare service       E0274 OVER-BED TABLE See Note N/A   Noncovered healthcare service       E0275 BED PAN STANDARD See Note N/A   Noncovered healthcare service       E0276 BED PAN FRACTURE See Note N/A   Noncovered healthcare service       E0246 TRANSFER TUB RAIL ATTACHMENT See Note N/A   Noncovered healthcare service       E0280 BED CRADLE See Note N/A   Noncovered healthcare service       E0245 TUB STOOL OR BENCH See Note N/A   Noncovered healthcare service       E0710 RESTRAINTS ANY TYPE See Note N/A   Noncovered healthcare service       E0951 HEEL LOOP/HOLDER, ANY TYPE, W/ OR W/OUT ANKLE STRAP, EACH See Note N/A   Noncovered healthcare service       E0952 TOE LOOP/HOLDER, ANY TYPE, EACH See Note N/A   Noncovered healthcare service       E1300 WHIRLPOOL, PORTABLE (OVERTUB TYPE) See Note N/A   Noncovered healthcare service       E1301 WHIRLPOOL TUB, WALK-IN, PORTABLE See Note N/A   Noncovered healthcare service       E1310 WHIRLPOOL NON-PORTABLE See Note N/A   Noncovered healthcare service       E1639 SCALE, EACH See Note N/A   Noncovered healthcare service       E3000 SPEECH VOLUME MODULATION SYSTEM, ANY TYPE, INCLUDING ALL COMPONENTS AND ACCESSORIES See Note N/A   Noncovered healthcare service       E0277 ALTERNATING PRESSURE MATTRESS See Note N/A   Noncovered healthcare service       E0221 INFRARED HEATING PAD SYSTEM See Note N/A   Noncovered healthcare service       E0190 POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTS AND ACCESSORIES See Note N/A   Noncovered healthcare service       E0191 PROTECTOR HEEL OR ELBOW See Note N/A   Noncovered healthcare service       E0200 HEAT LAMP WITHOUT STAND See Note N/A   Noncovered healthcare service       E0202 PHOTOTHERAPY LIGHT W/PHOTOMETER See Note N/A   Noncovered healthcare service       E0203 THERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODEL See Note N/A   Noncovered healthcare service       E0205 HEAT LAMP W/ STAND See Note N/A   Noncovered healthcare service       E0210 ELECTRIC HEAT PAD STANDARD See Note N/A   Noncovered healthcare service       E0215 ELECTRIC HEAT PAD MOIST See Note N/A   Noncovered healthcare service       E0247 TRANSFER BENCH FOR TUB OR TOILET W/ OR W/OUT COMMODE OPENING See Note N/A   Noncovered healthcare service       E0218 WATER CIRCULATING COLD PAD W/PUMP See Note N/A   Noncovered healthcare service       A4235 REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOODGLUCOSE MONITOR OWNED BY PATIENT, EACH See Note N/A   Noncovered healthcare service       E0231 WOUND WARMING DEVICE See Note N/A   Noncovered healthcare service       E0232 WARMING CARD FOR NWT See Note N/A   Noncovered healthcare service       E0235 PARAFFIN BATH UNIT PORTABLE See Note N/A   Noncovered healthcare service       E0240 BATH/SHOWER CHAIR, W/ OR W/OUT WHEELS, ANY SIZE See Note N/A   Noncovered healthcare service       E0241 BATH TUB WALL RAIL, EACH See Note N/A   Noncovered healthcare service       E0242 BATH TUB RAIL, FLOOR BASE See Note N/A   Noncovered healthcare service       E0243 TOILET RAIL, EACH See Note N/A   Noncovered healthcare service       E0244 RAISED TOILET SEAT See Note N/A   Noncovered healthcare service       E0217 WATER CIRCULATING HEAT PAD W/PUMP See Note N/A   Noncovered healthcare service       0401U CARDIOLOGY (CORONARY HEART DISEASE [CAD]), 9 GENES (12 VARIANTS), TARGETED VARIANT GENOTYPING, BLOOD, SALIVA, OR BUCCAL SWAB, ALGORITHM REPORTED AS A GENETIC RISK SCORE FOR A CORONARY EVENT See Note N/A   Noncovered healthcare service       0576T INTERROGATION DEVICE EVALUATION (IN PERSON) OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE, WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONN See Note N/A   Noncovered healthcare service       0255U ANDROLOGY (INFERTILITY), SPERM-CAPACITATION ASSESSMENT OF GANGLIOSIDE GM1 DISTRIBUTION PATTERNS, FLUORESCENCE MICROSCOPY, FRESH OR FROZEN SPECIMEN, REPORTED AS PERCENTAGE OF CAPACITATED SPERM AND PROBABILITY OF GENERATING A PREGNANCY SCORE See Note N/A   Noncovered healthcare service       0357T CRYOPRESERVATION; IMMATURE OOCYTE(S) See Note N/A   Noncovered healthcare service       0370U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), SURGICAL WOUND PATHOGENS, 34 MICROORGANISMS AND IDENTIFICATION OF 21 ASSOCIATED ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE, WOUND SWAB See Note N/A   Noncovered healthcare service       0371U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), GENITOURINARY PATHOGEN, SEMIQUANTITATIVE IDENTIFICATION, DNA FROM 16 BACTERIAL ORGANISMS AND 1 FUNGAL ORGANISM, MULTIPLEX AMPLIFIED PROBE TECHNIQUE VIA QUANTITATIVE POLYMERASE CHAIN REACTION (QPCR), See Note N/A   Noncovered healthcare service       0372U INFECTIOUS DISEASE (GENITOURINARY PATHOGENS), ANTIBIOTIC-RESISTANCE GENE DETECTION, MULTIPLEX AMPLIFIED PROBE TECHNIQUE, URINE, REPORTED AS AN ANTIMICROBIAL STEWARDSHIP RISK SCORE See Note N/A   Noncovered healthcare service       0373U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), RESPIRATORY TRACT INFECTION, 17 BACTERIA, 8 FUNGUS, 13 VIRUS, AND 16 ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE, UPPER OR LOWER RESPIRATORY SPECIMEN See Note N/A   Noncovered healthcare service       0374U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), GENITOURINARY PATHOGENS, IDENTIFICATION OF 21 BACTERIAL AND FUNGAL ORGANISMS AND IDENTIFICATION OF 21 ASSOCIATED ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE, URINE See Note N/A   Noncovered healthcare service       0253U REPRODUCTIVE MEDICINE (ENDOMETRIAL RECEPTIVITY ANALYSIS), RNA GENE EXPRESSION PROFILE, 238 GENES BY NEXT-GENERATION SEQUENCING, ENDOMETRIAL TISSUE, PREDICTIVE ALGORITHM REPORTED AS ENDOMETRIAL WINDOW OF IMPLANTATION (EG, PRE-RECEPTIVE, RECEPTIVE, POST-REC See Note N/A   Noncovered healthcare service       0396U OBSTETRICS (PRE-IMPLANTATION GENETIC TESTING), EVALUATION OF 300000 DNA SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) BY MICROARRAY, EMBRYONIC TISSUE, ALGORITHM REPORTED AS A PROBABILITY FOR SINGLE-GENE GERMLINE CONDITIONS See Note N/A   Noncovered healthcare service       0247U OBSTETRICS (PRETERM BIRTH), INSULIN-LIKE GROWTH FACTOR-BINDING PROTEIN 4 (IBP4), SEX HORMONE-BINDING GLOBULIN (SHBG), QUANTITATIVE MEASUREMENT BY LC-MS/MS, UTILIZING MATERNAL SERUM, COMBINED WITH CLINICAL DATA, REPORTED AS PREDICTIVE-RISK STRATIFICATION F See Note N/A   Noncovered healthcare service       0559T ANATOMIC MODEL 3D-PRINTED FROM IMAGE DATA SET(S); FIRST INDIVIDUALLY PREPARED AND PROCESSED COMPONENT OF AN ANATOMIC STRUCTURE See Note N/A   Noncovered healthcare service       0560T ; EACH ADDITIONAL INDIVIDUALLY PREPARED AND PROCESSED COMPONENT OF AN ANATOMIC STRUCTURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE See Note N/A   Noncovered healthcare service       0561T ANATOMIC GUIDE 3D-PRINTED AND DESIGNED FROM IMAGE DATA SET*S(; FIRST ANATOMIC GUIDE See Note N/A   Noncovered healthcare service       0562T  ANATOMIC GUIDE 3D PRINTED EA ADDL ANATOMIC GUIDE See Note N/A   Noncovered healthcare service       0571T INSERTION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE(S), INCLUDING ALL IMAGING GUIDANCE AND ELECTROPHYSIOLOGICAL EVALUATION (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUAT See Note N/A   Noncovered healthcare service       0572T INSERTION OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELECTRODE See Note N/A   Noncovered healthcare service       0574T REPOSITIONING OF PREVIOUSLY IMPLANTED SUBSTERNAL IMPLANTABLE DEFIBRILLATOR-PACING ELECTRODE See Note N/A   Noncovered healthcare service       A4247 BETADINE OR IODINE SWABS/WIPES, PER BOX See Note N/A   Noncovered healthcare service       0394U PERFLUOROALKYL SUBSTANCES (PFAS) (EG, PERFLUOROOCTANOIC ACID, PERFLUOROOCTANE SULFONIC ACID), 16 PFAS COMPOUNDS BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), PLASMA OR SERUM, QUANTITATIVE See Note N/A   Noncovered healthcare service       97171 ATHLETIC TRAINING EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A MEDICAL HISTORY AND PHYSICAL ACTIVITY PROFILE, WITH 3 OR MORE COMORBIDITIES THAT AFFECT PHYSICAL ACTIVITY; A COMPREHENSIVE EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AN See Note N/A   Noncovered healthcare service       0112 ROOM & BOARD-PRIVATE (ONE BED)-OB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     90876 BIOFEEDBACK See Note N/A   Noncovered healthcare service       90880 HYPNOTHERAPY See Note N/A   Noncovered healthcare service       90901 BIOFEEDBACK See Note N/A   Noncovered healthcare service       90911 BIOFEEDBACK See Note N/A   Noncovered healthcare service       92066 ORTHOPTIC TRAINING UNDER SUPERVISION OF NONPHYSICIAN HEALTH CARE PROFESSIONAL See Note N/A   Noncovered healthcare service       95919 BILATERAL QUANTITATIVE PUPILLOMETRY WITH INTERPRETATION AND REPORT BY A QUALIFIED HEALTH PROFESSIONAL See Note N/A   Noncovered healthcare service       96902 MICROSCOPIC EXAM OF HAIR See Note N/A   Noncovered healthcare service       0254U REPRODUCTIVE MEDICINE (PREIMPLANTATION GENETIC ASSESSMENT), ANALYSIS OF 24 CHROMOSOMES USING EMBRYONIC DNA GENOMIC SEQUENCE ANALYSIS FOR ANEUPLOIDY, AND A MITOCHONDRIAL DNA SCORE IN EUPLOID EMBRYOS, RESULTS REPORTED AS NORMAL (EUPLOIDY), MONOSOMY, TRISOMY See Note N/A   Noncovered healthcare service       97170 ATHLETIC TRAINING EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A MEDICAL HISTORY AND PHYSICAL ACTIVITY PROFILE WITH 1-2 COMORBIDITIES THAT AFFECT PHYSICAL ACTIVITY; AN EXAMINATION OF AFFECTED BODY AREA AND OTHER SYMPTOMATIC OR RELATED SYST See Note N/A   Noncovered healthcare service       0577T ELECTROPHYSIOLOGIC EVALUATION OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAM See Note N/A   Noncovered healthcare service       97172 RE-EVALUATION OF ATHLETIC TRAINING ESTABLISHED PLAN OF CARE REQUIRING THESE COMPONENTS: AN ASSESSMENT OF PATIENT'S CURRENT FUNCTIONAL STATUS WHEN THERE IS A DOCUMENTED CHANGE; AND A REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT A See Note N/A   Noncovered healthcare service       97179 ATHLETIC TRAINING EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A MEDICAL HISTORY AND PHYSICAL ACTIVITY PROFILE WITH 1-2 COMORBIDITIES THAT AFFECT PHYSICAL ACTIVITY; AN EXAMINATION OF AFFECTED BODY AREA AND OTHER SYMPTOMATIC OR RELATED SYST See Note N/A   Noncovered healthcare service       97810 ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT See Note N/A   Noncovered healthcare service       97811 ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT, WITH RE-INSERTION OF NEEDLE(S) See Note N/A   Noncovered healthcare service       97813 ACUPUNCTURE, 1 OR MORE NEEDLES; WITH ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT See Note N/A   Noncovered healthcare service       97814 ACUPUNCTURE, 1 OR MORE NEEDLES; WITH ELECTRICAL STIMULATION, EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT, WITH RE-INSERTION OF NEEDLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) See Note N/A   Noncovered healthcare service       99071 PATIENT EDUCATION MATERIALS See Note N/A   Noncovered healthcare service       99075 MEDICAL TESTIMONY See Note N/A   Noncovered healthcare service       97169 ATHLETIC TRAINING EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY AND PHYSICAL ACTIVITY PROFILE WITH NO COMORBIDITIES THAT AFFECT PHYSICAL ACTIVITY; AN EXAMINATION OF AFFECTED BODY AREA AND OTHER SYMPTOMATIC OR RELATED SYSTEMS ADDRESSING See Note N/A   Noncovered healthcare service       A4211 SUPP FOR SELF-ADMIN INJECTIONS See Note N/A   Noncovered healthcare service       0575T PROGRAMMING DEVICE EVALUATION (IN PERSON) OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE, WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WIT See Note N/A   Noncovered healthcare service       0670T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION- ARTERIAL ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       0687T QUANTITATIVE MAGNETIC RESONANCE FOR ANALYSIS OF TISSUE COMPOSITION (EG, FAT, IRON, WATER CONTENT), INCLUDING MULTIPARAMETRIC DATA ACQUISITION, DATA PREPARATION AND TRANSMISSION, INTERPRETATION AND REPORT, OBTAINED WITHOUT DIAGNOSTIC MRI EXAMINATION OF THE See Note N/A   Noncovered healthcare service       0698T QUANTITATIVE MAGNETIC RESONANCE FOR ANALYSIS OF TISSUE COMPOSITION (EG, FAT, IRON, WATER CONTENT), INCLUDING MULTIPARAMETRIC DATA ACQUISITION, DATA PREPARATION AND TRANSMISSION, INTERPRETATION AND REPORT, OBTAINED WITH DIAGNOSTIC MRI EXAMINATION OF THE SA See Note N/A   Noncovered healthcare service       0813T ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL, WITH VOLUME ADJUSTMENT OF INTRAGASTRIC BARIATRIC BALLOON See Note N/A   Noncovered healthcare service       A4206 1 CC STERILE SYRINGE & NEEDLE See Note N/A   Noncovered healthcare service       A4207 2 CC STERILE SYRINGE & NEEDLE See Note N/A   Noncovered healthcare service       A4208 3 CC STERILE SYRINGE & NEEDLE See Note N/A   Noncovered healthcare service       0668T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       A4210 NEEDLE-FREE INJECTION DEVICE See Note N/A   Noncovered healthcare service       0667T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       A4212 NON CORING NEEDLE OR STYLET See Note N/A   Noncovered healthcare service       A4213 20+ CC SYRINGE ONLY See Note N/A   Noncovered healthcare service       A4215 NEEDLE, STERILE, ANY SIZE, EACH See Note N/A   Noncovered healthcare service       A4216 STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML See Note N/A   Noncovered healthcare service       A4217 STERILE WATER/SALINE, 500 ML See Note N/A   Noncovered healthcare service       A4218 STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML See Note N/A   Noncovered healthcare service       A4233 REPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE WITH MEDICALLYNECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH See Note N/A   Noncovered healthcare service       A4234 REPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOMEBLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH See Note N/A   Noncovered healthcare service       A4209 5+ CC STERILE SYRINGE & NEEDLE See Note N/A   Noncovered healthcare service       0620T ENDOVASCULAR VENOUS ARTERIALIZATION, TIBIAL OR PERONEAL VEIN, WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT GRAFT(S) AND CLOSURE BY ANY METHOD, INCLUDING PERCUTANEOUS OR OPEN VASCULAR ACCESS, ULTRASOUND GUIDANCE FOR VASCULAR ACCESS WHEN PERFORMED, A See Note N/A   Noncovered healthcare service       0578T INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS, SUBSTERNAL LEAD IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH INTERIM ANALYSIS, REVIEW(S) AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL See Note N/A   Noncovered healthcare service       0579T INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS, SUBSTERNAL LEAD IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS See Note N/A   Noncovered healthcare service       0582T TRANSURETHRAL ABLATION OF MALIGNANT PROSTATE TISSUE BY HIGH-ENERGY WATER VAPOR THERMOTHERAPY, INCLUDING INTRAOPERATIVE IMAGING AND NEEDLE GUIDANCE See Note N/A   Noncovered healthcare service       0602T GLOMERULAR FILTRATION RATE (GFR) MEASUREMENT(S), TRANSDERMAL, INCLUDING SENSOR PLACEMENT AND ADMINISTRATION OF A SINGLE DOSE MEDICINE M-MED149 8 OF FLUORESCENT PYRAZINE AGENT (E.G., TRANSDERMAL GFR SYSTEM [MEDIBEACON]) See Note N/A   Noncovered healthcare service       0603T GLOMERULAR FILTRATION RATE (GFR) MONITORING, TRANSDERMAL, INCLUDING SENSOR PLACEMENT AND ADMINISTRATION OF MORE THAN ONE DOSE OF FLUORESCENT PYRAZINE AGENT, EACH 24 HOURS See Note N/A   Noncovered healthcare service       0604T OPTICAL COHERENCE TOMOGRAPHY (OCT) OF RETINA, REMOTE, PATIENT-INITIATED IMAGE CAPTURE AND TRANSMISSION TO A REMOTE SURVEILLANCE CENTER UNILATERAL OR BILATERAL; INITIAL DEVICE PROVISION, SET-UP AND PATIENT EDUCATION ON USE OF EQUIPMENT (E.G., HOME OCT [NOT See Note N/A   Noncovered healthcare service       0605T OPTICAL COHERENCE TOMOGRAPHY (OCT) OF RETINA, REMOTE, PATIENT-INITIATED IMAGE CAPTURE AND TRANSMISSION TO A REMOTE SURVEILLANCE CENTER UNILATERAL OR BILATERAL; REMOTE SURVEILLANCE CENTER TECHNICAL SUPPORT, DATA ANALYSES AND REPORTS, WITH A MINIMUM OF 8 DA See Note N/A   Noncovered healthcare service       0606T OPTICAL COHERENCE TOMOGRAPHY (OCT) OF RETINA, REMOTE, PATIENT-INITIATED IMAGE CAPTURE AND TRANSMISSION TO A REMOTE SURVEILLANCE CENTER UNILATERAL OR BILATERAL; REVIEW, INTERPRETATION AND REPORT BY THE PRESCRIBING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE P See Note N/A   Noncovered healthcare service       0669T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       0614T REMOVAL AND REPLACEMENT OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR See Note N/A   Noncovered healthcare service       G8979 MOBILITY: WALKING & MOVING AROUND FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       0640T NONCONTACT NEAR-INFRARED SPECTROSCOPY STUDIES OF FLAP OR WOUND (EG, FOR MEASUREMENT OF DEOXYHEMOGLOBIN, OXYHEMOGLOBIN, AND RATIO OF NOT MEDICALLY REASONABLE OR NECESSARY UNDER MEDICARE AND §1862(A)(1)(A). THIS IS MEDICINE M-MED149 11 TISSUE OXYGENATION [S See Note N/A   Noncovered healthcare service       0641T ADME- IMAGE ACQUISITION ONLY, EACH FLAP OR WOUND See Note N/A   Noncovered healthcare service       0642T SAME -; INTERPRETATION AND REPORT ONLY, EACH FLAP OR WOUND See Note N/A   Noncovered healthcare service       0648T QUANTITATIVE MAGNETIC RESONANCE FOR ANALYSIS OF TISSUE COMPOSITION (EG, FAT, IRON, WATER CONTENT), INCLUDING MULTIPARAMETRIC DATA ACQUISITION, DATA PREPARATION AND TRANSMISSION, INTERPRETATION AND REPORT, OBTAINED WITHOUT DIAGNOSTIC MRI EXAMINATION OF THE See Note N/A   Noncovered healthcare service       0649T QUANTITATIVE MAGNETIC RESONANCE FOR ANALYSIS OF TISSUE COMPOSITION (EG, FAT, IRON, WATER CONTENT), INCLUDING MULTIPARAMETRIC DATA ACQUISITION, DATA PREPARATION AND TRANSMISSION, INTERPRETATION AND REPORT, OBTAINED WITHOUT DIAGNOSTIC MRI EXAMINATION OF THE See Note N/A   Noncovered healthcare service       0664T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       0665T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       0666T BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH See Note N/A   Noncovered healthcare service       0613T PERCUTANEOUS TRANSCATHETER IMPLANTATION OF INTERATRIAL SEPTAL SHUNT DEVICE, INCLUDING RIGHT AND LEFT HEART CATHETERIZATION, INTRACARDIAC ECHOCARDIOGRAPHY, AND IMAGING GUIDANCE BY THE PROCEDURALIST, WHEN PERFORMED (E.G., VWAVE SHUNT [V-WAVE MEDICAL]) See Note N/A   Noncovered healthcare service       0030U DRUG METABOLISM (WARFARIN DRUG RESPONSE), TARGETED SEQUENCE ANALYSIS (IE, CYP2C9, CYP4F2, VKORC1, RS12777823) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0050U TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, ACUTE MYELOGENOUS LEUKEMIA, DNA ANALYSIS, 194 GENES, INTERROGATION FOR SEQUENCE VARIANTS, COPY NUMBER VARIANTS OR REARRANGEMENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0009M FETAL ANEUPLOIDY (TRISOMY 21, AND 18) DNA SEQUENCE ANALYSIS OF SELECTED REGIONS USING MATERNAL PLASMA, ALGORITHM REPORTED AS A RISK SCORE FOR EACH TRISOMY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0011M ONCOLOGY, PROSTATE CANCER, MRNA EXPRESSION ASSAY OF 12 GENES (10 CONTENT AND 2 HOUSEKEEPING), RT-PCR TEST UTILIZING BLOOD PLASMA AND URINE, ALGORITHMS TO PREDICT HIGH-GRADE PROSTATE CANCER RISK Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0012M ONCOLOGY (UROTHELIAL), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF FIVE GENES (MDK, HOXA13, CDC2 [CDK1], IGFBP5, AND CXCR2), UTILIZING URINE, ALGORITHM REPORTED AS A RISK SCORE FOR HAVING UROTHELIAL CARCINOMA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0013M ONCOLOGY (UROTHELIAL), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF FIVE GENES (MDK, HOXA13, CDC2 [CDK1], IGFBP5, AND CXCR2), UTILIZING URINE, ALGORITHM REPORTED AS A RISK SCORE FOR HAVING RECURRENT UROTHELIAL CARCINOMA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0015M ADRENAL CORTICAL TUMOR, BIOCHEMICAL ASSAY OF 25 STEROID MARKERS, UTILIZING 24-HOUR URINE SPECIMEN AND CLINICAL PARAMETERS, PROGNOSTIC ALGORITHM REPORTED AS A CLINICAL RISK AND INTEGRATED CLINICAL STEROID RISK FOR ADRENAL CORTICAL CARCINOMA, ADENOMA, OR OTHER ADRENAL MALIGNANCY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0016M ONCOLOGY (BLADDER), MRNA, MICROARRAY GENE EXPRESSION PROFILING OF 219 GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS MOLECULAR SUBTYPE (LUMINAL, LUMINAL INFILTRATED, BASAL, BASAL CLAUDIN-LOW, NEUROENDOCRINE-LIKE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   00170 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0006M ONCOLOGY (HEPATIC), MRNA EXPRESSION LEVELS OF 161 GENES, UTILIZING FRESH HEPATOCELLULAR CARCINOMA TUMOR TISSUE, WITH ALPHA-FETOPROTEIN LEVEL, ALGORITHM REPORTED AS A RISK CLASSIFIER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0021U ONCOLOGY (PROSTATE), DETECTION OF 8 AUTOANTIBODIES (ARF 6, NKX3-1, 5'-UTR-BMI1, CEP 164, 3'-UTR-ROPPORIN, DESMOCOLLIN, AURKAIP-1, CSNK2A2), MULTIPLEXED IMMUNOASSAY AND FLOW CYTOMETRY SERUM, ALGORITHM REPORTED AS RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0005U ONCOLOGY (PROSTATE) GENE EXPRESSION PROFILE BY REAL-TIME RT-PCR OF 3 GENES (ERG, PCA3, AND SPDEF), URINE, ALGORITHM REPORTED AS RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0031U CYP1A2 (CYTOCHROME P450 FAMILY 1, SUBFAMILY A, MEMBER 2) (EG, DRUG METABOLISM) GENE ANALYSIS, COMMON VARIANTS (IE, *1F, *1K, *6, *7) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0032U COMT (CATECHOL-O-METHYLTRANSFERASE) (EG, DRUG METABOLISM) GENE ANALYSIS, C.472G>A (RS4680) VARIANT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0033U HTR2A (5-HYDROXYTRYPTAMINE RECEPTOR 2A), HTR2C (5-HYDROXYTRYPTAMINE RECEPTOR 2C) (EG, CITALOPRAM METABOLISM) GENE ANALYSIS, COMMON VARIANTS (IE, HTR2A RS7997012 [C.614-2211T>C], HTR2C RS3813929 [C.-759C>T] AND RS1414334 [C.551-3008C>G]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0034U TPMT (THIOPURINE S-METHYLTRANSFERASE), NUDT15 (NUDIX HYDROXYLASE 15) (EG, THIOPURINE METABOLISM) GENE ANALYSIS, COMMON VARIANTS (IE, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0037U TARGETED GENOMIC SEQUENCE ANALYSIS, SOLID ORGAN NEOPLASM, DNA ANALYSIS OF 324 GENES, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY AND TUMOR MUTATIONAL BURDEN Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0042T CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST ADMINISTRATION, INCLUDING POST-PROCESSING OF PARAMETRIC MAPS WITH DETERMINATION OF CEREBRAL BLOOD FLOW, CEREBRAL BLOOD VOLUME, AND MEAN TRANSIT TIME Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0045U ONCOLOGY (BREAST DUCTAL CARCINOMA IN SITU), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 12 GENES (7 CONTENT AND 5 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS RECURRENCE SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0429 DERMAL FILLER INJ TREATMENT LD See Note N/A   Noncovered healthcare service       0019U ONCOLOGY, RNA, GENE EXPRESSION BY WHOLE TRANSCRIPTOME SEQUENCING, FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE OR FRESH FROZEN TISSUE, PREDICTIVE ALGORITHM REPORTED AS POTENTIAL TARGETS FOR THERAPEUTIC AGENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8655 NETUPITANT / PALONOSETRON See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8521 CAPECITABINE, ORAL, 500 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8530 CYCLOPHOSPHAMIDE, ORAL, 25 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8540 DEXAMETHASONE, ORAL, 0.25 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8560 ETOPOSIDE, ORAL, 50 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8562 FLUDARABINE PHOSPHATE, ORAL, 10 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8565 GEFITINIB, ORAL, 250 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8597 ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8600 MELPHALAN, ORAL, 2 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       0007M ONCOLOGY (GASTROINTESTINAL NEUROENDOCRINE TUMORS), REAL-TIME PCR EXPRESSION ANALYSIS OF 51 GENES, UTILIZING WHOLE PERIPHERAL BLOOD, ALGORITHM REPORTED AS A NOMOGRAM OF TUMOR DISEASE INDEX Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8650 NABILONE, ORAL, 1 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       0052U LIPOPROTEIN, BLOOD, HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROTEINS, INCLUDING ALL FIVE MAJOR LIPOPROTEIN CLASSES AND SUBCLASSES OF HDL, LDL, AND VLDL BY VERTICAL AUTO PROFILE ULTRACENTRIFUGATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8705 TOPOTECAN, ORAL, 0.25 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8999 ORAL PRESCRIPTION DRUG CHEMO See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       Q0162 ONDANSETRON See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       Q0167 DRONABINOL See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       S0175 FLUTAMIDE See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       0002U ONCOLOGY (COLORECTAL), QUANTITATIVE ASSESSMENT OF THREE URINE METABOLITES (ASCORBIC ACID, SUCCINIC ACID AND CARNITINE) BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) USING MULTIPLE REACTION MONITORING ACQUISITION, ALGORITHM REPORTED AS LIKELIHOOD OF ADENOMATOUS POLYPS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0003U ONCOLOGY (OVARIAN) BIOCHEMICAL ASSAYS OF FIVE PROTEINS (APOLIPOPROTEIN A-1, CA 125 II, FOLLICLE STIMULATING HORMONE, HUMAN EPIDIDYMIS PROTEIN 4, TRANSFERRIN), UTILIZING SERUM, ALGORITHM REPORTED AS A LIKELIHOOD SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0004M SCOLIOSIS, DNA ANALYSIS OF 53 SINGLE NUCLEOTIDE POLYMORPHISMS (SNPS), USING SALIVA, PROGNOSTIC ALGORITHM REPORTED AS A RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8610 METHOTREXATE, ORAL, 2.5 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       0106T QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING TOUCH PRESSURE STIMULI TO ASSESS LARGE DIAMETER SENSATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0048U ONCOLOGY (SOLID ORGAN NEOPLASIA), DNA, TARGETED SEQUENCING OF PROTEIN-CODING EXONS OF 468 CANCER-ASSOCIATED GENES, INCLUDING INTERROGATION FOR SOMATIC MUTATIONS AND MICROSATELLITE INSTABILITY, MATCHED WITH NORMAL SPECIMENS, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TUMOR TISSUE, REPORT OF CLINICALLY SIGNIFICANT MUTATION(S) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0097U GASTROINTESTINAL PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 22 TARGETS (CAMPYLOBACTER [C. JEJUNI/C. COLI/C. UPSALIENSIS], CLOSTRIDIUM DIFFICILE [C. DIFFICILE] TOXIN A/B, PLESIOMONAS SHIGELLOIDES, SALMONELLA, VIBRIO [V. PARAHAEMOLYTICUS/V. VULNIFICUS/V. CHOLERAE], INCLUDING SPECIFIC IDENTIFICATION OF VIBRIO CHOLERAE, YERSINIA ENTEROCOLITICA, ENTEROAGGREGATIVE ESCHERICHIA COLI [EAEC], ENTEROPATHOGENIC ESCHERICHIA COLI [EPEC], ENTE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0100 ALL-INCLUSIVE ROOM AND BOARD PLUS ANCILLARY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0100T PLACEMENT OF A SUBCONJUNCTIVAL RETINAL PROSTHESIS RECEIVER AND PULSE GENERATOR, AND IMPLANTATION OF INTRAOCULAR RETINAL ELECTRODE ARRAY, WITH VITRECTOMY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0101 ALL-INCLUSIVE ROOM AND BOARD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0101T EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCULOSKELETAL SYSTEM, NOT OTHERWISE SPECIFIED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0101U HEREDITARY COLON CANCER DISORDERS (EG, LYNCH SYNDROME, PTEN HAMARTOMA SYNDROME, COWDEN SYNDROME, FAMILIAL ADENOMATOSIS POLYPOSIS), GENOMIC SEQUENCE ANALYSIS PANEL UTILIZING A COMBINATION OF NGS, SANGER, MLPA, AND ARRAY CGH, WITH MRNA ANALYTICS TO RESOLVE VARIANTS OF UNKNOWN SIGNIFICANCE WHEN INDICATED (15 GENES [SEQUENCING AND DELETION/DUPLICATION], EPCAM AND GREM1 [DELETION/DUPLICATION ONLY]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0102T EXTRACORPOREAL SHOCK WAVE PERFORMED BY A PHYSICIAN, REQUIRING ANESTHESIA OTHER THAN LOCAL, AND INVOLVING THE LATERAL HUMERAL EPICONDYLE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0092U ONCOLOGY (LUNG), THREE PROTEIN BIOMARKERS, IMMUNOASSAY USING MAGNETIC NANOSENSOR TECHNOLOGY, PLASMA, ALGORITHM REPORTED AS RISK SCORE FOR LIKELIHOOD OF MALIGNANCY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0103U HEREDITARY OVARIAN CANCER (EG, HEREDITARY OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCER), GENOMIC SEQUENCE ANALYSIS PANEL UTILIZING A COMBINATION OF NGS, SANGER, MLPA, AND ARRAY CGH, WITH MRNA ANALYTICS TO RESOLVE VARIANTS OF UNKNOWN SIGNIFICANCE WHEN INDICATED (24 GENES [SEQUENCING AND DELETION/DUPLICATION], EPCAM [DELETION/DUPLICATION ONLY]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0091U ONCOLOGY (COLORECTAL) SCREENING, CELL ENUMERATION OF CIRCULATING TUMOR CELLS, UTILIZING WHOLE BLOOD, ALGORITHM, FOR THE PRESENCE OF ADENOMA OR CANCER, REPORTED AS A POSITIVE OR NEGATIVE RESULT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0106U GASTRIC EMPTYING, SERIAL COLLECTION OF 7 TIMED BREATH SPECIMENS, NON-RADIOISOTOPE CARBON-13 (13C) SPIRULINA SUBSTRATE, ANALYSIS OF EACH SPECIMEN BY GAS ISOTOPE RATIO MASS SPECTROMETRY, REPORTED AS RATE OF 13CO2 EXCRETION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0107T QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING VIBRATION STIMULI TO ASSESS LARGE DIAMETER FIBER SENSATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0108T QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING COOLING STIMULI TO ASSESS SMALL NERVE FIBER SENSATION AND HYPERALGESIA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0109T QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING HEAT-PAIN STIMULI TO ASSESS SMALL NERVE FIBER SENSATION AND HYPERALGESIA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0110 ROOM & BOARD-PRIVATE (ONE BED)-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0110T QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING OTHER STIMULI TO ASSESS SENSATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0111 ROOM & BOARD-PRIVATE (ONE BED)-MEDICAL/SURGICAL/GYN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22634 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0102U HEREDITARY BREAST CANCER-RELATED DISORDERS (EG, HEREDITARY BREAST CANCER, HEREDITARY OVARIAN CANCER, HEREDITARY ENDOMETRIAL CANCER), GENOMIC SEQUENCE ANALYSIS PANEL UTILIZING A COMBINATION OF NGS, SANGER, MLPA, AND ARRAY CGH, WITH MRNA ANALYTICS TO RESOLVE VARIANTS OF UNKNOWN SIGNIFICANCE WHEN INDICATED (17 GENES [SEQUENCING AND DELETION/DUPLICATION]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0071T FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL LEIOMYOMATA VOLUME LESS THAN 200 CC OF TISSUE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0054T COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON FLUOROSCOPIC IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0055T COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0055U CARDIOLOGY (HEART TRANSPLANT), CELL-FREE DNA, PCR ASSAY OF 96 DNA TARGET SEQUENCES (94 SINGLE NUCLEOTIDE POLYMORPHISM TARGETS AND TWO CONTROL TARGETS), PLASMA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0057U ONCOLOGY (SOLID ORGAN NEOPLASIA), MRNA, GENE EXPRESSION PROFILING BY MASSIVELY PARALLEL SEQUENCING FOR ANALYSIS OF 51 GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS A NORMALIZED PERCENTILE RANK Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0058U ONCOLOGY (MERKEL CELL CARCINOMA), DETECTION OF ANTIBODIES TO THE MERKEL CELL POLYOMA VIRUS ONCOPROTEIN (SMALL T ANTIGEN), SERUM, QUANTITATIVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0059U ONCOLOGY (MERKEL CELL CARCINOMA), DETECTION OF ANTIBODIES TO THE MERKEL CELL POLYOMA VIRUS CAPSID PROTEIN (VP1), SERUM, REPORTED AS POSITIVE OR NEGATIVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0063U NEUROLOGY (AUTISM), 32 AMINES BY LC-MS/MS, USING PLASMA, ALGORITHM REPORTED AS METABOLIC SIGNATURE ASSOCIATED WITH AUTISM SPECTRUM DISORDER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   00640 ANESTHESIA FOR MANIPULATION OF THE SPINE OR FOR CLOSED PROCEDURES ON THE CERVICAL, THORACIC OR LUMBAR SPINE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0094U GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME), RAPID SEQUENCE ANALYSIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0069U ONCOLOGY (COLORECTAL), MICRORNA, RT-PCR EXPRESSION PROFILING OF MIR-31-3P, FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS AN EXPRESSION SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8510 ORAL BISULFAN See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       0072T FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL LEIOMYOMATA VOLUME GREATER OR EQUAL TO 200 CC OF TISSUE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0075T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0076T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0080U ONCOLOGY (LUNG), MASS SPECTROMETRIC ANALYSIS OF GALECTIN-3-BINDING PROTEIN AND SCAVENGER RECEPTOR CYSTEINE-RICH TYPE 1 PROTEIN M130, WITH FIVE CLINICAL RISK FACTORS (AGE, SMOKING STATUS, NODULE DIAMETER, NODULE-SPICULATION STATUS AND NODULE LOCATION), UTILIZING PLASMA, ALGORITHM REPORTED AS A CATEGORICAL PROBABILITY OF MALIGNANCY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0087U CARDIOLOGY (HEART TRANSPLANT), MRNA GENE EXPRESSION PROFILING BY MICROARRAY OF 1283 GENES, TRANSPLANT BIOPSY TISSUE, ALLOGRAFT REJECTION AND INJURY ALGORITHM REPORTED AS A PROBABILITY SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0088U TRANSPLANTATION MEDICINE (KIDNEY ALLOGRAFT REJECTION), MICROARRAY GENE EXPRESSION PROFILING OF 1494 GENES, UTILIZING TRANSPLANT BIOPSY TISSUE, ALGORITHM REPORTED AS A PROBABILITY SCORE FOR REJECTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0089U ONCOLOGY (MELANOMA), GENE EXPRESSION PROFILING BY RTQPCR, PRAME AND LINC00518, SUPERFICIAL COLLECTION USING ADHESIVE PATCH(ES) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0090U ONCOLOGY (CUTANEOUS MELANOMA), MRNA GENE EXPRESSION PROFILING BY RT-PCR OF 23 GENES (14 CONTENT AND 9 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS A CATEGORICAL RESULT (IE, BENIGN, INTERMEDIATE, MALIGNANT) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0067U ONCOLOGY (BREAST), IMMUNOHISTOCHEMISTRY, PROTEIN EXPRESSION PROFILING OF 4 BIOMARKERS (MATRIX METALLOPROTEINASE-1 [MMP-1], CARCINOEMBRYONIC ANTIGEN-RELATED CELL ADHESION MOLECULE 6 [CEACAM6], HYALURONOGLUCOSAMINIDASE [HYAL1], HIGHLY EXPRESSED IN CANCER PROTEIN [HEC1]), FORMALIN-FIXED PARAFFIN-EMBEDDED PRECANCEROUS BREAST TISSUE, ALGORITHM REPORTED AS CARCINOMA RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4100 SKIN SUBSTITUTE NOT OTHERWISE See Note N/A   Noncovered healthcare service       J8520 CAPECITABINE, ORAL, 150 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J1726 MAKENA 10 MG See Note N/A   Noncovered healthcare service       J1729 INJECTION, HYDROXYPROGESTERONE CAPROATE, NOT OTHERWISE SPECIFIED, 10 MG See Note N/A   Noncovered healthcare service       J3355 INJECTION, UROFOLLITROPIN, 75 IU See Note N/A   Noncovered healthcare service       K1003 WHIRLPOOL TUB, WALK-IN, PORTABLE See Note N/A   Noncovered healthcare service       K1035 MOLECULAR DIAGNOSTIC TEST READER, NONPRESCRIPTION SELF-ADMINISTERED AND SELF-COLLECTED USE, FDA APPROVED, AUTHORIZED OR CLEARED See Note N/A   Noncovered healthcare service       M0010 ENHANCING ONCOLOGY MODEL (EOM) MONTHLY ENHANCED ONCOLOGY SERVICES (MEOS) PAYMENT FOR EOM ENHANCED SERVICES See Note N/A   Noncovered healthcare service       Q2026 INJECTION RADIESSE 0.1ML See Note N/A   Noncovered healthcare service       G8999 MOTOR SPEECH FUNCTIONAL LIMITATION, CURRENT STATUS AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       Q2028 INJECTION SCULPTRA 0.5 MG See Note N/A   Noncovered healthcare service       G8998 SWALLOWING FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       Q9985 INJECTION, HYDROXYPROGESTERONE CAPROATE, NOT OTHERWISE SPECIFIED, 10 MG See Note N/A   Noncovered healthcare service       Q9986 MAKENA 10 MG See Note N/A   Noncovered healthcare service       S0122 INJECTION, MENOTROPINS, 75 IU See Note N/A   Noncovered healthcare service       S0126 INJECTION, FOLLITROPIN ALFA, 75 IU See Note N/A   Noncovered healthcare service       S0128 INJECTION, FOLLITROPIN BETA, 75 IU See Note N/A   Noncovered healthcare service       S0132 INJECTION, GANIRELIX ACETATE, 250 MCG See Note N/A   Noncovered healthcare service       S3852 DNA ANALYSIS APOE ALZHEIMER See Note N/A   Noncovered healthcare service       S4011 IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION AND INCUBATION OF MATURE OOCYTES, FERTILIZATION WITH SPERM, INCUBATION OF EMBRYO(S), AND SUBSEQUENT VISUALIZATION FOR DETERMINATION OF DEVELOPMENT See Note N/A   Noncovered healthcare service       Q2027 DERMAL FILLER See Note N/A   Noncovered healthcare service       G8989 SELF CARE FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       90584 DENGUE VACCINE, QUADRIVALENT, LIVE, 2 DOSE SCHEDULE, FOR SUBCUTANEOUS USE See Note N/A   Noncovered healthcare service       G8980 MOBILITY: WALKING & MOVING AROUND FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8981 CHANGING & MAINTAINING BODY POSITION FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G8982 CHANGING & MAINTAINING BODY POSITION FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8983 CHANGING & MAINTAINING BODY POSITION FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8984 CARRYING, MOVING & HANDLING OBJECTS FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G8985 CARRYING, MOVING AND HANDLING OBJECTS, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8986 CARRYING, MOVING & HANDLING OBJECTS FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       J0591 INJECTION, DEOXYCHOLIC ACID, 1 MG See Note N/A   Noncovered healthcare service       G8988 SELF CARE FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       S4015 COMPLETE IN VITRO FERTILIZATION CYCLE, NOT OTHERWISE SPECIFIED, CASE RATE See Note N/A   Noncovered healthcare service       G8990 OTHER PHYSICAL OR OCCUPATIONAL THERAPY PRIMARY FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G8991 OTHER PHYSICAL OR OCCUPATIONAL THERAPY PRIMARY FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8992 OTHER PHYSICAL OR OCCUPATIONAL THERAPY PRIMARY FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8993 OTHER PHYSICAL OR OCCUPATIONAL THERAPY SUBSEQUENT FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G8994 OTHER PHYSICAL OR OCCUPATIONAL THERAPY SUBSEQUENT FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8995 OTHER PHYSICAL OR OCCUPATIONAL THERAPY SUBSEQUENT FUNCTIONAL LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8996 SWALLOWING FUNCTIONAL LIMITATION, CURRENT STATUS AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G8997 SWALLOWING FUNCTIONAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING See Note N/A   Noncovered healthcare service       G8987 SELF CARE FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G9037 INTERPROFESSIONAL TELEPHONE/INTERNET/ELECTRONIC HEALTH RECORD CLINICAL QUESTION/REQUEST FOR SPECIALTY RECOMMENDATIONS BY A TREATING/REQUESTING PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL FOR THE CARE OF THE PATIENT (I.E. NOT FOR PROFESSIONAL EDU See Note N/A   Noncovered healthcare service       0458U ONCOLOGY (BREAST CANCER), S100A8 AND S100A9, BY ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA), TEAR FLUID WITH AGE, ALGORITHM REPORTED AS A RISK SCORE See Note N/A   Noncovered healthcare service       0459U β-AMYLOID (ABETA42) AND TOTAL TAU (TTAU), ELECTROCHEMILUMINESCENT IMMUNOASSAY (ECLIA), CEREBRAL SPINAL FLUID, RATIO REPORTED AS POSITIVE OR NEGATIVE FOR AMYLOID PATHOLOGY See Note N/A   Noncovered healthcare service       0466U CARDIOLOGY (CORONARY ARTERY DISEASE [CAD]), DNA, GENOME-WIDE ASSOCIATION STUDIES (564856 SINGLE-NUCLEOTIDE POLYMORPHISMS [SNPS], TARGETED VARIANT GENOTYPING), PATIENT LIFESTYLE AND CLINICAL DATA, BUCCAL SWAB, ALGORITHM REPORTED AS POLYGENIC RISK TO ACQUIR See Note N/A   Noncovered healthcare service       0473U ONCOLOGY (SOLID TUMOR), NEXT-GENERATION SEQUENCING (NGS) OF DNA FROM FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE WITH COMPARATIVE SEQUENCE ANALYSIS FROM A MATCHED NORMAL SPECIMEN (BLOOD OR SALIVA), 648 GENES, INTERROGATION FOR SEQUENCE VARIANTS, INSERT See Note N/A   Noncovered healthcare service       0474U HEREDITARY PAN-CANCER (EG, HEREDITARY SARCOMAS, HEREDITARY ENDOCRINE TUMORS, HEREDITARY NEUROENDOCRINE TUMORS, HEREDITARY CUTANEOUS MELANOMA), GENOMIC SEQUENCE ANALYSIS PANEL OF 88 GENES WITH 20 DUPLICATIONS/DELETIONS USING NEXT-GENERATION SEQUENCING (NGS See Note N/A   Noncovered healthcare service       0475U HEREDITARY PROSTATE CANCER-RELATED DISORDERS, GENOMIC SEQUENCE ANALYSIS PANEL USING NEXT-GENERATION SEQUENCING (NGS), SANGER SEQUENCING, MULTIPLEX LIGATION-DEPENDENT PROBE AMPLIFICATION (MLPA), AND ARRAY COMPARATIVE GENOMIC HYBRIDIZATION (CGH), EVALUATION See Note N/A   Noncovered healthcare service       A9293 FERTILITY CYCLE (CONTRACEPTION & CONCEPTION) TRACKING SOFTWARE APPLICATION, FDA CLEARED, PER MONTH, INCLUDES ACCESSORIES (E.G., THERMOMETER) See Note N/A   Noncovered healthcare service       G0529 IN-HOME RESPITE CARE, 4-HOUR UNIT, FOR USE IN CMMI MODEL See Note N/A   Noncovered healthcare service       S4013 COMPLETE CYCLE, GAMETE INTRAFALLOPIAN TRANSFER (GIFT), CASE RATE See Note N/A   Noncovered healthcare service       G0531 FACILITY-BASED RESPITE, 24-HOUR UNIT, FOR USE IN CMMI MODEL See Note N/A   Noncovered healthcare service       0449U CARRIER SCREENING FOR SEVERE INHERITED CONDITIONS (EG, CYSTIC FIBROSIS, SPINAL MUSCULAR ATROPHY, BETA HEMOGLOBINOPATHIES [INCLUDING SICKLE CELL DISEASE], ALPHA THALASSEMIA), REGARDLESS OF RACE OR SELF-IDENTIFIED ANCESTRY, GENOMIC SEQUENCE ANALYSIS PANEL, See Note N/A   Noncovered healthcare service       G9038 CO-MANAGEMENT SERVICES WITH THE FOLLOWING ELEMENTS: NEW DIAGNOSIS OR ACUTE EXACERBATION AND STABILIZATION OF EXISTING CONDITION; CONDITION WHICH MAY BENEFIT FROM JOINT CARE PLANNING; CONDITION FOR WHICH SPECIALIST IS TAKING A CO-MANAGEMENT ROLE; CONDITION See Note N/A   Noncovered healthcare service       H0051 TRADITIONAL HEALING SERVICE See Note N/A   Noncovered healthcare service       S4988 PENILE CONTRACTURE DEVICE, MANUAL, GREATER THAN 3 LBS TRACTION FORCE See Note N/A   Noncovered healthcare service       J7512 PREDNISONE See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J7527 EVEROLIMUS See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       J8501 APREPITANT, ORAL, 5 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       G8978 MOBILITY: WALKING & MOVING AROUND FUNCTIONAL LIMITATION, CURRENT STATUS, AT THERAPY EPISODE OUTSET AND AT REPORTING INTERVALS See Note N/A   Noncovered healthcare service       G0530 ADULT DAY CENTER, 8-HOUR UNIT, FOR USE IN CMMI MODEL See Note N/A   Noncovered healthcare service       S4027 STORAGE OF PREVIOUSLY FROZEN EMBRYOS See Note N/A   Noncovered healthcare service       J8515 CABERGOLINE, ORAL, 0.25 MG See Note N/A   Oral drug processed through the Pharmacy Benefit. Consult the Pharmacy formulary for preauthorization requirements.       S4016 FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATE See Note N/A   Noncovered healthcare service       S4017 INCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO STIMULATION, CASE RATE See Note N/A   Noncovered healthcare service       S4018 FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE See Note N/A   Noncovered healthcare service       S4020 IN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATE See Note N/A   Noncovered healthcare service       S4021 IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE See Note N/A   Noncovered healthcare service       S4022 ASSISTED OOCYTE FERTILIZATION, CASE RATE See Note N/A   Noncovered healthcare service       S4023 DONOR EGG CYCLE, INCOMPLETE, CASE RATE See Note N/A   Noncovered healthcare service       0457U PERFLUOROALKYL SUBSTANCES (PFAS) (EG, PERFLUOROOCTANOIC ACID, PERFLUOROOCTANE SULFONIC ACID), 9 PFAS COMPOUNDS BY LC-MS/MS, PLASMA OR SERUM, QUANTITATIVE See Note N/A   Noncovered healthcare service       S4026 PROCUREMENT OF DONOR SPERM FROM SPERM BANK See Note N/A   Noncovered healthcare service       0454U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), IDENTIFICATION OF COPY NUMBER VARIATIONS, INVERSIONS, INSERTIONS, TRANSLOCATIONS, AND OTHER STRUCTURAL VARIANTS BY OPTICAL GENOME MAPPING See Note N/A   Noncovered healthcare service       S4035 STIMULATED INTRAUTERINE INSEMINATION (IUI), CASE RATE See Note N/A   Noncovered healthcare service       S8948 APPLICATION OF A MODALITY (REQUIRING CONSTANT PROVIDER ATTENDANCE) TO ONE OR MORE AREAS; LOW-HYPHENLEVEL LASER; EACH 15 MINUTES See Note N/A   Noncovered healthcare service       0204U ONCOLOGY (THYROID), MRNA, GENE EXPRESSION ANALYSIS OF 593 GENES (INCLUDING BRAF, RAS, RET, PAX8, AND NTRK) FOR SEQUENCE VARIANTS AND REARRANGEMENTS, UTILIZING FINE NEEDLE ASPIRATE, REPORTED AS DETECTED OR NOT DETECTED See Note N/A   Noncovered healthcare service       0416U DETECTION OF DNA OF 20 ORGANISMS IN URINE See Note N/A   Noncovered healthcare service       0439U CARDIOLOGY (CORONARY HEART DISEASE [CHD]), DNA, ANALYSIS OF 5 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) (RS11716050 [LOC105376934], RS6560711 [WDR37], RS3735222 [SCIN/LOC107986769], RS6820447 [INTERGENIC], AND RS9638144 [ESYT2]) AND 3 DNA METHYLATION MARKERS See Note N/A   Noncovered healthcare service       0446U AUTOIMMUNE DISEASES (SYSTEMIC LUPUS ERYTHEMATOSUS [SLE]), ANALYSIS OF 10 CYTOKINE SOLUBLE MEDIATOR BIOMARKERS BY IMMUNOASSAY, PLASMA, INDIVIDUAL COMPONENTS REPORTED WITH AN ALGORITHMIC RISK SCORE FOR CURRENT DISEASE ACTIVITY See Note N/A   Noncovered healthcare service       0447U AUTOIMMUNE DISEASES (SYSTEMIC LUPUS ERYTHEMATOSUS [SLE]), ANALYSIS OF 11 CYTOKINE SOLUBLE MEDIATOR BIOMARKERS BY IMMUNOASSAY, PLASMA, INDIVIDUAL COMPONENTS REPORTED WITH AN ALGORITHMIC PROGNOSTIC RISK SCORE FOR DEVELOPING A CLINICAL FLARE See Note N/A   Noncovered healthcare service       0448U ONCOLOGY (LUNG AND COLON CANCER), DNA, QUALITATIVE, NEXT-GENERATION SEQUENCING DETECTION OF SINGLE-NUCLEOTIDE VARIANTS AND DELETIONS IN EGFR AND KRAS GENES, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) SOLID TUMOR SAMPLES, REPORTED AS PRESENCE OR ABSENCE OF TA See Note N/A   Noncovered healthcare service       S4014 COMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT), CASE RATE See Note N/A   Noncovered healthcare service       S4025 DONOR SERVICES FOR IN VITRO FERTILIZATION (SPERM OR EMBRYO), CASE RATE See Note N/A   Noncovered healthcare service       0431T REMOVAL AND REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA, PULSE GENERATOR ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0435U ONCOLOGY, CHEMOTHERAPEUTIC DRUG CYTOTOXICITY ASSAY OF CANCER STEM CELLS (CSCS), FROM CULTURED CSCS AND PRIMARY TUMOR CELLS, CATEGORICAL DRUG RESPONSE REPORTED BASED ON CYTOTOXICITY PERCENTAGE OBSERVED, MINIMUM OF 14 DRUGS OR DRUG COMBINATIONS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0425U GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME), RAPID SEQUENCE ANALYSIS, EACH COMPARATOR GENOME (EG, PARENTS, SIBLINGS) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0426T INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0426U GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME), ULTRA-RAPID SEQUENCE ANALYSIS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0427T INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; PULSE GENERATOR ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0428T REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; PULSE GENERATOR ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0428U ONCOLOGY (BREAST), TARGETED HYBRID-CAPTURE GENOMIC SEQUENCE ANALYSIS PANEL, CIRCULATING TUMOR DNA (CTDNA) ANALYSIS OF 56 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY, AND TUMOR MUTATION BURDEN Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0429T REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0424U ONCOLOGY (PROSTATE), EXOSOME-BASED ANALYSIS OF 53 SMALL NONCODING RNAS (SNCRNAS) BY QUANTITATIVE REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION (RT-QPCR), URINE, REPORTED AS NO MOLECULAR EVIDENCE, LOW-, MODERATE-, OR ELEVATED-RISK OF PROSTATE CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0430U GASTROENTEROLOGY, MALABSORPTION EVALUATION OF ALPHA-1-ANTITRYPSIN, CALPROTECTIN, PANCREATIC ELASTASE AND REDUCING SUBSTANCES, FECES, QUANTITATIVE Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0424T COMPLETE SYSTEM (TRANSVENOUS PLACEMENT OF RIGHT OR LEFT STIMULATION LEAD, SENSING LEAD, IMPLANTABLE PULSE GENERATOR) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0431U GLYCINE RECEPTOR ALPHA1 IGG, SERUM OR CEREBROSPINAL FLUID (CSF), LIVE CELL-BINDING ASSAY (LCBA), QUALITATIVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0432T REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0432U KELCH-LIKE PROTEIN 11 (KLHL11) ANTIBODY, SERUM OR CEREBROSPINAL FLUID (CSF), CELL-BINDING ASSAY, QUALITATIVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0433T REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0433U ONCOLOGY (PROSTATE), 5 DNA REGULATORY MARKERS BY QUANTITATIVE PCR, WHOLE BLOOD, ALGORITHM, INCLUDING PROSTATE-SPECIFIC ANTIGEN, REPORTED AS LIKELIHOOD OF CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0434T INTERROGATION DEVICE EVALUATION IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM FOR CENTRAL SLEEP APNEA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0434U DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), GENOMIC ANALYSIS PANEL, VARIANT ANALYSIS OF 25 GENES WITH REPORTED PHENOTYPES Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0407U NEPHROLOGY (DIABETIC CHRONIC KIDNEY DISEASE [CKD]), MULTIPLEX ELECTROCHEMILUMINESCENT IMMUNOASSAY (ECLIA) OF SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR 1 (STNFR1), SOLUBLE TUMOR NECROSIS RECEPTOR 2 (STNFR2), AND KIDNEY INJURY MOLECULE 1 (KIM-1) COMBINED WITH CLINICAL DATA, PLASMA, ALGORITHM REPORTED AS RISK FOR PROGRESSIVE DECLINE IN KIDNEY FUNCTION Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0430T REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0419T DESTRUCTION OF NEUROFIBROMA, EXTENSIVE (CUTANEOUS, DERMAL EXTENDING INTO SUBCUTANEOUS); FACE, HEAD AND NECK, GREATER THAN 50 NEUROFIBROMAS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     90875 BIOFEEDBACK See Note N/A   Noncovered healthcare service       0409U ONCOLOGY (SOLID TUMOR), DNA (80 GENES) AND RNA (36 GENES), BY NEXT-GENERATION SEQUENCING FROM PLASMA, INCLUDING SINGLE NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, COPY NUMBER ALTERATIONS, MICROSATELLITE INSTABILITY, AND FUSIONS, REPORT SHOWING IDENTIFIED MUTATIONS WITH CLINICAL ACTIONABILITY Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0410U ONCOLOGY (PANCREATIC), DNA, WHOLE GENOME SEQUENCING WITH 5-HYDROXYMETHYLCYTOSINE ENRICHMENT, WHOLE BLOOD OR PLASMA, ALGORITHM REPORTED AS CANCER DETECTED OR NOT DETECTED Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0411U PSYCHIATRY (EG, DEPRESSION, ANXIETY, ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD]), GENOMIC ANALYSIS PANEL, VARIANT ANALYSIS OF 15 GENES, INCLUDING DELETION/DUPLICATION ANALYSIS OF CYP2D6 Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0412U BETA AMYLOID, Aβ42/40 RATIO, IMMUNOPRECIPITATION WITH QUANTITATION BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) AND QUALITATIVE APOE ISOFORM-SPECIFIC PROTEOTYPING, PLASMA COMBINED WITH AGE, ALGORITHM REPORTED AS PRESENCE OR ABSENCE OF BRAIN AMYLOID PATHOLOGY Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0413U ONCOLOGY (HEMATOLYMPHOID NEOPLASM), OPTICAL GENOME MAPPING FOR COPY NUMBER ALTERATIONS, ANEUPLOIDY, AND BALANCED/COMPLEX STRUCTURAL REARRANGEMENTS, DNA FROM BLOOD OR BONE MARROW, REPORT OF CLINICALLY SIGNIFICANT ALTERATIONS Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0414U ONCOLOGY (LUNG), AUGMENTATIVE ALGORITHMIC ANALYSIS OF DIGITIZED WHOLE SLIDE IMAGING FOR 8 GENES (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), AND KRAS G12C AND PD-L1, IF PERFORMED, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, REPORTED AS POSITIVE OR NEGATIVE FOR EACH BIOMARKER Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0415U CARDIOVASCULAR DISEASE (ACUTE CORONARY SYNDROME [ACS]), IL-16, FAS, FASLIGAND, HGF, CTACK, EOTAXIN, AND MCP-3 BY IMMUNOASSAY COMBINED WITH AGE, SEX, FAMILY HISTORY, AND PERSONAL HISTORY OF DIABETES, BLOOD, ALGORITHM REPORTED AS A 5-YEAR (DELETED RISK) SCORE FOR ACS Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0425T INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0418U ONCOLOGY (BREAST), AUGMENTATIVE ALGORITHMIC ANALYSIS OF DIGITIZED WHOLE SLIDE IMAGING OF 8 HISTOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES, REPORTED AS A RECURRENCE SCORE Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0436T PROGRAMMING DEVICE EVALUATION OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM FOR CENTRAL SLEEP APNEA; DURING SLEEP STUDY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0419U NEUROPSYCHIATRY (EG, DEPRESSION, ANXIETY), GENOMIC SEQUENCE ANALYSIS PANEL, VARIANT ANALYSIS OF 13 GENES, SALIVA OR BUCCAL SWAB, REPORT OF EACH GENE PHENOTYPE Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0420T DESTRUCTION OF NEUROFIBROMA, EXTENSIVE (CUTANEOUS, DERMAL EXTENDING INTO SUBCUTANEOUS); TRUNK AND EXTREMITIES, EXTENSIVE, GREATER THAN 100 NEUROFIBROMAS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0420U ONCOLOGY (UROTHELIAL), MRNA EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF MDK, HOXA13, CDC2, IGFBP5, AND CXCR2 IN COMBINATION WITH DROPLET DIGITAL PCR (DDPCR) ANALYSIS OF 6 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) OF GENES TERT AND FGFR3, URINE, ALGORITHM REPORTED AS A RISK SCORE FOR UROTHELIAL CARCINOMA Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0421T TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0421U ONCOLOGY (COLORECTAL) SCREENING, QUANTITATIVE REAL-TIME TARGET AND SIGNAL AMPLIFICATION OF 8 RNA MARKERS (GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2) AND FECAL HEMOGLOBIN, ALGORITHM REPORTED AS A POSITIVE OR NEGATIVE FOR COLORECTAL CANCER RISK Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0422U ONCOLOGY (PAN-SOLID TUMOR), ANALYSIS OF DNA BIOMARKER RESPONSE TO ANTI-CANCER THERAPY USING CELL-FREE CIRCULATING DNA, BIOMARKER COMPARISON TO A PREVIOUS BASELINE PRE-TREATMENT CELL-FREE CIRCULATING DNA ANALYSIS USING NEXT-GENERATION SEQUENCING, ALGORITHM REPORTED AS A QUANTITATIVE CHANGE FROM BASELINE, INCLUDING SPECIFIC ALTERATIONS, IF APPROPRIATE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0423T SECRETORY TYPE II PHOSPHOLIPASE A2 (SPLA2-IIA) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0423U PSYCHIATRY (EG, DEPRESSION, ANXIETY), GENOMIC ANALYSIS PANEL, INCLUDING VARIANT ANALYSIS OF 26 GENES, BUCCAL SWAB, REPORT INCLUDING METABOLIZER STATUS AND RISK OF DRUG TOXICITY BY CONDITION Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0417U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE MITOCHONDRIAL GENOME SEQUENCE WITH HETEROPLASMY DETECTION AND DELETION ANALYSIS, NUCLEAR-ENCODED MITOCHONDRIAL GENE ANALYSIS OF 335 NUCLEAR GENES, INCLUDING SEQUENCE CHANGES, DELETIONS, INSERTIONS, AND COPY NUMBER VARIANTS ANALYSIS, BLOOD OR SALIVA, IDENTIFICATION AND CATEGORIZATION OF MITOCHONDRIAL DISORDER-ASSOCIATED GENETIC VARIANTS Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0463U ONCOLOGY (CERVIX), MRNA GENE EXPRESSION PROFILING OF 14 BIOMARKERS (E6 AND E7 OF THE HIGHEST-RISK HUMAN PAPILLOMAVIRUS [HPV] TYPES 16, 18, 31, 33, 45, 52, 58), BY REAL-TIME NUCLEIC ACID SEQUENCE-BASED AMPLIFICATION (NASBA), EXO- OR ENDOCERVICAL EPITHELIAL CELLS, ALGORITHM REPORTED AS POSITIVE OR NEGATIVE FOR INCREASED RISK OF CERVICAL DYSPLASIA OR CANCER FOR EACH BIOMARKER Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0435T PROGRAMMING DEVICE EVALUATION OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM FOR CENTRAL SLEEP APNEA; SINGLE SESSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0457T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; MECHANO-ELECTRICAL SKIN INTERFACE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0458T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; SUBCUTANEOUS ELECTRODE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0459T RELOCATION OF SKIN POCKET WITH REPLACEMENT OF IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE, MECHANO-ELECTRICAL SKIN INTERFACE AND ELECTRODES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0460T REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE; SUBCUTANEOUS ELECTRODE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0460U ONCOLOGY, WHOLE BLOOD OR BUCCAL, DNA SINGLE-NUCLEOTIDE POLYMORPHISM (SNP) GENOTYPING BY REAL-TIME PCR OF 24 GENES, WITH VARIANT ANALYSIS AND REPORTED PHENOTYPES Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0461T REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE; AORTIC COUNTERPULSATION DEVICE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0461U ONCOLOGY, PHARMACOGENOMIC ANALYSIS OF SINGLE-NUCLEOTIDE POLYMORPHISM (SNP) GENOTYPING BY REAL-TIME PCR OF 24 GENES, WHOLE BLOOD OR BUCCAL SWAB, WITH VARIANT ANALYSIS, INCLUDING IMPACTED GENE-DRUG INTERACTIONS AND REPORTED PHENOTYPES Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0456T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0463T INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0455T COMPLETE SYSTEM (AORTIC COUNTERPULSATION DEVICE, VASCULAR HEMOSTATIC SEAL, MECHANO-ELECTRICAL SKIN INTERFACE AND ELECTRODES) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0464T VISUAL EVOKED POTENTIAL, TESTING FOR GLAUCOMA, WITH INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0464U ONCOLOGY (COLORECTAL) SCREENING, QUANTITATIVE REAL-TIME TARGET AND SIGNAL AMPLIFICATION, METHYLATED DNA MARKERS, INCLUDING LASS4, LRRC4 AND PPP2R5C, A REFERENCE MARKER ZDHHC1, AND A PROTEIN MARKER (FECAL HEMOGLOBIN), UTILIZING STOOL, ALGORITHM REPORTED AS A POSITIVE OR NEGATIVE RESULT Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0465T SUPRACHOROIDAL INJECTION OF A PHARMACOLOGIC AGENT (DOES NOT INCLUDE SUPPLY OF MEDICATION) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0465U ONCOLOGY (UROTHELIAL CARCINOMA), DNA, QUANTITATIVE METHYLATION-SPECIFIC PCR OF 2 GENES (ONECUT2, VIM), ALGORITHMIC ANALYSIS REPORTED AS POSITIVE OR NEGATIVE Yes 9/1/2024     OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines   0467U ONCOLOGY (BLADDER), DNA, NEXT-GENERATION SEQUENCING (NGS) OF 60 GENES AND WHOLE GENOME ANEUPLOIDY, URINE, ALGORITHMS REPORTED AS MINIMAL RESIDUAL DISEASE (MRD) STATUS POSITIVE OR NEGATIVE AND QUANTITATIVE DISEASE BURDEN Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0468U HEPATOLOGY (NONALCOHOLIC STEATOHEPATITIS [NASH]), MIR-34A-5P, ALPHA 2-MACROGLOBULIN, YKL40, HBA1C, SERUM AND WHOLE BLOOD, ALGORITHM REPORTED AS A SINGLE SCORE FOR NASH ACTIVITY AND FIBROSIS Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0469T RETINAL POLARIZATION SCAN, OCULAR SCREENING WITH ON-SITE AUTOMATED RESULTS, BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0469U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE GENOME SEQUENCE ANALYSIS FOR CHROMOSOMAL ABNORMALITIES, COPY NUMBER VARIANTS, DUPLICATIONS/DELETIONS, INVERSIONS, UNBALANCED TRANSLOCATIONS, REGIONS OF HOMOZYGOSITY (ROH), INHERITANCE PATTERN THAT INDICATE UNIPARENTAL DISOMY (UPD), AND ANEUPLOIDY, FETAL SAMPLE (AMNIOTIC FLUID, CHORIONIC VILLUS SAMPLE, OR PRODUCTS OF CONCEPTION), IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS, DIAGNOSTIC REPORT OF FETAL RESULTS BASED ON PHENOTYPE WI Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0462T PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE MECHANO-ELECTRICAL SKIN INTERFACE AND/OR EXTERNAL DRIVER TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING REVIEW AND REPORT, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0445U β-AMYLOID (ABETA42) AND PHOSPHO TAU (181P) (PTAU181), ELECTROCHEMILUMINESCENT IMMUNOASSAY (ECLIA), CEREBRAL SPINAL FLUID, RATIO REPORTED AS POSITIVE OR NEGATIVE FOR AMYLOID PATHOLOGY Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0436U ONCOLOGY (LUNG), PLASMA ANALYSIS OF 388 PROTEINS, USING APTAMER-BASED PROTEOMICS TECHNOLOGY, PREDICTIVE ALGORITHM REPORTED AS CLINICAL BENEFIT FROM IMMUNE CHECKPOINT INHIBITOR THERAPY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0437U PSYCHIATRY (ANXIETY DISORDERS), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 15 BIOMARKERS, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0438U DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), BUCCAL SPECIMEN, GENE-DRUG INTERACTIONS, VARIANT ANALYSIS OF 33 GENES, INCLUDING DELETION/DUPLICATION ANALYSIS OF CYP2D6, INCLUDING REPORTED PHENOTYPES AND IMPACTED GENE-DRUG INTERACTIONS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0440U CARDIOLOGY (CORONARY HEART DISEASE [CHD]), DNA, ANALYSIS OF 10 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) (RS710987 [LINC010019], RS1333048 [CDKN2B-AS1], RS12129789 [KCND3], RS942317 [KTN1-AS1], RS1441433 [PPP3CA], RS2869675 [PREX1], RS4639796 [ZBTB41], RS4376434 [LINC00972], RS12714414 [TMEM18], AND RS7585056 [TMEM18]) AND 6 DNA METHYLATION MARKERS (CG03725309 [SARS1], CG12586707 [CXCL1], CG04988978 [MPO], CG17901584 [DHCR24-DT], CG21161138 [AHRR], AND CG12655112 [EHD4]), QPCR AND DIGITAL PCR, WHOL Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0441U INFECTIOUS DISEASE (BACTERIAL, FUNGAL, OR VIRAL INFECTION), SEMIQUANTITATIVE BIOMECHANICAL ASSESSMENT (VIA DEFORMABILITY CYTOMETRY), WHOLE BLOOD, WITH ALGORITHMIC ANALYSIS AND RESULT REPORTED AS AN INDEX Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0442U INFECTIOUS DISEASE (RESPIRATORY INFECTION), MYXOVIRUS RESISTANCE PROTEIN A (MXA) AND C-REACTIVE PROTEIN (CRP), FINGERSTICK WHOLE BLOOD SPECIMEN, EACH BIOMARKER REPORTED AS PRESENT OR ABSENT Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0443U NEUROFILAMENT LIGHT CHAIN (NFL), ULTRA-SENSITIVE IMMUNOASSAY, SERUM OR CEREBROSPINAL FLUID Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0444T INITIAL PLACEMENT OF A DRUG-ELUTING OCULAR INSERT UNDER ONE OR MORE EYELIDS, INCLUDING FITTING, TRAINING, AND INSERTION, UNILATERAL OR BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0456U AUTOIMMUNE (RHEUMATOID ARTHRITIS), NEXT-GENERATION SEQUENCING (NGS), GENE EXPRESSION TESTING OF 19 GENES, WHOLE BLOOD, WITH ANALYSIS OF ANTI-CYCLIC CITRULLINATED PEPTIDES (CCP) LEVELS, COMBINED WITH SEX, PATIENT GLOBAL ASSESSMENT, AND BODY MASS INDEX (BMI), ALGORITHM REPORTED AS A SCORE THAT PREDICTS NONRESPONSE TO TUMOR NECROSIS FACTOR INHIBITOR (TNFI) THERAPY Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0445T SUBSEQUENT PLACEMENT OF A DRUG-ELUTING OCULAR INSERT UNDER ONE OR MORE EYELIDS, INCLUDING RE-TRAINING, AND REMOVAL OF EXISTING INSERT, UNILATERAL OR BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0406U ONCOLOGY (LUNG), FLOW CYTOMETRY, SPUTUM, 5 MARKERS (MESO-TETRA [4-CARBOXYPHENYL] PORPHYRIN [TCPP], CD206, CD66B, CD3, CD19), ALGORITHM REPORTED AS LIKELIHOOD OF LUNG CANCER Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0450U ONCOLOGY (MULTIPLE MYELOMA), LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), MONOCLONAL PARAPROTEIN SEQUENCING ANALYSIS, SERUM, RESULTS REPORTED AS BASELINE PRESENCE OR ABSENCE OF DETECTABLE CLONOTYPIC PEPTIDES Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0451T COMPLETE SYSTEM (COUNTERPULSATION DEVICE, VASCULAR GRAFT, IMPLANTABLE VASCULAR HEMOSTATIC SEAL, MECHANO-ELECTRICAL SKIN INTERFACE AND SUBCUTANEOUS ELECTRODES) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0451U ONCOLOGY (MULTIPLE MYELOMA), LC-MS/MS, PEPTIDE ION QUANTIFICATION, SERUM, RESULTS COMPARED WITH BASELINE TO DETERMINE MONOCLONAL PARAPROTEIN ABUNDANCE Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0452T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0452U ONCOLOGY (BLADDER), METHYLATED PENK DNA DETECTION BY LINEAR TARGET ENRICHMENT-QUANTITATIVE METHYLATION-SPECIFIC REAL-TIME PCR (LTE-QMSP), URINE, REPORTED AS LIKELIHOOD OF BLADDER CANCER Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0453T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; MECHANO-ELECTRICAL SKIN INTERFACE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0453U ONCOLOGY (COLORECTAL CANCER), CELL-FREE DNA (CFDNA), METHYLATION-BASED QUANTITATIVE PCR ASSAY (SEPTIN9, IKZF1, BCAT1, SEPTIN9-2, VAV3, BCAN), PLASMA, REPORTED AS PRESENCE OR ABSENCE OF CIRCULATING TUMOR DNA (CTDNA) Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0454T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; SUBCUTANEOUS ELECTRODE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0444U ONCOLOGY (SOLID ORGAN NEOPLASIA), TARGETED GENOMIC SEQUENCE ANALYSIS PANEL OF 361 GENES, INTERROGATION FOR GENE FUSIONS, TRANSLOCATIONS, OR OTHER REARRANGEMENTS, USING DNA FROM FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TUMOR TISSUE, REPORT OF CLINICALLY SIGNIFICANT VARIANT(S) Yes 9/1/2024     OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines   0349U DRUG METABOLISM OR PROCESSING (MULTIPLE CONDITIONS), WHOLE BLOOD OR BUCCAL SPECIMEN, DNA ANALYSIS, 27 GENE REPORT, WITH VARIANT ANALYSIS, INCLUDING REPORTED PHENOTYPES AND IMPACTED GENE-DRUG INTERACTIONS Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0360U ONCOLOGY (LUNG), ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) OF 7 AUTOANTIBODIES (P53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, AND HUD), PLASMA, ALGORITHM REPORTED AS A CATEGORICAL RESULT FOR RISK OF MALIGNANCY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0342U ONCOLOGY (PANCREATIC CANCER), MULTIPLEX IMMUNOASSAY OF C5, C4, CYSTATIN C, FACTOR B, OSTEOPROTEGERIN (OPG), GELSOLIN, IGFBP3, CA125 AND MULTIPLEX ELECTROCHEMILUMINESCENT IMMUNOASSAY (ECLIA) FOR CA19-9, SERUM, DIAGNOSTIC ALGORITHM REPORTED QUALITATIVELY AS POSITIVE, NEGATIVE, OR BORDERLINE Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0343U ONCOLOGY (PROSTATE), EXOSOME-BASED ANALYSIS OF 442 SMALL NONCODING RNAS (SNCRNAS) BY QUANTITATIVE REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION (RT-QPCR), URINE, REPORTED AS MOLECULAR EVIDENCE OF NO-, LOW-, INTERMEDIATE- OR HIGH-RISK OF PROSTATE CANCER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0344U HEPATOLOGY (NONALCOHOLIC FATTY LIVER DISEASE [NAFLD]), SEMIQUANTITATIVE EVALUATION OF 28 LIPID MARKERS BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), SERUM, REPORTED AS AT-RISK FOR NONALCOHOLIC STEATOHEPATITIS (NASH) OR NOT NASH Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0345U PSYCHIATRY (EG, DEPRESSION, ANXIETY, ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD]), GENOMIC ANALYSIS PANEL, VARIANT ANALYSIS OF 15 GENES, INCLUDING DELETION/DUPLICATION ANALYSIS OF CYP2D6 Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0347T PLACEMENT OF INTERSTITIAL DEVICE(S) IN BONE FOR RADIOSTEREOMETRIC ANALYSIS (RSA) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0347U DRUG METABOLISM OR PROCESSING (MULTIPLE CONDITIONS), WHOLE BLOOD OR BUCCAL SPECIMEN, DNA ANALYSIS, 16 GENE REPORT, WITH VARIANT ANALYSIS AND REPORTED PHENOTYPES Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0348T RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); SPINE, (INCLUDES CERVICAL, THORACIC AND LUMBOSACRAL, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0341U FETAL ANEUPLOIDY DNA SEQUENCING COMPARATIVE ANALYSIS, FETAL DNA FROM PRODUCTS OF CONCEPTION, REPORTED AS NORMAL (EUPLOIDY), MONOSOMY, TRISOMY, OR PARTIAL DELETION/DUPLICATION, MOSAICISM, AND SEGMENTAL ANEUPLOID Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0349T RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); UPPER EXTREMITY(IES), (INCLUDES SHOULDER, ELBOW, AND WRIST, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0339T TRANSCATHETER RENAL SYMPATHETIC DENERVATION, PERCUTANEOUS APPROACH INCLUDING ARTERIAL PUNCTURE, SELECTIVE CATHETER PLACEMENT(S) RENAL ARTERY(IES), FLUOROSCOPY, CONTRAST INJECTION(S), INTRAPROCEDURAL ROADMAPPING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS, FLUSH AORTOGRAM AND DIAGNOSTIC RENAL ANGIOGRAPHY WHEN PERFORMED; BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0350T RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); LOWER EXTREMITY(IES), (INCLUDES HIP, PROXIMAL FEMUR, KNEE, AND ANKLE, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0350U DRUG METABOLISM OR PROCESSING (MULTIPLE CONDITIONS), WHOLE BLOOD OR BUCCAL SPECIMEN, DNA ANALYSIS, 27 GENE REPORT, WITH VARIANT ANALYSIS AND REPORTED PHENOTYPES Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0351U INFECTIOUS DISEASE (BACTERIAL OR VIRAL), BIOCHEMICAL ASSAYS, TUMOR NECROSIS FACTOR-RELATED APOPTOSIS-INDUCING LIGAND (TRAIL), INTERFERON GAMMA-INDUCED PROTEIN-10 (IP-10), AND C-REACTIVE PROTEIN, SERUM, OR VENOUS WHOLE BLOOD, ALGORITHM REPORTED AS LIKELIHOOD OF BACTERIAL INFECTION Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0355U APOL1 (APOLIPOPROTEIN L1) (EG, CHRONIC KIDNEY DISEASE), RISK VARIANTS (G1, G2) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0356U ONCOLOGY (OROPHARYNGEAL OR ANAL), EVALUATION OF 17 DNA BIOMARKERS USING DROPLET DIGITAL PCR (DDPCR), CELL-FREE DNA, ALGORITHM REPORTED AS A PROGNOSTIC RISK SCORE FOR CANCER RECURRENCE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0358T BIOELECTRICAL IMPEDANCE ANALYSIS WHOLE BODY COMPOSITION ASSESSMENT, WITH INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0358U NEUROLOGY (MILD COGNITIVE IMPAIRMENT), ANALYSIS OF β-AMYLOID 1-42 AND 1-40, CHEMILUMINESCENCE ENZYME IMMUNOASSAY, CEREBRAL SPINAL FLUID, REPORTED AS POSITIVE, LIKELY POSITIVE, OR NEGATIVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0408U INFECTIOUS AGENT ANTIGEN DETECTION BY BULK ACOUSTIC WAVE BIOSENSOR IMMUNOASSAY, SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0348U DRUG METABOLISM OR PROCESSING (MULTIPLE CONDITIONS), WHOLE BLOOD OR BUCCAL SPECIMEN, DNA ANALYSIS, 25 GENE REPORT, WITH VARIANT ANALYSIS AND REPORTED PHENOTYPES Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0331U ONCOLOGY (HEMATOLYMPHOID NEOPLASIA), OPTICAL GENOME MAPPING FOR COPY NUMBER ALTERATIONS AND GENE REARRANGEMENTS UTILIZING DNA FROM BLOOD OR BONE MARROW, REPORT OF CLINICALLY SIGNIFICANT ALTERATIONS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0318U PEDIATRICS (CONGENITAL EPIGENETIC DISORDERS), WHOLE GENOME METHYLATION ANALYSIS BY MICROARRAY FOR 50 OR MORE GENES, BLOOD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0319U NEPHROLOGY (RENAL TRANSPLANT), RNA EXPRESSION BY SELECT TRANSCRIPTOME SEQUENCING, USING PRETRANSPLANT PERIPHERAL BLOOD, ALGORITHM REPORTED AS A RISK SCORE FOR EARLY ACUTE REJECTION Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0321U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), GENITOURINARY PATHOGENS, IDENTIFICATION OF 20 BACTERIAL AND FUNGAL ORGANISMS AND IDENTIFICATION OF 16 ASSOCIATED ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0322U NEUROLOGY (AUTISM SPECTRUM DISORDER [ASD]), QUANTITATIVE MEASUREMENTS OF 14 ACYL CARNITINES AND MICROBIOME-DERIVED METABOLITES, LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), PLASMA, RESULTS REPORTED AS NEGATIVE OR POSITIVE FOR RISK OF METABOLIC SUBTYPES ASSOCIATED WITH ASD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0323U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), CENTRAL NERVOUS SYSTEM PATHOGEN, METAGENOMIC NEXT-GENERATION SEQUENCING, CEREBROSPINAL FLUID (CSF), IDENTIFICATION OF PATHOGENIC BACTERIA, VIRUSES, PARASITES, OR FUNGI Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0326U TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, CELL-FREE CIRCULATING DNA ANALYSIS OF 83 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY AND TUMOR MUTATIONAL BURDEN Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0328U DRUG ASSAY, DEFINITIVE, 120 OR MORE DRUGS AND METABOLITES, URINE, QUANTITATIVE LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), INCLUDES SPECIMEN VALIDITY AND ALGORITHMIC ANALYSIS DESCRIBING DRUG OR METABOLITE AND PRESENCE OR ABSENCE OF RISKS FOR A SIGNIFICANT PATIENT-ADVERSE EVENT, PER DATE OF SERVICE Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0329U ONCOLOGY (NEOPLASIA), EXOME AND TRANSCRIPTOME SEQUENCE ANALYSIS FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS AND DELETIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY AND TUMOR MUTATIONAL BURDEN UTILIZING DNA AND RNA FROM TUMOR WITH DNA FROM NORMAL BLOOD OR SALIVA FOR SUBTRACTION, REPORT OF CLINICALLY SIGNIFICANT MUTATION(S) WITH THERAPY ASSOCIATIONS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0342T THERAPEUTIC APHERESIS WITH SELECTIVE HDL DELIPIDATION AND PLASMA REINFUSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0331T MYOCARDIAL SYMPATHETIC INNERVATION IMAGING, PLANAR QUALITATIVE AND QUANTITATIVE ASSESSMENT; Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0361U NEUROFILAMENT LIGHT CHAIN, DIGITAL IMMUNOASSAY, PLASMA, QUANTITATIVE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0332T MYOCARDIAL SYMPATHETIC INNERVATION IMAGING, PLANAR QUALITATIVE AND QUANTITATIVE ASSESSMENT; WITH TOMOGRAPHIC SPECT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0332U ONCOLOGY (PAN-TUMOR), GENETIC PROFILING OF 8 DNA-REGULATORY (EPIGENETIC) MARKERS BY QUANTITATIVE POLYMERASE CHAIN REACTION (QPCR), WHOLE BLOOD, REPORTED AS A HIGH OR LOW PROBABILITY OF RESPONDING TO IMMUNE CHECKPOINT-INHIBITOR THERAPY Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0333U ONCOLOGY (LIVER), SURVEILLANCE FOR HEPATOCELLULAR CARCINOMA (HCC) IN HIGH-RISK PATIENTS, ANALYSIS OF METHYLATION PATTERNS ON CIRCULATING CELL-FREE DNA (CFDNA) PLUS MEASUREMENT OF SERUM OF AFP/AFP-L3 AND ONCOPROTEIN DES-GAMMA-CARBOXY-PROTHROMBIN (DCP), ALGORITHM REPORTED AS NORMAL OR ABNORMAL RESULT Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0334U ONCOLOGY (SOLID ORGAN), TARGETED GENOMIC SEQUENCE ANALYSIS, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TUMOR TISSUE, DNA ANALYSIS, 84 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY AND TUMOR MUTATIONAL BURDEN Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0335T INSERTION OF SINUS TARSI IMPLANT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0335U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE GENOME SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, COPY NUMBER VARIANTS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, UNIPARENTAL DISOMY (UPD), INVERSIONS, ANEUPLOIDY, MITOCHONDRIAL GENOME SEQUENCE ANALYSIS WITH HETEROPLASMY AND LARGE DELETIONS, SHORT TANDEM REPEAT (STR) GENE EXPANSIONS, FETAL SAMPLE, IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0336U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE GENOME SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, COPY NUMBER VARIANTS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, UNIPARENTAL DISOMY (UPD), INVERSIONS, ANEUPLOIDY, MITOCHONDRIAL GENOME SEQUENCE ANALYSIS WITH HETEROPLASMY AND LARGE DELETIONS, SHORT TANDEM REPEAT (STR) GENE EXPANSIONS, BLOOD OR SALIVA, IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS, EACH COMPARATOR GENOME (EG, PARENT) Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0338T TRANSCATHETER RENAL SYMPATHETIC DENERVATION, PERCUTANEOUS APPROACH INCLUDING ARTERIAL PUNCTURE, SELECTIVE CATHETER PLACEMENT(S) RENAL ARTERY(IES), FLUOROSCOPY, CONTRAST INJECTION(S), INTRAPROCEDURAL ROADMAPPING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS, FLUSH AORTOGRAM AND DIAGNOSTIC RENAL ANGIOGRAPHY WHEN PERFORMED; UNILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0330T TEAR FILM IMAGING, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0394T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0359U ONCOLOGY (PROSTATE CANCER), ANALYSIS OF ALL PROSTATE-SPECIFIC ANTIGEN (PSA) STRUCTURAL ISOFORMS BY PHASE SEPARATION AND IMMUNOASSAY, PLASMA, ALGORITHM REPORTS RISK OF CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0384U NEPHROLOGY (CHRONIC KIDNEY DISEASE), CARBOXYMETHYLLYSINE, METHYLGLYOXAL HYDROIMIDAZOLONE, AND CARBOXYETHYL LYSINE BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) AND HBA1C AND ESTIMATED GLOMERULAR FILTRATION RATE (GFR), WITH RISK SCORE REPORTED FOR PREDICTIVE PROGRESSION TO HIGH-STAGE KIDNEY DISEASE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0385U NEPHROLOGY (CHRONIC KIDNEY DISEASE), APOLIPOPROTEIN A4 (APOA4), CD5 ANTIGEN-LIKE (CD5L), AND INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN 3 (IGFBP3) BY ENZYME-LINKED IMMUNOASSAY (ELISA), PLASMA, ALGORITHM COMBINING RESULTS WITH HDL, ESTIMATED GLOMERULAR FILTRATION RATE (GFR) AND CLINICAL DATA REPORTED AS A RISK SCORE FOR DEVELOPING DIABETIC KIDNEY DISEASE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0387U ONCOLOGY (MELANOMA), AUTOPHAGY AND BECLIN 1 REGULATOR 1 (AMBRA1) AND LORICRIN (AMLO) BY IMMUNOHISTOCHEMISTRY, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, REPORT FOR RISK OF PROGRESSION Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0388U ONCOLOGY (NON-SMALL CELL LUNG CANCER), NEXT-GENERATION SEQUENCING WITH IDENTIFICATION OF SINGLE NUCLEOTIDE VARIANTS, COPY NUMBER VARIANTS, INSERTIONS AND DELETIONS, AND STRUCTURAL VARIANTS IN 37 CANCER-RELATED GENES, PLASMA, WITH REPORT FOR ALTERATION DETECTION Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0389U PEDIATRIC FEBRILE ILLNESS (KAWASAKI DISEASE [KD]), INTERFERON ALPHA-INDUCIBLE PROTEIN 27 (IFI27) AND MAST CELL-EXPRESSED MEMBRANE PROTEIN 1 (MCEMP1), RNA, USING QUANTITATIVE REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION (RT-QPCR), BLOOD, REPORTED AS A RISK SCORE FOR KD Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0390U OBSTETRICS (PREECLAMPSIA), KINASE INSERT DOMAIN RECEPTOR (KDR), ENDOGLIN (ENG), AND RETINOL-BINDING PROTEIN 4 (RBP4), BY IMMUNOASSAY, SERUM, ALGORITHM REPORTED AS A RISK SCORE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0391U ONCOLOGY (SOLID TUMOR), DNA AND RNA BY NEXT-GENERATION SEQUENCING, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, 437 GENES, INTERPRETIVE REPORT FOR SINGLE NUCLEOTIDE VARIANTS, SPLICE-SITE VARIANTS, INSERTIONS/DELETIONS, COPY NUMBER ALTERATIONS, GENE FUSIONS, TUMOR MUTATIONAL BURDEN, AND MICROSATELLITE INSTABILITY, WITH ALGORITHM QUANTIFYING IMMUNOTHERAPY RESPONSE SCORE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0382U HYPERPHENYLALANINEMIA MONITORING BY PATIENT-COLLECTED BLOOD CARD SAMPLE, QUANTITATIVE MEASUREMENT OF PHENYLALANINE AND TYROSINE, LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0393U NEUROLOGY (EG, PARKINSON DISEASE, DEMENTIA WITH LEWY BODIES), CEREBROSPINAL FLUID (CSF), DETECTION OF MISFOLDED α-SYNUCLEIN PROTEIN BY SEED AMPLIFICATION ASSAY, QUALITATIVE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0381U MAPLE SYRUP URINE DISEASE MONITORING BY PATIENT-COLLECTED BLOOD CARD SAMPLE, QUANTITATIVE MEASUREMENT OF ALLO-ISOLEUCINE, LEUCINE, ISOLEUCINE, AND VALINE, LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0395U ONCOLOGY (LUNG), MULTI-OMICS (MICROBIAL DNA BY SHOTGUN NEXT-GENERATION SEQUENCING AND CARCINOEMBRYONIC ANTIGEN AND OSTEOPONTIN BY IMMUNOASSAY), PLASMA, ALGORITHM REPORTED AS MALIGNANCY RISK FOR LUNG NODULES IN EARLY-STAGE DISEASE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0397T ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP), WITH OPTICAL ENDOMICROSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0398U GASTROENTEROLOGY (BARRETT'S ESOPHAGUS), P16, RUNX3, HPP1, AND FBN1 DNA METHYLATION ANALYSIS USING PCR, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS RISK SCORE FOR PROGRESSION TO HIGH-GRADE DYSPLASIA OR CANCER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0399T MYOCARDIAL STRAIN IMAGING (QUANTITATIVE ASSESSMENT OF MYOCARDIAL MECHANICS USING IMAGE-BASED ANALYSIS OF LOCAL MYOCARDIAL DYNAMICS) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0400U OBSTETRICS (EXPANDED CARRIER SCREENING), 145 GENES BY NEXT-GENERATION SEQUENCING, FRAGMENT ANALYSIS AND MULTIPLEX LIGATION-DEPENDENT PROBE AMPLIFICATION, DNA, REPORTED AS CARRIER POSITIVE OR NEGATIVE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0403U ONCOLOGY (PROSTATE), MRNA, GENE EXPRESSION PROFILING OF 18 GENES, FIRST-CATCH URINE, ALGORITHM REPORTED AS PERCENTAGE OF LIKELIHOOD OF DETECTING CLINICALLY SIGNIFICANT PROSTATE CANCER Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0404U ONCOLOGY (BREAST), SEMIQUANTITATIVE MEASUREMENT OF THYMIDINE KINASE ACTIVITY BY IMMUNOASSAY, SERUM, RESULTS REPORTED AS RISK OF DISEASE PROGRESSION Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0405U ONCOLOGY (PANCREATIC), 59 METHYLATION HAPLOTYPE BLOCK MARKERS, NEXT-GENERATION SEQUENCING, PLASMA, REPORTED AS CANCER SIGNAL DETECTED OR NOT DETECTED Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0392U DRUG METABOLISM (DEPRESSION, ANXIETY, ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD]), GENE-DRUG INTERACTIONS, VARIANT ANALYSIS OF 16 GENES, INCLUDING DELETION/DUPLICATION ANALYSIS OF CYP2D6, REPORTED AS IMPACT OF GENE-DRUG INTERACTION FOR EACH DRUG Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0375T TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION), CERVICAL, THREE OR MORE LEVELS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0362T BEHAVIOR IDENTIFICATION SUPPORTING ASSESSMENT, EACH 15 MINUTES OF TECHNICIANS' TIME FACE-TO-FACE WITH A PATIENT, REQUIRING THE FOLLOWING COMPONENTS: ADMINISTRATION BY THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL WHO IS ON SITE; WITH THE ASSISTANCE OF TWO OR MORE TECHNICIANS; FOR A PATIENT WHO EXHIBITS DESTRUCTIVE BEHAVIOR; COMPLETION IN AN ENVIRONMENT THAT IS CUSTOMIZED TO THE PATIENT'S BEHAVIOR. Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     0362U ONCOLOGY (PAPILLARY THYROID CANCER), GENE-EXPRESSION PROFILING VIA TARGETED HYBRID CAPTURE-ENRICHMENT RNA SEQUENCING OF 82 CONTENT GENES AND 10 HOUSEKEEPING GENES, FINE NEEDLE ASPIRATE OR FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS ONE OF THREE MOLECULAR SUBTYPES Yes 12/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0363U ONCOLOGY (UROTHELIAL), MRNA, GENE-EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF 5 GENES (MDK, HOXA13, CDC2 [CDK1], IGFBP5, AND CXCR2), UTILIZING URINE, ALGORITHM INCORPORATES AGE, SEX, SMOKING HISTORY, AND MACROHEMATURIA FREQUENCY, REPORTED AS A RISK SCORE FOR HAVING UROTHELIAL CARCINOMA Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0364U ONCOLOGY (HEMATOLYMPHOID NEOPLASM), GENOMIC SEQUENCE ANALYSIS USING MULTIPLEX (PCR) AND NEXT-GENERATION SEQUENCING WITH ALGORITHM, QUANTIFICATION OF DOMINANT CLONAL SEQUENCE(S), REPORTED AS PRESENCE OR ABSENCE OF MINIMAL RESIDUAL DISEASE (MRD) WITH QUANTITATION OF DISEASE BURDEN, WHEN APPROPRIATE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0365U ONCOLOGY (BLADDER), ANALYSIS OF 10 PROTEIN BIOMARKERS (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, AND VEGFA) BY IMMUNOASSAYS, URINE, ALGORITHM REPORTED AS A PROBABILITY OF BLADDER CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0366U ONCOLOGY (BLADDER), ANALYSIS OF 10 PROTEIN BIOMARKERS (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, AND VEGFA) BY IMMUNOASSAYS, URINE, ALGORITHM REPORTED AS A PROBABILITY OF RECURRENT BLADDER CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0367U ONCOLOGY (BLADDER), ANALYSIS OF 10 PROTEIN BIOMARKERS (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, AND VEGFA) BY IMMUNOASSAYS, URINE, DIAGNOSTIC ALGORITHM REPORTED AS A RISK SCORE FOR PROBABILITY OF RAPID RECURRENCE OF RECURRENT OR PERSISTENT CANCER FOLLOWING TRANSURETHRAL RESECTION Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0368U ONCOLOGY (COLORECTAL CANCER), EVALUATION FOR MUTATIONS OF APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, AND TP53, AND METHYLATION MARKERS (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132, AND TWIST1), MULTIPLEX QUANTITATIVE POLYMERASE CHAIN REACTION (QPCR), CIRCULATING CELL-FREE DNA (CFDNA), PLASMA, REPORT OF RISK SCORE FOR ADVANCED ADENOMA OR COLORECTAL CANCER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0383U TYROSINEMIA TYPE I MONITORING BY PATIENT-COLLECTED BLOOD CARD SAMPLE, QUANTITATIVE MEASUREMENT OF TYROSINE, PHENYLALANINE, METHIONINE, SUCCINYLACETONE, NITISINONE, LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0373T ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, EACH 15 MINUTES OF TECHNICIANS' TIME FACE-TO-FACE WITH A PATIENT, REQUIRING THE FOLLOWING COMPONENTS: ADMINISTRATION BY THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL WHO IS ON SITE; WITH THE ASSISTANCE OF TWO OR MORE TECHNICIANS; FOR A PATIENT WHO EXHIBITS DESTRUCTIVE BEHAVIOR; COMPLETION IN AN ENVIRONMENT THAT IS CUSTOMIZED TO THE PATIENT'S BEHAVIOR. Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     0472T DEVICE EVALUATION, INTERROGATION, AND INITIAL PROGRAMMING OF INTRAOCULAR RETINAL ELECTRODE ARRAY (EG, RETINAL PROSTHESIS), IN PERSON, WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST FUNCTIONALITY, SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING VISUAL TRAINING, WITH REVIEW AND REPORT BY A QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0375U ONCOLOGY (OVARIAN), BIOCHEMICAL ASSAYS OF 7 PROTEINS (FOLLICLE STIMULATING HORMONE, HUMAN EPIDIDYMIS PROTEIN 4, APOLIPOPROTEIN A-1, TRANSFERRIN, BETA-2 MACROGLOBULIN, PREALBUMIN [IE, TRANSTHYRETIN], AND CANCER ANTIGEN 125), ALGORITHM REPORTED AS OVARIAN CANCER RISK SCORE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0376U ONCOLOGY (PROSTATE CANCER), IMAGE ANALYSIS OF AT LEAST 128 HISTOLOGIC FEATURES AND CLINICAL FACTORS, PROGNOSTIC ALGORITHM DETERMINING THE RISK OF DISTANT METASTASES, AND PROSTATE CANCER-SPECIFIC MORTALITY, INCLUDES PREDICTIVE ALGORITHM TO ANDROGEN DEPRIVATION-THERAPY RESPONSE, IF APPROPRIATE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0377U CARDIOVASCULAR DISEASE, QUANTIFICATION OF ADVANCED SERUM OR PLASMA LIPOPROTEIN PROFILE, BY NUCLEAR MAGNETIC RESONANCE (NMR) SPECTROMETRY WITH REPORT OF A LIPOPROTEIN PROFILE (INCLUDING 23 VARIABLES) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0378T VISUAL FIELD ASSESSMENT, WITH CONCURRENT REAL TIME DATA ANALYSIS AND ACCESSIBLE DATA STORAGE WITH PATIENT INITIATED DATA TRANSMITTED TO A REMOTE SURVEILLANCE CENTER FOR UP TO 30 DAYS; REVIEW AND INTERPRETATION WITH REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0378U RFC1 (REPLICATION FACTOR C SUBUNIT 1), REPEAT EXPANSION VARIANT ANALYSIS BY TRADITIONAL AND REPEAT-PRIMED PCR, BLOOD, SALIVA, OR BUCCAL SWAB Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0379T VISUAL FIELD ASSESSMENT, WITH CONCURRENT REAL TIME DATA ANALYSIS AND ACCESSIBLE DATA STORAGE WITH PATIENT INITIATED DATA TRANSMITTED TO A REMOTE SURVEILLANCE CENTER FOR UP TO 30 DAYS; TECHNICAL SUPPORT AND PATIENT INSTRUCTIONS, SURVEILLANCE, ANALYSIS, AND TRANSMISSION OF DAILY AND EMERGENT DATA REPORTS AS PRESCRIBED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0379U TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, DNA (523 GENES) AND RNA (55 GENES) BY NEXT-GENERATION SEQUENCING, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, GENE REARRANGEMENTS, MICROSATELLITE INSTABILITY, AND TUMOR MUTATIONAL BURDEN Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0380U DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), TARGETED SEQUENCE ANALYSIS, 20 GENE VARIANTS AND CYP2D6 DELETION OR DUPLICATION ANALYSIS WITH REPORTED GENOTYPE AND PHENOTYPE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0369U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), GASTROINTESTINAL PATHOGENS, 31 BACTERIAL, VIRAL, AND PARASITIC ORGANISMS AND IDENTIFICATION OF 21 ASSOCIATED ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   43846 GASTRIC BYPASS, OBESITY W/SHRT LMB See Note N/A   Noncovered healthcare service       55980 INTERSEX SURGERY; FEMALE TO MALE See Note N/A   Noncovered healthcare service       19324 ENLARGEMENT OF BREAST W/O IMPL See Note N/A   Noncovered healthcare service       19325 BREAST AUGMENTATION WITH IMPLANT See Note N/A   Noncovered healthcare service       21137 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) See Note N/A   Noncovered healthcare service       21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) See Note N/A   Noncovered healthcare service       21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL See Note N/A   Noncovered healthcare service       43774 LAP REMOV ADJ GAST BAND/PORT See Note N/A   Noncovered healthcare service       43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY) See Note N/A   Noncovered healthcare service       19300 MASTECTOMY FOR GYNECOMASTIA See Note N/A   Noncovered healthcare service       43843 GASTRIC REVISION FOR OBESITY See Note N/A   Noncovered healthcare service       19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS [SUPERNUMERARY NIPPLES] See Note N/A   Noncovered healthcare service       43847 GASTRIC BYPS, OBESITY W/SML INTEST See Note N/A   Noncovered healthcare service       43848 GASTRIC BYPASS REVISION See Note N/A   Noncovered healthcare service       43886 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY See Note N/A   Noncovered healthcare service       43887 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY See Note N/A   Noncovered healthcare service       43888 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT COMPONENT ONLY See Note N/A   Noncovered healthcare service       49568 IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL OR VENTRAL HERNIA REPAIR OR MESH FOR CLOSURE OF DEBRIDEMENT FOR NECROTIZING SOFT TISSUE INFECTION (LIST SEPARATELY IN ADDITION TO CODE FOR THE INCISIONAL OR VENTRAL HERNIA REPAIR) See Note N/A   Noncovered healthcare service       54680 RELOCATION OF TESTIS(ES) TO THIGH See Note N/A   Noncovered healthcare service       0470U ONCOLOGY (OROPHARYNGEAL), DETECTION OF MINIMAL RESIDUAL DISEASE BY NEXT-GENERATION SEQUENCING (NGS) BASED QUANTITATIVE EVALUATION OF 8 DNA TARGETS, CELL-FREE HPV 16 AND 18 DNA FROM PLASMA Yes 9/1/2024     OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines   43842 GASTRIC REVISION FOR OBESITY See Note N/A   Noncovered healthcare service       15839 REMOVE EXCESSIVE SKIN, OTHER A See Note N/A   Noncovered healthcare service       15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, P-FLAP) See Note N/A   Noncovered healthcare service       15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK See Note N/A   Noncovered healthcare service       15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP See Note N/A   Noncovered healthcare service       15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH See Note N/A   Noncovered healthcare service       15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG See Note N/A   Noncovered healthcare service       15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP See Note N/A   Noncovered healthcare service       15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK See Note N/A   Noncovered healthcare service       15836  EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM See Note N/A   Noncovered healthcare service       19316 MASTOPEXY See Note N/A   Noncovered healthcare service       15838 REMOVE EXCESS SKIN/TISSUE, FAT See Note N/A   Noncovered healthcare service       56620 VULVECTOMY SIMPLE; PARTIAL See Note N/A   Noncovered healthcare service       15847 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (E.G. ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) See Note N/A   Noncovered healthcare service       15876 SUCTION REMOVE FAT TISSUE,HEAD See Note N/A   Noncovered healthcare service       15878 SUCTION REMOVE FAT TISSUE, ARM See Note N/A   Noncovered healthcare service       15879 SUCTION REMOVE FAT TISSUE, LEG See Note N/A   Noncovered healthcare service       17250 CHEM CAUT OF GRANLTJ TISSUE See Note N/A   Noncovered healthcare service       17360 CHEMICAL SKIN PEEL FOR ACNE See Note N/A   Noncovered healthcare service       17380 HAIR REMOVAL, ELECTROLYSIS, 1/ See Note N/A   Noncovered healthcare service       17999 SKIN TISSUE PROCEDURE NEC See Note N/A   Noncovered healthcare service       15837 REMOVE EXCESSIVE SKIN, FOREARM See Note N/A   Noncovered healthcare service       89337 CRYOPRESERVATION OOCYTE(S) See Note N/A   Noncovered healthcare service       55970 INTERSEX SURGERY; MALE TO FEMALE See Note N/A   Noncovered healthcare service       89258 CRYOPRESERVATION; EMBRYO(S) See Note N/A   Noncovered healthcare service       89259 CRYOPRESERVATION; SPERM See Note N/A   Noncovered healthcare service       89264 SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR CRYOPRESERVED See Note N/A   Noncovered healthcare service       89268 INSEMINATION OF OOCYTES See Note N/A   Noncovered healthcare service       89272 EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS See Note N/A   Noncovered healthcare service       89280 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; LESS THAN OR EQUAL TO 10 OOCYTES See Note N/A   Noncovered healthcare service       89281 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; GREATER THAN 10 OOCYTES See Note N/A   Noncovered healthcare service       89255 PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) See Note N/A   Noncovered healthcare service       89291 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS See Note N/A   Noncovered healthcare service       89254 OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID See Note N/A   Noncovered healthcare service       89342 STORAGE (PER YEAR); EMBRYO(S) See Note N/A   Noncovered healthcare service       89343 STORAGE (PER YEAR); SPERM/SEMEN See Note N/A   Noncovered healthcare service       89344 STORAGE (PER YEAR); REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN See Note N/A   Noncovered healthcare service       89346 STORAGE (PER YEAR); OOCYTE(S) See Note N/A   Noncovered healthcare service       89352 THAWING OF CRYOPRESERVED; EMBRYO(S) See Note N/A   Noncovered healthcare service       89353 THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT See Note N/A   Noncovered healthcare service       89354 THAWING OF CRYOPRESERVED; REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN See Note N/A   Noncovered healthcare service       89356 THAWING OF CRYOPRESERVED; OOCYTES, EACH ALIQUOT See Note N/A   Noncovered healthcare service       89290 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS See Note N/A   Noncovered healthcare service       58976 GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY METHOD See Note N/A   Noncovered healthcare service       56800 PLASTIC REPAIR OF INTROITUS See Note N/A   Noncovered healthcare service       56805 CLITOROPLASTY FOR INTERSEX STATE See Note N/A   Noncovered healthcare service       56810 PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE) See Note N/A   Noncovered healthcare service       57291 CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT OR WITH GRAFT See Note N/A   Noncovered healthcare service       57335 VAGINOPLASTY FOR INTERSEX STATE See Note N/A   Noncovered healthcare service       58321 ARTIFICIAL INSEMINATION See Note N/A   Noncovered healthcare service       58322 ARTIFICIAL INSEMINATION; INTRA-UTERINE See Note N/A   Noncovered healthcare service       58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION See Note N/A   Noncovered healthcare service       89257 SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL FLUID) See Note N/A   Noncovered healthcare service       58974 EMBRYO TRANSFER, INTRAUTERINE See Note N/A   Noncovered healthcare service       15792 CHEMICAL PEEL NONFACIAL See Note N/A   Noncovered healthcare service       65765 REVISION OF CORNEA See Note N/A   Noncovered healthcare service       65771 RADIAL KERATOTOMY See Note N/A   Noncovered healthcare service       69090 PIERCE EARLOBES See Note N/A   Noncovered healthcare service       69300 REVISE PROTRUDING EXTERNAL EAR See Note N/A   Noncovered healthcare service       76948 ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, IMAGING SUPERVISION AND INTERPRETATION See Note N/A   Noncovered healthcare service       89250 CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; See Note N/A   Noncovered healthcare service       89251 CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; WITH CO-CULTURE OF OOCYTE(S)/EMBRYOS See Note N/A   Noncovered healthcare service       89253 ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) See Note N/A   Noncovered healthcare service       58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD See Note N/A   Noncovered healthcare service       0504U INFECTIOUS DISEASE (URINARY TRACT INFECTION), IDENTIFICATION OF 17 PATHOLOGIC ORGANISMS, URINE, REAL-TIME PCR, REPORTED AS POSITIVE OR NEGATIVE FOR EACH ORGANISM Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15824 RHYTIDECTOMY See Note N/A   Noncovered healthcare service       0495U ONCOLOGY (PROSTATE), ANALYSIS OF CIRCULATING PLASMA PROTEINS (TPSA, FPSA, KLK2, PSP94, AND GDF15), GERMLINE POLYGENIC RISK SCORE (60 VARIANTS), CLINICAL INFORMATION (AGE, FAMILY HISTORY OF PROSTATE CANCER, PRIOR NEGATIVE PROSTATE BIOPSY), ALGORITHM REPORTED AS RISK OF LIKELIHOOD OF DETECTING CLINICALLY SIGNIFICANT PROSTATE CANCER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0496U ONCOLOGY (COLORECTAL), CELL-FREE DNA, 8 GENES FOR MUTATIONS, 7 GENES FOR METHYLATION BY REAL-TIME RT-PCR, AND 4 PROTEINS BY ENZYME-LINKED IMMUNOSORBENT ASSAY, BLOOD, REPORTED POSITIVE OR NEGATIVE FOR COLORECTAL CANCER OR ADVANCED ADENOMA RISK Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0497U ONCOLOGY (PROSTATE), MRNA GENE-EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 6 GENES (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, AND PPP2CA), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS A RISK SCORE FOR PROSTATE CANCER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0498U ONCOLOGY (COLORECTAL), NEXT-GENERATION SEQUENCING FOR MUTATION DETECTION IN 43 GENES AND METHYLATION PATTERN IN 45 GENES, BLOOD, AND FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, REPORT OF VARIANTS AND METHYLATION PATTERN WITH INTERPRETATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0499T CYSTOURETHROSCOPY, WITH MECHANICAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY FOR URETHRAL STRICTURE OR STENOSIS, INCLUDING FLUOROSCOPY, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0499U ONCOLOGY (COLORECTAL AND LUNG), DNA FROM FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, NEXT-GENERATION SEQUENCING OF 8 GENES (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, AND TP53), MUTATION DETECTION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0500U AUTOINFLAMMATORY DISEASE (VEXAS SYNDROME), DNA, UBA1 GENE MUTATIONS, TARGETED VARIANT ANALYSIS (M41T, M41V, M41L, C.118-2A>C, C.118-1G>C, C.118-9_118-2DEL, S56F, S621C) Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0493U TRANSPLANTATION MEDICINE, QUANTIFICATION OF DONOR-DERIVED CELL-FREE DNA (CFDNA) USING NEXT-GENERATION SEQUENCING, PLASMA, REPORTED AS PERCENTAGE OF DONOR-DERIVED CELL-FREE DNA Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0503U NEUROLOGY (ALZHEIMER DISEASE), BETA AMYLOID (Aβ40, Aβ42, Aβ42/40 RATIO) AND TAU-PROTEIN (PTAU217, NP-TAU217, PTAU217/NP-TAU217 RATIO), BLOOD, IMMUNOPRECIPITATION WITH QUANTITATION BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), ALGORITHM SCORE REPORTED AS LIKELIHOOD OF POSITIVE OR NEGATIVE FOR AMYLOID PLAQUES Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0492U ONCOLOGY (SOLID TUMOR), CIRCULATING TUMOR CELL SELECTION, MORPHOLOGICAL CHARACTERIZATION AND ENUMERATION BASED ON DIFFERENTIAL EPITHELIAL CELL ADHESION MOLECULE (EPCAM), CYTOKERATINS 8, 18, AND 19, CD45 PROTEIN BIOMARKERS, AND QUANTIFICATION OF PD-L1 PROTEIN BIOMARKER-EXPRESSING CELLS, PERIPHERAL BLOOD Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0505U INFECTIOUS DISEASE (VAGINAL INFECTION), IDENTIFICATION OF 32 PATHOGENIC ORGANISMS, SWAB, REAL-TIME PCR, REPORTED AS POSITIVE OR NEGATIVE FOR EACH ORGANISM Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0506U GASTROENTEROLOGY (BARRETT'S ESOPHAGUS), ESOPHAGEAL CELLS, DNA METHYLATION ANALYSIS BY NEXT-GENERATION SEQUENCING OF AT LEAST 89 DIFFERENTIALLY METHYLATED GENOMIC REGIONS, ALGORITHM REPORTED AS LIKELIHOOD FOR BARRETT'S ESOPHAGUS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0507T NEAR INFRARED DUAL IMAGING (IE, SIMULTANEOUS REFLECTIVE AND TRANSILLUMINATED LIGHT) OF MEIBOMIAN GLANDS, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0507U ONCOLOGY (OVARIAN), DNA, WHOLE-GENOME SEQUENCING WITH 5-HYDROXYMETHYLCYTOSINE (5HMC) ENRICHMENT, USING WHOLE BLOOD OR PLASMA, ALGORITHM REPORTED AS CANCER DETECTED OR NOT DETECTED Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0508T PULSE-ECHO ULTRASOUND BONE DENSITY MEASUREMENT RESULTING IN INDICATOR OF AXIAL BONE MINERAL DENSITY, TIBIA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0508U TRANSPLANTATION MEDICINE, QUANTIFICATION OF DONOR-DERIVED CELL-FREE DNA USING 40 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS), PLASMA, AND URINE, INITIAL EVALUATION REPORTED AS PERCENTAGE OF DONOR-DERIVED CELL-FREE DNA WITH RISK FOR ACTIVE REJECTION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0509U TRANSPLANTATION MEDICINE, QUANTIFICATION OF DONOR-DERIVED CELL-FREE DNA USING UP TO 12 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) PREVIOUSLY IDENTIFIED, PLASMA, REPORTED AS PERCENTAGE OF DONOR-DERIVED CELL-FREE DNA WITH RISK FOR ACTIVE REJECTION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0510T REMOVAL OF SINUS TARSI IMPLANT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0501U ONCOLOGY (COLORECTAL), BLOOD, QUANTITATIVE MEASUREMENT OF CELL-FREE DNA (CFDNA) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0485T OPTICAL COHERENCE TOMOGRAPHY (OCT) OF MIDDLE EAR, WITH INTERPRETATION AND REPORT; UNILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0113 ROOM & BOARD-PRIVATE (ONE BED)-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0473T DEVICE EVALUATION AND INTERROGATION OF INTRAOCULAR RETINAL ELECTRODE ARRAY (EG, RETINAL PROSTHESIS), IN PERSON, INCLUDING REPROGRAMMING AND VISUAL TRAINING, WHEN PERFORMED, WITH REVIEW AND REPORT BY A QUALIFIED HEALTH CARE PROFESSIONAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0476U DRUG METABOLISM, PSYCHIATRY (EG, MAJOR DEPRESSIVE DISORDER, GENERAL ANXIETY DISORDER, ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD], SCHIZOPHRENIA), WHOLE BLOOD, BUCCAL SWAB, AND PHARMACOGENOMIC GENOTYPING OF 14 GENES AND CYP2D6 COPY NUMBER VARIANT ANALYSIS AND REPORTED PHENOTYPES Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0477U DRUG METABOLISM, PSYCHIATRY (EG, MAJOR DEPRESSIVE DISORDER, GENERAL ANXIETY DISORDER, ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD], SCHIZOPHRENIA), WHOLE BLOOD, BUCCAL SWAB, AND PHARMACOGENOMIC GENOTYPING OF 14 GENES AND CYP2D6 COPY NUMBER VARIANT ANALYSIS, INCLUDING IMPACTED GENE-DRUG INTERACTIONS AND REPORTED PHENOTYPES Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0478U ONCOLOGY (NON-SMALL CELL LUNG CANCER), DNA AND RNA, DIGITAL PCR ANALYSIS OF 9 GENES (EGFR, KRAS, BRAF, ALK, ROS1, RET, NTRK 1/2/3, ERBB2, AND MET) IN FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, INTERROGATION FOR SINGLE-NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, GENE REARRANGEMENTS, AND REPORTED AS ACTIONABLE DETECTED VARIANTS FOR THERAPY SELECTION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0479U TAU, PHOSPHORYLATED, PTAU217 Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0480U INFECTIOUS DISEASE (BACTERIA, VIRUSES, FUNGI, AND PARASITES), CEREBROSPINAL FLUID (CSF), METAGENOMIC NEXT-GENERATION SEQUENCING (DNA AND RNA), BIOINFORMATIC ANALYSIS, WITH POSITIVE PATHOGEN IDENTIFICATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0481T INJECTION(S), AUTOLOGOUS WHITE BLOOD CELL CONCENTRATE (AUTOLOGOUS PROTEIN SOLUTION), ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0494U RED BLOOD CELL ANTIGEN (FETAL RHD GENE ANALYSIS), NEXT-GENERATION SEQUENCING OF CIRCULATING CELL-FREE DNA (CFDNA) OF BLOOD IN PREGNANT INDIVIDUALS KNOWN TO BE RHD NEGATIVE, REPORTED AS POSITIVE OR NEGATIVE Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0482U OBSTETRICS (PREECLAMPSIA), BIOCHEMICAL ASSAY OF SOLUBLE FMS-LIKE TYROSINE KINASE 1 (SFLT-1) AND PLACENTAL GROWTH FACTOR (PLGF), SERUM, RATIO REPORTED FOR SFLT-1/PLGF, WITH RISK OF PROGRESSION FOR PREECLAMPSIA WITH SEVERE FEATURES WITHIN 2 WEEKS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0511U ONCOLOGY (SOLID TUMOR), TUMOR CELL CULTURE IN 3D MICROENVIRONMENT, 36 OR MORE DRUG PANEL, REPORTED AS TUMOR-RESPONSE PREDICTION FOR EACH DRUG Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0485U ONCOLOGY (SOLID TUMOR), CELL-FREE DNA AND RNA BY NEXT-GENERATION SEQUENCING, INTERPRETATIVE REPORT FOR GERMLINE MUTATIONS, CLONAL HEMATOPOIESIS OF INDETERMINATE POTENTIAL, AND TUMOR-DERIVED SINGLE-NUCLEOTIDE VARIANTS, SMALL INSERTIONS/DELETIONS, COPY NUMBER ALTERATIONS, FUSIONS, MICROSATELLITE INSTABILITY, AND TUMOR MUTATIONAL BURDEN Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0486T OPTICAL COHERENCE TOMOGRAPHY (OCT) OF MIDDLE EAR, WITH INTERPRETATION AND REPORT; BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0486U ONCOLOGY (PAN-SOLID TUMOR), NEXT-GENERATION SEQUENCING ANALYSIS OF TUMOR METHYLATION MARKERS PRESENT IN CELL-FREE CIRCULATING TUMOR DNA, ALGORITHM REPORTED AS QUANTITATIVE MEASUREMENT OF METHYLATION AS A CORRELATE OF TUMOR FRACTION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0487U ONCOLOGY (SOLID TUMOR), CELL-FREE CIRCULATING DNA, TARGETED GENOMIC SEQUENCE ANALYSIS PANEL OF 84 GENES, INTERROGATION FOR SEQUENCE VARIANTS, ANEUPLOIDY-CORRECTED GENE COPY NUMBER AMPLIFICATIONS AND LOSSES, GENE REARRANGEMENTS, AND MICROSATELLITE INSTABILITY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0488U OBSTETRICS (FETAL ANTIGEN NONINVASIVE PRENATAL TEST), CELL-FREE DNA SEQUENCE ANALYSIS FOR DETECTION OF FETAL PRESENCE OR ABSENCE OF 1 OR MORE OF THE RH, C, C, D, E, DUFFY (FYA), OR KELL (K) ANTIGEN IN ALLOIMMUNIZED PREGNANCIES, REPORTED AS SELECTED ANTIGEN(S) DETECTED OR NOT DETECTED Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0489U OBSTETRICS (SINGLE-GENE NONINVASIVE PRENATAL TEST), CELL-FREE DNA SEQUENCE ANALYSIS OF 1 OR MORE TARGETS (EG, CFTR, SMN1, HBB, HBA1, HBA2) TO IDENTIFY PATERNALLY INHERITED PATHOGENIC VARIANTS, AND RELATIVE MUTATION-DOSAGE ANALYSIS BASED ON MOLECULAR COUNTS TO DETERMINE FETAL INHERITANCE OF MATERNAL MUTATION, ALGORITHM REPORTED AS A FETAL RISK SCORE FOR THE CONDITION (EG, CYSTIC FIBROSIS, SPINAL MUSCULAR ATROPHY, BETA HEMOGLOBINOPATHIES [INCLUDING SICKLE CELL DISEASE], ALPHA THALASSEMIA) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0490U ONCOLOGY (CUTANEOUS OR UVEAL MELANOMA), CIRCULATING TUMOR CELL SELECTION, MORPHOLOGICAL CHARACTERIZATION AND ENUMERATION BASED ON DIFFERENTIAL CD146, HIGH MOLECULAR-WEIGHT MELANOMA-ASSOCIATED ANTIGEN, CD34 AND CD45 PROTEIN BIOMARKERS, PERIPHERAL BLOOD Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0491U ONCOLOGY (SOLID TUMOR), CIRCULATING TUMOR CELL SELECTION, MORPHOLOGICAL CHARACTERIZATION AND ENUMERATION BASED ON DIFFERENTIAL EPITHELIAL CELL ADHESION MOLECULE (EPCAM), CYTOKERATINS 8, 18, AND 19, CD45 PROTEIN BIOMARKERS, AND QUANTIFICATION OF ESTROGEN RECEPTOR (ER) PROTEIN BIOMARKER-EXPRESSING CELLS, PERIPHERAL BLOOD Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0481U IDH1 (ISOCITRATE DEHYDROGENASE 1 [NADP+]), IDH2 (ISOCITRATE DEHYDROGENASE 2 [NADP+]), AND TERT (TELOMERASE REVERSE TRANSCRIPTASE) PROMOTER (EG, CENTRAL NERVOUS SYSTEM [CNS] TUMORS), NEXT-GENERATION SEQUENCING (SINGLE-NUCLEOTIDE VARIANTS [SNV], DELETIONS, AND INSERTIONS) Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     11952 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 5.1 TO 10.0 CC See Note N/A   Noncovered healthcare service       41821 EXCISION OF GUM FLAP See Note N/A   Noncovered healthcare service       41870 PERIODONTAL MUCOSAL GRAFTING See Note N/A   Noncovered healthcare service       43770 LAP, PLACE GASTR ADJUST BAND See Note N/A   Noncovered healthcare service       43771 LAP, REVISE ADJUST GAST BAND See Note N/A   Noncovered healthcare service       43772 LAP, REMOVE ADJUST GAST BAND See Note N/A   Noncovered healthcare service       43773 LAP, CHANGE ADJUST GAST BAND See Note N/A   Noncovered healthcare service       11200 REMOVAL OF SKIN TAGS, UP TO 15 See Note N/A   Noncovered healthcare service       11201 REMOVAL OF EACH ADDL 10 SKIN See Note N/A   Noncovered healthcare service       0510U ONCOLOGY (PANCREATIC CANCER), AUGMENTATIVE ALGORITHMIC ANALYSIS OF 16 GENES FROM PREVIOUSLY SEQUENCED RNA WHOLE-TRANSCRIPTOME DATA, REPORTED AS PROBABILITY OF PREDICTED MOLECULAR SUBTYPE Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11951 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1.1 TO 5.0 CC See Note N/A   Noncovered healthcare service       31830 REVISION OF TRACHEOSTOMY SCAR See Note N/A   Noncovered healthcare service       11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); OVER 10.0 CC See Note N/A   Noncovered healthcare service       11960 INSERT TISSUE EXPANDER(S) See Note N/A   Noncovered healthcare service       15775 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS See Note N/A   Noncovered healthcare service       15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS See Note N/A   Noncovered healthcare service       15777  IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) See Note N/A   Noncovered healthcare service       15787 ABRASION; EACH ADDITIONAL 4 LESIONS OR LESS  See Note N/A   Noncovered healthcare service       15788 CHEMICAL PEEL FACIAL EPIDERMAL See Note N/A   Noncovered healthcare service       0471U ONCOLOGY (COLORECTAL CANCER), QUALITATIVE REAL-TIME PCR OF 35 VARIANTS OF KRAS AND NRAS GENES (EXONS 2, 3, 4), FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE), PREDICTIVE, IDENTIFICATION OF DETECTED MUTATIONS Yes 9/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11950 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1 CC OR LESS See Note N/A   Noncovered healthcare service       0517T INSERTION OF WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED; BOTH COMPONENTS OF PULSE GENERATOR (BATTERY AND TRANSMITTER) ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15819 PLASTIC SURGERY NECK See Note N/A   Noncovered healthcare service       0512T EXTRACORPOREAL SHOCK WAVE FOR INTEGUMENTARY WOUND HEALING, INCLUDING TOPICAL APPLICATION AND DRESSING CARE; INITIAL WOUND Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0512U ONCOLOGY (PROSTATE), AUGMENTATIVE ALGORITHMIC ANALYSIS OF DIGITIZED WHOLE-SLIDE IMAGING OF HISTOLOGIC FEATURES FOR MICROSATELLITE INSTABILITY (MSI) STATUS, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, REPORTED AS INCREASED OR DECREASED PROBABILITY OF MSI-HIGH (MSI-H) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0513T EXTRACORPOREAL SHOCK WAVE FOR INTEGUMENTARY WOUND HEALING, INCLUDING TOPICAL APPLICATION AND DRESSING CARE; EACH ADDITIONAL WOUND (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0513U ONCOLOGY (PROSTATE), AUGMENTATIVE ALGORITHMIC ANALYSIS OF DIGITIZED WHOLE-SLIDE IMAGING OF HISTOLOGIC FEATURES FOR MICROSATELLITE INSTABILITY (MSI) AND HOMOLOGOUS RECOMBINATION DEFICIENCY (HRD) STATUS, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, REPORTED AS INCREASED OR DECREASED PROBABILITY OF EACH BIOMARKER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0514U GASTROENTEROLOGY (IRRITABLE BOWEL DISEASE [IBD]), IMMUNOASSAY FOR QUANTITATIVE DETERMINATION OF ADALIMUMAB (ADL) LEVELS IN VENOUS SERUM IN PATIENTS UNDERGOING ADALIMUMAB THERAPY, RESULTS REPORTED AS A NUMERICAL VALUE AS MICROGRAMS PER MILLILITER (µG/ML) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0515T INSERTION OF WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED; COMPLETE SYSTEM (INCLUDES ELECTRODE AND GENERATOR [TRANSMITTER AND BATTERY]) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0515U GASTROENTEROLOGY (IRRITABLE BOWEL DISEASE [IBD]), IMMUNOASSAY FOR QUANTITATIVE DETERMINATION OF INFLIXIMAB (IFX) LEVELS IN VENOUS SERUM IN PATIENTS UNDERGOING INFLIXIMAB THERAPY, RESULTS REPORTED AS A NUMERICAL VALUE AS MICROGRAMS PER MILLILITER (µG/ML) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   40500 LIP SHAVE, VERMILION See Note N/A   Noncovered healthcare service       0516U DRUG METABOLISM, WHOLE BLOOD, PHARMACOGENOMIC GENOTYPING OF 40 GENES AND CYP2D6 COPY NUMBER VARIANT ANALYSIS, REPORTED AS METABOLIZER STATUS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   36468 NJX SCLRSNT SPIDER VEINS See Note N/A   Noncovered healthcare service       0517U THERAPEUTIC DRUG MONITORING, 80 OR MORE PSYCHOACTIVE DRUGS OR SUBSTANCES, LC-MS/MS, PLASMA, QUALITATIVE AND QUANTITATIVE THERAPEUTIC MINIMALLY AND MAXIMALLY EFFECTIVE DOSE OF PRESCRIBED AND NON-PRESCRIBED MEDICATIONS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0518T REMOVAL OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING; BATTERY COMPONENT ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0518U THERAPEUTIC DRUG MONITORING, 90 OR MORE PAIN AND MENTAL HEALTH DRUGS OR SUBSTANCES, LC-MS/MS, PLASMA, QUALITATIVE AND QUANTITATIVE THERAPEUTIC MINIMALLY EFFECTIVE RANGE OF PRESCRIBED AND NON-PRESCRIBED MEDICATIONS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL See Note N/A   Noncovered healthcare service       21280 MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) See Note N/A   Noncovered healthcare service       21282 LATERAL CANTHOPEXY See Note N/A   Noncovered healthcare service       26590 REPAIR MACRODACTYLIA, EACH DIGIT See Note N/A   Noncovered healthcare service       27326 NEURECTOMY, POPLITEAL (GASTROCNEMIUS) See Note N/A   Noncovered healthcare service       0511T REMOVAL AND REINSERTION OF SINUS TARSI IMPLANT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0516T INSERTION OF WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING, AND IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED; ELECTRODE ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15110 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15241 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15012 HARVEST OF SKIN FOR SKIN CELL SUSPENSION AUTOGRAFT; EACH ADDITIONAL 25 SQ CM OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15013 PREPARATION OF SKIN CELL SUSPENSION AUTOGRAFT, REQUIRING ENZYMATIC PROCESSING, MANUAL MECHANICAL DISAGGREGATION OF SKIN CELLS, AND FILTRATION; FIRST 25 SQ CM OR LESS OF HARVESTED SKIN Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15014 PREPARATION OF SKIN CELL SUSPENSION AUTOGRAFT, REQUIRING ENZYMATIC PROCESSING, MANUAL MECHANICAL DISAGGREGATION OF SKIN CELLS, AND FILTRATION; EACH ADDITIONAL 25 SQ CM OF HARVESTED SKIN OR PART THEREOF Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15015 APPLICATION OF SKIN CELL SUSPENSION AUTOGRAFT TO WOUND AND DONOR SITES, INCLUDING APPLICATION OF PRIMARY DRESSING, TRUNK, ARMS, LEGS; FIRST 480 SQ CM OR LESS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15016 APPLICATION OF SKIN CELL SUSPENSION AUTOGRAFT TO WOUND AND DONOR SITES, INCLUDING APPLICATION OF PRIMARY DRESSING, TRUNK, ARMS, LEGS; EACH ADDITIONAL 480 SQ CM OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15017 APPLICATION OF SKIN CELL SUSPENSION AUTOGRAFT TO WOUND AND DONOR SITES, INCLUDING APPLICATION OF PRIMARY DRESSING, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 480 SQ CM OR LESS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   15018 APPLICATION OF SKIN CELL SUSPENSION AUTOGRAFT TO WOUND AND DONOR SITES, INCLUDING APPLICATION OF PRIMARY DRESSING, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 480 SQ CM OR PART THEREOF Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   14302 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15101 SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     14301 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15111 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15115 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15116 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15120 SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15220 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15100 SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11971 REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0905 INTENSIVE OUTPATIENT MENTAL HEALTH PROGRAM 3-4 HOURS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11401 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11402 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11403 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11404 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11406 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15011 HARVEST OF SKIN FOR SKIN CELL SUSPENSION AUTOGRAFT; FIRST 25 SQ CM OR LESS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11970 REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15273 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, 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 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     12051 REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     13131 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     13133 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15845 GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15820 BLEPHAROPLASTY, LOWER EYELID; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15822 BLEPHAROPLASTY, UPPER EYELID; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15826 RHYTIDECTOMY; GLABELLAR FROWN LINES Yes 8/15/2023     InterQual® Evidence-Based Criteria & Guidelines     15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15840 GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING OBTAINING FASCIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15789 CHEMICAL PEEL, FACIAL; DERMAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15842 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE FLAP BY MICROSURGICAL TECHNIQUE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15877 SUCTION ASSISTED LIPECTOMY; TRUNK Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS THAN 10 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     17107 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); 10.0 TO 50.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     17108 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); OVER 50.0 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     17111 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   19105 ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING ULTRASOUND GUIDANCE, EACH FIBROADENOMA Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   19301 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); Yes 1/1/2023     InterQual® Evidence-Based Criteria & Guidelines     15841 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15769 GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15274 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; 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) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15275 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15277 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, 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 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15278 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; 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) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15574 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15734 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15738 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15740 FLAP; ISLAND PEDICLE REQUIRING IDENTIFICATION AND DISSECTION OF AN ANATOMICALLY NAMED AXIAL VESSEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15793 CHEMICAL PEEL, NONFACIAL; DERMAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11312 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15771 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15772 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15773 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15774 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 25 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15781 DERMABRASION; SEGMENTAL, FACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15782 DERMABRASION; REGIONAL, OTHER THAN FACE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     15750 FLAP; NEUROVASCULAR PEDICLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0940T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR GREATER THAN 15 DAYS UP TO 30 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0953T TOTALLY IMPLANTABLE ACTIVE MIDDLE EAR HEARING IMPLANT; REVISION OR REPLACEMENT, WITHOUT MASTOIDECTOMY AND REPLACEMENT OF SOUND PROCESSOR Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0931T ELECTROPHYSIOLOGIC EVALUATION OF CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATOR LEADS, INCLUDING DEFIBRILLATION-THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND THERAPY FOR ARRHYTHMIA TERMINATION), SEPARATE FROM INITIAL IMPLANTATION OR REPLACEMENT WITH TESTING OF CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATOR PULSE GENERATOR Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0932T NONINVASIVE DETECTION OF HEART FAILURE DERIVED FROM AUGMENTATIVE ANALYSIS OF AN ECHOCARDIOGRAM THAT DEMONSTRATED PRESERVED EJECTION FRACTION, WITH INTERPRETATION AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0933T TRANSCATHETER IMPLANTATION OF WIRELESS LEFT ATRIAL PRESSURE SENSOR FOR LONG-TERM LEFT ATRIAL PRESSURE MONITORING, INCLUDING SENSOR CALIBRATION AND DEPLOYMENT, RIGHT HEART CATHETERIZATION, TRANSSEPTAL PUNCTURE, IMAGING GUIDANCE, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0934T REMOTE MONITORING OF A WIRELESS LEFT ATRIAL PRESSURE SENSOR FOR UP TO 30 DAYS, INCLUDING DATA FROM DAILY UPLOADS OF LEFT ATRIAL PRESSURE RECORDINGS, INTERPRETATION(S) AND TREND ANALYSIS, WITH ADJUSTMENTS TO THE DIURETICS PLAN, TREATMENT PARADIGM THRESHOLDS, MEDICATIONS OR LIFESTYLE MODIFICATIONS, WHEN PERFORMED, AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0935T CYSTOURETHROSCOPY WITH RENAL PELVIC SYMPATHETIC DENERVATION, RADIOFREQUENCY ABLATION, RETROGRADE URETERAL APPROACH, INCLUDING INSERTION OF GUIDE WIRE, SELECTIVE PLACEMENT OF URETERAL SHEATH(S) AND MULTIPLE CONFORMABLE ELECTRODES, CONTRAST INJECTION(S), AND FLUOROSCOPY, BILATERAL Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0936T PHOTOBIOMODULATION THERAPY OF RETINA, SINGLE SESSION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0937T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR GREATER THAN 15 DAYS UP TO 30 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; INCLUDING RECORDING, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0929T INTERROGATION DEVICE EVALUATION (REMOTE), UP TO 90 DAYS, CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS, TECHNICIAN REVIEW, TECHNICAL SUPPORT, AND DISTRIBUTION OF RESULTS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0939T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR GREATER THAN 15 DAYS UP TO 30 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; SCANNING ANALYSIS WITH REPORT Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0928T INTERROGATION DEVICE EVALUATION (REMOTE), UP TO 90 DAYS, CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM WITH INTERIM ANALYSIS AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0941T CYSTOURETHROSCOPY, FLEXIBLE; WITH INSERTION AND EXPANSION OF PROSTATIC URETHRAL SCAFFOLD USING INTEGRATED CYSTOSCOPIC VISUALIZATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0942T CYSTOURETHROSCOPY, FLEXIBLE; WITH REMOVAL AND REPLACEMENT OF PROSTATIC URETHRAL SCAFFOLD Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0943T CYSTOURETHROSCOPY, FLEXIBLE; WITH REMOVAL OF PROSTATIC URETHRAL SCAFFOLD Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0944T 3D CONTOUR SIMULATION OF TARGET LIVER LESION(S) AND MARGIN(S) FOR IMAGE-GUIDED PERCUTANEOUS MICROWAVE ABLATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0947T MAGNETIC RESONANCE IMAGE GUIDED LOW INTENSITY FOCUSED ULTRASOUND (MRGFUS), STEREOTACTIC BLOOD-BRAIN BARRIER DISRUPTION USING MICROBUBBLE RESONATORS TO INCREASE THE CONCENTRATION OF BLOOD-BASED BIOMARKERS OF TARGET, INTRACRANIAL, INCLUDING STEREOTACTIC NAVIGATION AND FRAME PLACEMENT, WHEN PERFORMED Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0950T ABLATION OF BENIGN PROSTATE TISSUE, TRANSRECTAL, WITH HIGH INTENSITY€“FOCUSED ULTRASOUND (HIFU), INCLUDING ULTRASOUND GUIDANCE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0951T TOTALLY IMPLANTABLE ACTIVE MIDDLE EAR HEARING IMPLANT; INITIAL PLACEMENT, INCLUDING MASTOIDECTOMY, PLACEMENT OF AND ATTACHMENT TO SOUND PROCESSOR Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0938T EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR GREATER THAN 15 DAYS UP TO 30 DAYS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDING CONNECTION AND INITIAL RECORDING) Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0917T INSERTION OF PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM COMPONENT(S), INCLUDING FLUOROSCOPIC GUIDANCE, AND EVALUATION AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; SINGLE TRANSVENOUS LEAD (PACING OR DEFIBRILLATION) ONLY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0111T LONG-CHAIN (C20-22) OMEGA-3 FATTY ACIDS IN RED BLOOD CELL (RBC) MEMBRANES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0906T CONCURRENT OPTICAL AND MAGNETIC STIMULATION (COMS) THERAPY, WOUND ASSESSMENT AND DRESSING CARE; FIRST APPLICATION, TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQ CM Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0907T CONCURRENT OPTICAL AND MAGNETIC STIMULATION (COMS) THERAPY, WOUND ASSESSMENT AND DRESSING CARE; EACH ADDITIONAL APPLICATION, TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0908T OPEN IMPLANTATION OF INTEGRATED NEUROSTIMULATION SYSTEM, VAGUS NERVE, INCLUDING ANALYSIS AND PROGRAMMING, WHEN PERFORMED Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     0910 CRISIS INTERVENTION MENTAL HEALTH SERVICE DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0912 PARTIAL HOSPITALIZATION- MENTAL HEALTH/SUBSTANCE ABUSE/EATING DISORDER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0913 PARTIAL HOSPITALIZATION- MENTAL HEALTH/SUBSTANCE ABUSE/EATING DISORDER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0913T PERCUTANEOUS TRANSCATHETER THERAPEUTIC DRUG DELIVERY BY INTRACORONARY DRUG-DELIVERY BALLOON (EG, DRUG-COATED, DRUG-ELUTING), INCLUDING MECHANICAL DILATION BY NONDRUG-DELIVERY BALLOON ANGIOPLASTY, ENDOLUMINAL IMAGING USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) WHEN PERFORMED, IMAGING SUPERVISION, INTERPRETATION, AND REPORT, SINGLE MAJOR CORONARY ARTERY OR BRANCH Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     0930T ELECTROPHYSIOLOGIC EVALUATION OF CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATOR LEADS, INCLUDING DEFIBRILLATION-THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND THERAPY FOR ARRHYTHMIA TERMINATION), AT TIME OF INITIAL IMPLANTATION OR REPLACEMENT WITH TESTING OF CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATOR PULSE GENERATOR Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0915T INSERTION OF PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM COMPONENT(S), INCLUDING FLUOROSCOPIC GUIDANCE, AND EVALUATION AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; PULSE GENERATOR AND DUAL TRANSVENOUS ELECTRODES/LEADS (PACING AND DEFIBRILLATION) Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0954T TOTALLY IMPLANTABLE ACTIVE MIDDLE EAR HEARING IMPLANT; REPLACEMENT OF SOUND PROCESSOR ONLY, WITH ATTACHMENT TO EXISTING TRANSDUCERS Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0919T REMOVAL OF A PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM COMPONENT(S); PULSE GENERATOR ONLY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0921T REMOVAL OF A PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM COMPONENT(S); SINGLE TRANSVENOUS DEFIBRILLATION LEAD ONLY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0922T REMOVAL OF A PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM COMPONENT(S); DUAL (PACING AND DEFIBRILLATION) TRANSVENOUS LEADS ONLY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0923T REMOVAL AND REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION PULSE GENERATOR ONLY Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0924T REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION TRANSVENOUS ELECTRODE(S)/LEAD(S), INCLUDING FLUOROSCOPIC GUIDANCE AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0925T RELOCATION OF SKIN POCKET FOR IMPLANTED CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION PULSE GENERATOR Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0926T PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING REVIEW AND REPORT, IMPLANTABLE CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0927T INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW, AND REPORT, INCLUDING CONNECTION, RECORDING, AND DISCONNECTION, PER PATIENT ENCOUNTER, IMPLANTABLE CARDIAC CONTRACTILITY MODULATION-DEFIBRILLATION SYSTEM Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0914T PERCUTANEOUS TRANSCATHETER THERAPEUTIC DRUG DELIVERY BY INTRACORONARY DRUG-DELIVERY BALLOON (EG, DRUG-COATED, DRUG-ELUTING) PERFORMED ON A SEPARATE TARGET LESION FROM THE TARGET LESION TREATED WITH BALLOON ANGIOPLASTY, CORONARY STENT PLACEMENT OR CORONARY ATHERECTOMY, INCLUDING MECHANICAL DILATION BY NONDRUG-DELIVERY BALLOON ANGIOPLASTY, ENDOLUMINAL IMAGING USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) WHEN PERFORMED, IMAGING SUPERVISION, INTERPRETATION, AND REPORT, Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0952T TOTALLY IMPLANTABLE ACTIVE MIDDLE EAR HEARING IMPLANT; REVISION OR REPLACEMENT, WITH MASTOIDECTOMY AND REPLACEMENT OF SOUND PROCESSOR Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0983T REMOTE MONITORING OF AN IMPLANTED INFERIOR VENA CAVA SENSOR FOR UP TO 30 DAYS, INCLUDING AT LEAST WEEKLY DOWNLOADS OF INFERIOR VENA CAVA AREA RECORDINGS, INTERPRETATION(S), TREND ANALYSIS, AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0984T INTRAVASCULAR IMAGING OF EXTRACRANIAL CEREBRAL VESSELS USING OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING ALL ASSOCIATED RADIOLOGICAL SUPERVISION, INTERPRETATION, AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0985T INTRAVASCULAR IMAGING OF EXTRACRANIAL CEREBRAL VESSELS USING OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING ALL ASSOCIATED RADIOLOGICAL SUPERVISION, INTERPRETATION, AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0986T INTRAVASCULAR IMAGING OF INTRACRANIAL CEREBRAL VESSELS USING OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING ALL ASSOCIATED RADIOLOGICAL SUPERVISION, INTERPRETATION, AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0987T INTRAVASCULAR IMAGING OF INTRACRANIAL CEREBRAL VESSELS USING OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING ALL ASSOCIATED RADIOLOGICAL SUPERVISION, INTERPRETATION, AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   1001 BEHAVIORAL HEALTH SERVICES; SHORT-TERM RESIDENTIAL; HOSPITAL/NON-HOSPITAL, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     1002 ACUTE/SUB-ACUTE DETOXIFICATION; RESIDENTIAL ADDICTION PROGRAM INPATIENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0981T TRANSCATHETER IMPLANTATION OF WIRELESS INFERIOR VENA CAVA SENSOR FOR LONG-TERM HEMODYNAMIC MONITORING, INCLUDING DEPLOYMENT OF THE SENSOR, RADIOLOGICAL SUPERVISION AND INTERPRETATION, RIGHT HEART CATHETERIZATION, AND INFERIOR VENA CAVA VENOGRAPHY, WHEN PERFORMED Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0980T SUBMUCOSAL CRYOLYSIS THERAPY; BASE OF TONGUE AND LINGUAL TONSIL ONLY Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   11302 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11303 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11305 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11306 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11307 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11308 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11310 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     10040 ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0971T ABLATION, MALIGNANT BREAST TUMOR(S), PERCUTANEOUS, LASER, INCLUDING IMAGING GUIDANCE WHEN PERFORMED, UNILATERAL Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0955T TOTALLY IMPLANTABLE ACTIVE MIDDLE EAR HEARING IMPLANT; REMOVAL, INCLUDING REMOVAL OF SOUND PROCESSOR AND ALL IMPLANT COMPONENTS Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0962T ASSISTIVE ALGORITHMIC ANALYSIS OF ACOUSTIC AND ELECTROCARDIOGRAM RECORDING FOR DETECTION OF CARDIAC DYSFUNCTION (EG, REDUCED EJECTION FRACTION, CARDIAC MURMURS, ATRIAL FIBRILLATION), WITH REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0963T ANOSCOPY WITH DIRECTED SUBMUCOSAL INJECTION OF BULKING AGENT INTO ANAL CANAL Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0964T IMPRESSION AND CUSTOM PREPARATION OF JAW EXPANSION ORAL PROSTHESIS FOR OBSTRUCTIVE SLEEP APNEA, INCLUDING INITIAL ADJUSTMENT; SINGLE ARCH, WITHOUT MANDIBULAR ADVANCEMENT MECHANISM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0965T IMPRESSION AND CUSTOM PREPARATION OF JAW EXPANSION ORAL PROSTHESIS FOR OBSTRUCTIVE SLEEP APNEA, INCLUDING INITIAL ADJUSTMENT; DUAL ARCH, WITH ADDITIONAL MANDIBULAR ADVANCEMENT, NON-FIXED HINGE MECHANISM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0966T IMPRESSION AND CUSTOM PREPARATION OF JAW EXPANSION ORAL PROSTHESIS FOR OBSTRUCTIVE SLEEP APNEA, INCLUDING INITIAL ADJUSTMENT; DUAL ARCH, WITH ADDITIONAL MANDIBULAR ADVANCEMENT, FIXED HINGE MECHANISM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0967T TRANSANAL INSERTION OF ENDOLUMINAL TEMPORARY COLORECTAL ANASTOMOSIS PROTECTION DEVICE, INCLUDING VACUUM ANCHORING COMPONENT AND FLEXIBLE SHEATH CONNECTED TO EXTERNAL VACUUM SOURCE AND MONITORING SYSTEM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0968T INSERTION OR REPLACEMENT OF EPICRANIAL NEUROSTIMULATOR SYSTEM, INCLUDING ELECTRODE ARRAY AND PULSE GENERATOR, WITH CONNECTION TO ELECTRODE ARRAY Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0982T REMOTE MONITORING OF IMPLANTABLE INFERIOR VENA CAVA PRESSURE SENSOR, PHYSIOLOGIC PARAMETER(S) (EG, WEIGHT, BLOOD PRESSURE, PULSE OXIMETRY, RESPIRATORY FLOW RATE), INITIAL SET-UP AND PATIENT EDUCATION ON USE OF EQUIPMENT Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0970T ABLATION, BENIGN BREAST TUMOR (EG, FIBROADENOMA), PERCUTANEOUS, LASER, INCLUDING IMAGING GUIDANCE WHEN PERFORMED, EACH TUMOR Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   19306 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY AND INTERNAL MAMMARY LYMPH NODES (URBAN TYPE OPERATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0972T ASSISTIVE ALGORITHMIC CLASSIFICATION OF BURN HEALING (IE, HEALING OR NONHEALING) BY NONINVASIVE MULTISPECTRAL IMAGING, INCLUDING SYSTEM SET-UP AND ACQUISITION, SELECTION, AND TRANSMISSION OF IMAGES, WITH AUTOMATED GENERATION OF REPORT Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0973T SELECTIVE ENZYMATIC DEBRIDEMENT, PARTIAL-THICKNESS AND/OR FULL-THICKNESS BURN ESCHAR, REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION), INCLUDING PATIENT MONITORING, TRUNK, ARMS, LEGS; FIRST 100 SQ CM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0974T SELECTIVE ENZYMATIC DEBRIDEMENT, PARTIAL-THICKNESS AND/OR FULL-THICKNESS BURN ESCHAR, REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION), INCLUDING PATIENT MONITORING, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0975T SELECTIVE ENZYMATIC DEBRIDEMENT, PARTIAL-THICKNESS AND/OR FULL-THICKNESS BURN ESCHAR, REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION), INCLUDING PATIENT MONITORING, SCALP, NECK, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0976T SELECTIVE ENZYMATIC DEBRIDEMENT, PARTIAL-THICKNESS AND/OR FULL-THICKNESS BURN ESCHAR, REQUIRING ANESTHESIA (IE, GENERAL ANESTHESIA, MODERATE SEDATION), INCLUDING PATIENT MONITORING, SCALP, NECK, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0977T UPPER GASTROINTESTINAL BLOOD DETECTION, SENSOR CAPSULE, WITH INTERPRETATION AND REPORT Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0978T SUBMUCOSAL CRYOLYSIS THERAPY; SOFT PALATE, BASE OF TONGUE, AND LINGUAL TONSIL Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0979T SUBMUCOSAL CRYOLYSIS THERAPY; SOFT PALATE ONLY Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0969T REMOVAL OF EPICRANIAL NEUROSTIMULATOR SYSTEM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22100 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22207 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21485 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21742 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21743 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21440 CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22015 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21299 UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22101 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22102 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22103 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22110 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22112 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22114 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22116 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19303 MASTECTOMY, SIMPLE, COMPLETE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22010 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21256 RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND WITH BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, MICRO-OPHTHALMIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21243 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21244 RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL BONE PLATE (EG, MANDIBULAR STAPLE BONE PLATE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21245 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; PARTIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21246 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; COMPLETE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21247 RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL MICROSOMIA) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21248 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); PARTIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21445 OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22208 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21260 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; EXTRACRANIAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21261 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21263 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; WITH FOREHEAD ADVANCEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21267 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, WITH BONE GRAFTS; EXTRACRANIAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21268 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, WITH BONE GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21295 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC HYPERTROPHY); EXTRAORAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21296 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC HYPERTROPHY); INTRAORAL APPROACH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21249 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); COMPLETE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22206 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22527 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; 1 OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22532 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22534 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22548 ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22551 ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22552 ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22525 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22556 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22524 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (E.G. KYPHOPLASTY); LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22590 ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22595 ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22600 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22610 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22554 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22210 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22212 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22214 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22216 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22220 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22222 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22224 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22226 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22526 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22520 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22521 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22522 PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22523 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (E.G. KYPHOPLASTY); THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     22505 MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21235 GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20930 ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20931 ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20936 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20937 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20938 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20983 ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; CRYOABLATION Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   20251 BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20250 BIOPSY, VERTEBRAL BODY, OPEN; THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21060 MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21070 CORONOIDECTOMY (SEPARATE PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21073 MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE) Yes 7/1/2019     InterQual® Evidence-Based Criteria & Guidelines     21076 IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21077 IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21079 IMPRESSION AND CUSTOM PREPARATION; INTERIM OBTURATOR PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21080 IMPRESSION AND CUSTOM PREPARATION; DEFINITIVE OBTURATOR PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21082 IMPRESSION AND CUSTOM PREPARATION; PALATAL AUGMENTATION PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     20985 COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   19361 BREAST RECONSTRUCTION; WITH LATISSIMUS DORSI FLAP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0901T PLACEMENT OF BONE MARROW SAMPLING PORT, INCLUDING IMAGING GUIDANCE WHEN PERFORMED Yes 3/1/2025     InterQual® Evidence-Based Criteria & Guidelines     19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19318 BREAST REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19328 REMOVAL OF INTACT BREAST IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19330 REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19340 INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19342 INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19350 NIPPLE/AREOLA RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19357 TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21086 IMPRESSION AND CUSTOM PREPARATION; AURICULAR PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     19364 BREAST RECONSTRUCTION; WITH FREE FLAP (EG, FTRAM, DIEP, SIEA, GAP FLAP) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19367 BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19368 BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP, REQUIRING SEPARATE MICROVASCULAR ANASTOMOSIS (SUPERCHARGING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19369 BREAST RECONSTRUCTION; WITH BIPEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19370 REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19371 PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19380 REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19355 CORRECTION OF INVERTED NIPPLES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21175 RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION (EG, PLAGIOCEPHALY, TRIGONOCEPHALY, BRACHYCEPHALY), WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21180 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21182 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING LESS THAN 40 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21183 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 40 SQ CM BUT LESS THAN 80 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21184 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 80 SQ CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21083 IMPRESSION AND CUSTOM PREPARATION; PALATAL LIFT PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21194 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR L OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21198 OSTEOTOMY, MANDIBLE, SEGMENTAL; Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21206 OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21209 OSTEOPLASTY, FACIAL BONES; REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     19305 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR L OSTEOTOMY; WITHOUT BONE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21230 GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAINING GRAFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21087 IMPRESSION AND CUSTOM PREPARATION; NASAL PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21088 IMPRESSION AND CUSTOM PREPARATION; FACIAL PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21116 INJECTION PROCEDURE FOR TEMPOROMANDIBULAR JOINT ARTHROGRAPHY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21122 GENIOPLASTY; SLIDING OSTEOTOMIES, 2 OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21142 RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21143 RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21146 RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21147 RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     21084 IMPRESSION AND CUSTOM PREPARATION; SPEECH AID PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0228T INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0232U CSTB (CYSTATIN B) (EG, PROGRESSIVE MYOCLONIC EPILEPSY TYPE 1A, UNVERRICHT-LUNDBORG DISEASE), FULL GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT (STR) EXPANSIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0218U NEUROLOGY (MUSCULAR DYSTROPHY), DMD GENE SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, DELETIONS, DUPLICATIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS, BLOOD OR SALIVA, IDENTIFICATION AND CHARACTERIZATION OF GENETIC VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0219 CORONARY CARE-OTHER CORONARY CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0219T PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; CERVICAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0220T PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; THORACIC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0220U ONCOLOGY (BREAST CANCER), IMAGE ANALYSIS WITH ARTIFICIAL INTELLIGENCE ASSESSMENT OF 12 HISTOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES, REPORTED AS A RECURRENCE SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0221T PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; LUMBAR Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0222T PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0217T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0227U DRUG ASSAY, PRESUMPTIVE, 30 OR MORE DRUGS OR METABOLITES, URINE, LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) USING MULTIPLE REACTION MONITORING (MRM), WITH DRUG OR METABOLITE DESCRIPTION, INCLUDES SAMPLE VALIDATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0216T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0228U ONCOLOGY (PROSTATE), MULTIANALYTE MOLECULAR PROFILE BY PHOTOMETRIC DETECTION OF MACROMOLECULES ADSORBED ON NANOSPONGE ARRAY SLIDES WITH MACHINE LEARNING, UTILIZING FIRST MORNING VOIDED URINE, ALGORITHM REPORTED AS LIKELIHOOD OF PROSTATE CANCER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0229T INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; EACH ADDITIONAL LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0229U BCAT1 (BRANCHED CHAIN AMINO ACID TRANSAMINASE 1) AND IKZF1 (IKAROS FAMILY ZINC FINGER 1) (EG, COLORECTAL CANCER) PROMOTER METHYLATION ANALYSIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0230T INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0230U AR (ANDROGEN RECEPTOR) (EG, SPINAL AND BULBAR MUSCULAR ATROPHY, KENNEDY DISEASE, X CHROMOSOME INACTIVATION), FULL SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT (STR) EXPANSIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0231T INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; EACH ADDITIONAL LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0231U CACNA1A (CALCIUM VOLTAGE-GATED CHANNEL SUBUNIT ALPHA 1A) (EG, SPINOCEREBELLAR ATAXIA), FULL GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT (STR) GENE EXPANSIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0202 INTENSIVE CARE-MEDICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0226U SURROGATE VIRAL NEUTRALIZATION TEST (SVNT), SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ELISA, PLASMA, SERUM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0212 CORONARY CARE-PULMONARY CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0906 INTENSIVE OUTPATIENT SUBSTANCE ABUSE 3-4 HOURS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0203 INTENSIVE CARE-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0206 INTENSIVE CARE-INTERMEDIATE ICU Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0207 INTENSIVE CARE-BURN CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0207T EVACUATION OF MEIBOMIAN GLANDS, AUTOMATED, USING HEAT AND INTERMITTENT PRESSURE, UNILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0208 INTENSIVE CARE-TRAUMA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0209 INTENSIVE CARE-OTHER INTENSIVE CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0210 CORONARY CARE-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0218T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0211U ONCOLOGY (PAN-TUMOR), DNA AND RNA BY NEXT-GENERATION SEQUENCING, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, INTERPRETATIVE REPORT FOR SINGLE NUCLEOTIDE VARIANTS, COPY NUMBER ALTERATIONS, TUMOR MUTATIONAL BURDEN, AND MICROSATELLITE INSTABILITY, WITH THERAPY ASSOCIATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0233U FXN (FRATAXIN) (EG, FRIEDREICH ATAXIA), GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT (STR) EXPANSIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0212U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE GENOME AND MITOCHONDRIAL DNA SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT GENE EXPANSIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS, BLOOD OR SALIVA, IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS, PROBAND Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0213 CORONARY CARE-HEART TRANSPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0213T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0214 CORONARY CARE-INTERMEDIATE CCU Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0214T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0214U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE EXOME AND MITOCHONDRIAL DNA SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT GENE EXPANSIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS, BLOOD OR SALIVA, IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS, PROBAND Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0215T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0215U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), WHOLE EXOME AND MITOCHONDRIAL DNA SEQUENCE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES, DELETIONS, DUPLICATIONS, SHORT TANDEM REPEAT GENE EXPANSIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS, BLOOD OR SALIVA, IDENTIFICATION AND CATEGORIZATION OF GENETIC VARIANTS, EACH COMPARATOR EXOME (EG, PARENT, SIBLING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0211 CORONARY CARE-MYOCARDIAL INFARCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0267T IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, UNILATERAL (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0232T INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0262U ONCOLOGY (SOLID TUMOR), GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 7 GENE PATHWAYS (ER, AR, PI3K, MAPK, HH, TGFB, NOTCH), FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE), ALGORITHM REPORTED AS GENE PATHWAY ACTIVITY SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0263T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; COMPLETE PROCEDURE INCLUDING UNILATERAL OR BILATERAL BONE MARROW HARVEST Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0263U NEUROLOGY (AUTISM SPECTRUM DISORDER [ASD]), QUANTITATIVE MEASUREMENTS OF 16 CENTRAL CARBON METABOLITES (IE, α-KETOGLUTARATE, ALANINE, LACTATE, PHENYLALANINE, PYRUVATE, SUCCINATE, CARNITINE, CITRATE, FUMARATE, HYPOXANTHINE, INOSINE, MALATE, S-SULFOCYSTEINE, TAURINE, URATE, AND XANTHINE), LIQUID CHROMATOGRAPHY TANDEM MASS SPECTROMETRY (LC-MS/MS), PLASMA, ALGORITHMIC ANALYSIS WITH RESULT REPORTED AS NEGATIVE OR POSITIVE (WITH METABOLIC SUBTYPES OF ASD) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0264T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; COMPLETE PROCEDURE EXCLUDING BONE MARROW HARVEST Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0264U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), IDENTIFICATION OF COPY NUMBER VARIATIONS, INVERSIONS, INSERTIONS, TRANSLOCATIONS, AND OTHER STRUCTURAL VARIANTS BY OPTICAL GENOME MAPPING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0265T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; UNILATERAL OR BILATERAL BONE MARROW HARVEST ONLY FOR INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0265U RARE CONSTITUTIONAL AND OTHER HERITABLE DISORDERS, WHOLE GENOME AND MITOCHONDRIAL DNA SEQUENCE ANALYSIS, BLOOD, FROZEN AND FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, SALIVA, BUCCAL SWABS OR CELL LINES, IDENTIFICATION OF SINGLE NUCLEOTIDE AND COPY NUMBER VARIANTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0260U RARE DISEASES (CONSTITUTIONAL/HERITABLE DISORDERS), IDENTIFICATION OF COPY NUMBER VARIATIONS, INVERSIONS, INSERTIONS, TRANSLOCATIONS, AND OTHER STRUCTURAL VARIANTS BY OPTICAL GENOME MAPPING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0266U UNEXPLAINED CONSTITUTIONAL OR OTHER HERITABLE DISORDERS OR SYNDROMES, TISSUE-SPECIFIC GENE EXPRESSION BY WHOLE-TRANSCRIPTOME AND NEXT-GENERATION SEQUENCING, BLOOD, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE OR FRESH FROZEN TISSUE, REPORTED AS PRESENCE OR ABSENCE OF SPLICING OR EXPRESSION CHANGES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0259U NEPHROLOGY (CHRONIC KIDNEY DISEASE), NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY MEASUREMENT OF MYO-INOSITOL, VALINE, AND CREATININE, ALGORITHMICALLY COMBINED WITH CYSTATIN C (BY IMMUNOASSAY) AND DEMOGRAPHIC DATA TO DETERMINE ESTIMATED GLOMERULAR FILTRATION RATE (GFR), SERUM, QUANTITATIVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0267U RARE CONSTITUTIONAL AND OTHER HERITABLE DISORDERS, IDENTIFICATION OF COPY NUMBER VARIATIONS, INVERSIONS, INSERTIONS, TRANSLOCATIONS, AND OTHER STRUCTURAL VARIANTS BY OPTICAL GENOME MAPPING AND WHOLE GENOME SEQUENCING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0268T IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE GENERATOR ONLY (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0268U HEMATOLOGY (ATYPICAL HEMOLYTIC UREMIC SYNDROME [AHUS]), GENOMIC SEQUENCE ANALYSIS OF 15 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0269T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0269U HEMATOLOGY (AUTOSOMAL DOMINANT CONGENITAL THROMBOCYTOPENIA), GENOMIC SEQUENCE ANALYSIS OF 22 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0270T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, UNILATERAL (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0270U HEMATOLOGY (CONGENITAL COAGULATION DISORDERS), GENOMIC SEQUENCE ANALYSIS OF 20 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0271T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE GENERATOR ONLY (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0266T IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0246U RED BLOOD CELL ANTIGEN TYPING, DNA, GENOTYPING OF AT LEAST 16 BLOOD GROUPS WITH PHENOTYPE PREDICTION OF AT LEAST 51 RED BLOOD CELL ANTIGENS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0234U MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME), FULL GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0235U PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME, PTEN HAMARTOMA TUMOR SYNDROME), FULL GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0236U SMN1 (SURVIVAL OF MOTOR NEURON 1, TELOMERIC) AND SMN2 (SURVIVAL OF MOTOR NEURON 2, CENTROMERIC) (EG, SPINAL MUSCULAR ATROPHY) FULL GENE ANALYSIS, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DUPLICATIONS, DELETIONS, AND MOBILE ELEMENT INSERTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0237U CARDIAC ION CHANNELOPATHIES (EG, BRUGADA SYNDROME, LONG QT SYNDROME, SHORT QT SYNDROME, CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA), GENOMIC SEQUENCE ANALYSIS PANEL INCLUDING ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, AND SCN5A, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0238U ONCOLOGY (LYNCH SYNDROME), GENOMIC DNA SEQUENCE ANALYSIS OF MLH1, MSH2, MSH6, PMS2, AND EPCAM, INCLUDING SMALL SEQUENCE CHANGES IN EXONIC AND INTRONIC REGIONS, DELETIONS, DUPLICATIONS, MOBILE ELEMENT INSERTIONS, AND VARIANTS IN NON-UNIQUELY MAPPABLE REGIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0239U TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, CELL-FREE DNA, ANALYSIS OF 311 OR MORE GENES, INTERROGATION FOR SEQUENCE VARIANTS, INCLUDING SUBSTITUTIONS, INSERTIONS, DELETIONS, SELECT REARRANGEMENTS, AND COPY NUMBER VARIATIONS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0242U TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, CELL-FREE CIRCULATING DNA ANALYSIS OF 55-74 GENES, INTERROGATION FOR SEQUENCE VARIANTS, GENE COPY NUMBER AMPLIFICATIONS, AND GENE REARRANGEMENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0243U OBSTETRICS (PREECLAMPSIA), BIOCHEMICAL ASSAY OF PLACENTAL-GROWTH FACTOR, TIME-RESOLVED FLUORESCENCE IMMUNOASSAY, MATERNAL SERUM, PREDICTIVE ALGORITHM REPORTED AS A RISK SCORE FOR PREECLAMPSIA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0261U ONCOLOGY (COLORECTAL CANCER), IMAGE ANALYSIS WITH ARTIFICIAL INTELLIGENCE ASSESSMENT OF 4 HISTOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES (CD3 AND CD8 WITHIN TUMOR-STROMA BORDER AND TUMOR CORE), TISSUE, REPORTED AS IMMUNE RESPONSE AND RECURRENCE-RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0245U ONCOLOGY (THYROID), MUTATION ANALYSIS OF 10 GENES AND 37 RNA FUSIONS AND EXPRESSION OF 4 MRNA MARKERS USING NEXT-GENERATION SEQUENCING, FINE NEEDLE ASPIRATE, REPORT INCLUDES ASSOCIATED RISK OF MALIGNANCY EXPRESSED AS A PERCENTAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0201T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), BILATERAL INJECTIONS, INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 2 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0248U ONCOLOGY, SPHEROID CELL CULTURE IN 3D MICROENVIRONMENT, 12-DRUG PANEL, BRAIN- OR BRAIN METASTASIS-RESPONSE PREDICTION FOR EACH DRUG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0249U ONCOLOGY (BREAST), SEMIQUANTITATIVE ANALYSIS OF 32 PHOSPHOPROTEINS AND PROTEIN ANALYTES, INCLUDES LASER CAPTURE MICRODISSECTION, WITH ALGORITHMIC ANALYSIS AND INTERPRETATIVE REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0250U ONCOLOGY (SOLID ORGAN NEOPLASM), TARGETED GENOMIC SEQUENCE DNA ANALYSIS OF 505 GENES, INTERROGATION FOR SOMATIC ALTERATIONS (SNVS [SINGLE NUCLEOTIDE VARIANT], SMALL INSERTIONS AND DELETIONS, ONE AMPLIFICATION, AND FOUR TRANSLOCATIONS), MICROSATELLITE INSTABILITY AND TUMOR-MUTATION BURDEN Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0251U HEPCIDIN-25, ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA), SERUM OR PLASMA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0252U FETAL ANEUPLOIDY SHORT TANDEM-REPEAT COMPARATIVE ANALYSIS, FETAL DNA FROM PRODUCTS OF CONCEPTION, REPORTED AS NORMAL (EUPLOIDY), MONOSOMY, TRISOMY, OR PARTIAL DELETION/DUPLICATION, MOSAICISM, AND SEGMENTAL ANEUPLOIDY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0256U TRIMETHYLAMINE/TRIMETHYLAMINE N-OXIDE (TMA/TMAO) PROFILE, TANDEM MASS SPECTROMETRY (MS/MS), URINE, WITH ALGORITHMIC ANALYSIS AND INTERPRETIVE REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0257U VERY LONG CHAIN ACYL-COENZYME A (COA) DEHYDROGENASE (VLCAD), LEUKOCYTE ENZYME ACTIVITY, WHOLE BLOOD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0258U AUTOIMMUNE (PSORIASIS), MRNA, NEXT-GENERATION SEQUENCING, GENE EXPRESSION PROFILING OF 50-100 GENES, SKIN-SURFACE COLLECTION USING ADHESIVE PATCH, ALGORITHM REPORTED AS LIKELIHOOD OF RESPONSE TO PSORIASIS BIOLOGICS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0244U ONCOLOGY (SOLID ORGAN), DNA, COMPREHENSIVE GENOMIC PROFILING, 257 GENES, INTERROGATION FOR SINGLE-NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, COPY NUMBER ALTERATIONS, GENE REARRANGEMENTS, TUMOR-MUTATIONAL BURDEN AND MICROSATELLITE INSTABILITY, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TUMOR TISSUE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0142 ROOM & BOARD-DELUXE PRIVATE-OB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0152 ROOM & BOARD-WARD-OB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0136 INPATIENT SUBSTANCE ABUSE 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0136U ATM (ATAXIA TELANGIECTASIA MUTATED) (EG, ATAXIA TELANGIECTASIA) MRNA SEQUENCE ANALYSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0137 ROOM & BOARD-THREE AND FOUR BEDS-ONCOLOGY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0137U PALB2 (PARTNER AND LOCALIZER OF BRCA2) (EG, BREAST AND PANCREATIC CANCER) MRNA SEQUENCE ANALYSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0138 ROOM & BOARD-THREE AND FOUR BEDS-REHABILITATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0139 ROOM & BOARD-THREE AND FOUR BEDS-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0139U NEUROLOGY (AUTISM SPECTRUM DISORDER [ASD]), QUANTITATIVE MEASUREMENTS OF 6 CENTRAL CARBON METABOLITES (IE, ?KETOGLUTARATE, ALANINE, LACTATE, PHENYLALANINE, PYRUVATE, AND SUCCINATE), LC-MS/MS, PLASMA, ALGORITHMIC ANALYSIS WITH RESULT REPORTED AS NEGATIVE OR POSITIVE (WITH METABOLIC SUBTYPES OF ASD) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0133 ROOM & BOARD-THREE AND FOUR BEDS-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0141 ROOM & BOARD-DELUXE PRIVATE-MEDICAL/SURGICAL/GYN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0132 ROOM & BOARD-THREE AND FOUR BEDS-OB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0143 ROOM & BOARD-DELUXE PRIVATE-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0144 INPATIENT MENTAL HEALTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0146 INPATIENT SUBSTANCE ABUSE 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0147 ROOM & BOARD-DELUXE PRIVATE-ONCOLOGY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0148 ROOM & BOARD-DELUXE PRIVATE-REHABILITATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0149 ROOM & BOARD-DELUXE PRIVATE-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0150 ROOM & BOARD-WARD-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0202T POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0140 ROOM & BOARD-DELUXE PRIVATE-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0124 INPATIENT MENTAL HEALTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0114 INPATIENT MENTAL HEALTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0116 INPATIENT SUBSTANCE ABUSE 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0117 ROOM & BOARD-PRIVATE (ONE BED)-ONCOLOGY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0118 ROOM & BOARD-PRIVATE (ONE BED)-REHABILITATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0119 ROOM & BOARD-PRIVATE (ONE BED)-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0120 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0120U ONCOLOGY (B-CELL LYMPHOMA CLASSIFICATION), MRNA, GENE EXPRESSION PROFILING BY FLUORESCENT PROBE HYBRIDIZATION OF 58 GENES (45 CONTENT AND 13 HOUSEKEEPING GENES), FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS LIKELIHOOD FOR PRIMARY MEDIASTINAL B-CELL LYMPHOMA (PMBCL) AND DIFFUSE LARGE B-CELL LYMPHOMA (DLBCL) WITH CELL OF ORIGIN SUBTYPING IN THE LATTER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0121 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL/SURGICAL/GYN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0134 INPATIENT MENTAL HEALTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0123 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0153 ROOM & BOARD-WARD-PEDIATRIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0126 INPATIENT SUBSTANCE ABUSE 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0126T COMMON CAROTID INTIMA-MEDIA THICKNESS (IMT) STUDY FOR EVALUATION OF ATHEROSCLEROTIC BURDEN OR CORONARY HEART DISEASE RISK FACTOR ASSESSMENT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0127 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-ONCOLOGY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0128 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-REHABILITATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0129 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0130 ROOM & BOARD-THREE AND FOUR BEDS-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0130U HEREDITARY COLON CANCER DISORDERS (EG, LYNCH SYNDROME, PTEN HAMARTOMA SYNDROME, COWDEN SYNDROME, FAMILIAL ADENOMATOSIS POLYPOSIS), TARGETED MRNA SEQUENCE ANALYSIS PANEL (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, AND TP53) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0131 ROOM & BOARD-THREE AND FOUR BEDS-MEDICAL/SURGICAL/GYN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0122 ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-OB Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0191 SUBACUTE CARE-LEVEL I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0151 ROOM & BOARD-WARD-MEDICAL/SURGICAL/GYN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0177U ONCOLOGY (BREAST CANCER), DNA, PIK3CA (PHOSPHATIDYLINOSITOL-4,5-BISPHOSPHATE 3-KINASE CATALYTIC SUBUNIT ALPHA) GENE ANALYSIS OF 11 GENE VARIANTS UTILIZING PLASMA, REPORTED AS PIK3CA GENE MUTATION STATUS Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0179 NURSERY-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0179U ONCOLOGY (NON-SMALL CELL LUNG CANCER), CELL-FREE DNA, TARGETED SEQUENCE ANALYSIS OF 23 GENES (SINGLE NUCLEOTIDE VARIATIONS, INSERTIONS AND DELETIONS, FUSIONS WITHOUT PRIOR KNOWLEDGE OF PARTNER/BREAKPOINT, COPY NUMBER VARIATIONS), WITH REPORT OF SIGNIFICANT MUTATION(S) Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0180 LEAVE OF ABSENCE-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0182 LEAVE OF ABSENCE-PATIENT CONVENIENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0183 LEAVE OF ABSENCE-THERAPEUTIC LEAVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0185 LEAVE OF ABSENCE-NURSING HOME (FOR HOSPITALIZATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0174U ONCOLOGY (SOLID TUMOR), MASS SPECTROMETRIC 30 PROTEIN TARGETS, FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, PROGNOSTIC AND PREDICTIVE ALGORITHM REPORTED AS LIKELY, UNLIKELY, OR UNCERTAIN BENEFIT OF 39 CHEMOTHERAPY AND TARGETED THERAPEUTIC ONCOLOGY AGENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0190 SUBACUTE CARE-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0174 NURSERY-NEWBORN-LEVEL IV Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0192 SUBACUTE CARE-LEVEL II Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0193 SUBACUTE CARE-LEVEL III Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0194 SUBACUTE CARE-LEVEL IV Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0198T MEASUREMENT OF OCULAR BLOOD FLOW BY REPETITIVE INTRAOCULAR PRESSURE SAMPLING, WITH INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0199 SUBACUTE CARE-OTHER SUBACUTE CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0200 INTENSIVE CARE-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0200T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), UNILATERAL INJECTION(S), INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 1 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0201 INTENSIVE CARE-SURGICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0189 LEAVE OF ABSENCE-OTHER LEAVE OF ABSENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0164T REMOVAL OF TOTAL DISC ARTHROPLASTY, (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0154 INPATIENT MENTAL HEALTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0156 INPATIENT SUBSTANCE ABUSE 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0156U COPY NUMBER (EG, INTELLECTUAL DISABILITY, DYSMORPHOLOGY), SEQUENCE ANALYSIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0157 ROOM & BOARD-WARD-ONCOLOGY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0157U APC (APC REGULATOR OF WNT SIGNALING PATHWAY) (EG, FAMILIAL ADENOMATOSIS POLYPOSIS [FAP]) MRNA SEQUENCE ANALYSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0158 INPATIENT REHABILITATION 1 DAY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0159 ROOM & BOARD-WARD-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0160 ROOM & BOARD-OTHER-GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0175U PSYCHIATRY (EG, DEPRESSION, ANXIETY), GENOMIC ANALYSIS PANEL, VARIANT ANALYSIS OF 15 GENES Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0164 ROOM & BOARD-OTHER-STERILE ENVIRONMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0272U HEMATOLOGY (GENETIC BLEEDING DISORDERS), GENOMIC SEQUENCE ANALYSIS OF 60 GENES AND DUPLICATION/DELETION OF PLAU, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID, COMPREHENSIVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0167 ROOM & BOARD-OTHER-SELF-CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0169 ROOM & BOARD-OTHER-OTHER Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0170 NURSERY - GENERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0171 NURSERY-NEWBORN-LEVEL I Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0172 NURSERY-NEWBORN-LEVEL II Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0172U ONCOLOGY (SOLID TUMOR AS INDICATED BY THE LABEL), SOMATIC MUTATION ANALYSIS OF BRCA1 (BRCA1, DNA REPAIR ASSOCIATED), BRCA2 (BRCA2, DNA REPAIR ASSOCIATED) AND ANALYSIS OF HOMOLOGOUS RECOMBINATION DEFICIENCY PATHWAYS, DNA, FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM QUANTIFYING TUMOR GENOMIC INSTABILITY SCORE Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     0173 NURSERY-NEWBORN-LEVEL III Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0173U PSYCHIATRY (IE, DEPRESSION, ANXIETY), GENOMIC ANALYSIS PANEL, INCLUDES VARIANT ANALYSIS OF 14 GENES Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0162U HEREDITARY COLON CANCER (LYNCH SYNDROME), TARGETED MRNA SEQUENCE ANALYSIS PANEL (MLH1, MSH2, MSH6, PMS2) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0682T REMOVAL OF PULSE GENERATOR ONLY, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0713T NONINVASIVE ARTERIAL PLAQUE ANALYSIS USING SOFTWARE PROCESSING OF DATA FROM NON-CORONARY COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY; DATA REVIEW, INTERPRETATION AND REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0672T ENDOVAGINAL CRYOGEN-COOLED, MONOPOLAR RADIOFREQUENCY REMODELING OF THE TISSUES SURROUNDING THE FEMALE BLADDER NECK AND PROXIMAL URETHRA FOR URINARY INCONTINENCE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0674T LAPAROSCOPIC INSERTION OF NEW OR REPLACEMENT OF PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, INCLUDING AN IMPLANTABLE PULSE GENERATOR AND DIAPHRAGMATIC LEAD(S) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0675T LAPAROSCOPIC INSERTION OF NEW OR REPLACEMENT OF DIAPHRAGMATIC LEAD(S), PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, INCLUDING CONNECTION TO AN EXISTING PULSE GENERATOR; FIRST LEAD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0676T LAPAROSCOPIC INSERTION OF NEW OR REPLACEMENT OF DIAPHRAGMATIC LEAD(S), PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, INCLUDING CONNECTION TO AN EXISTING PULSE GENERATOR; EACH ADDITIONAL LEAD (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0677T LAPAROSCOPIC REPOSITIONING OF DIAPHRAGMATIC LEAD(S), PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, INCLUDING CONNECTION TO AN EXISTING PULSE GENERATOR; FIRST REPOSITIONED LEAD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0678T LAPAROSCOPIC REPOSITIONING OF DIAPHRAGMATIC LEAD(S), PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, INCLUDING CONNECTION TO AN EXISTING PULSE GENERATOR; EACH ADDITIONAL REPOSITIONED LEAD (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0679T LAPAROSCOPIC REMOVAL OF DIAPHRAGMATIC LEAD(S), PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0660T IMPLANTATION OF ANTERIOR SEGMENT INTRAOCULAR NONBIODEGRADABLE DRUG-ELUTING SYSTEM, INTERNAL APPROACH Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0681T RELOCATION OF PULSE GENERATOR ONLY, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, WITH CONNECTION TO EXISTING DUAL LEADS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0657T ANTERIOR LUMBAR OR THORACOLUMBAR VERTEBRAL BODY TETHERING; 8 OR MORE VERTEBRAL SEGMENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0683T PROGRAMMING DEVICE EVALUATION (IN-PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0684T PERI-PROCEDURAL DEVICE EVALUATION (IN-PERSON) AND PROGRAMMING OF DEVICE SYSTEM PARAMETERS BEFORE OR AFTER A SURGERY, PROCEDURE, OR TEST WITH ANALYSIS, REVIEW, AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0685T INTERROGATION DEVICE EVALUATION (IN-PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0686T HISTOTRIPSY (IE, NON-THERMAL ABLATION VIA ACOUSTIC ENERGY DELIVERY) OF MALIGNANT HEPATOCELLULAR TISSUE, INCLUDING IMAGE GUIDANCE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0694T 3-DIMENSIONAL VOLUMETRIC IMAGING AND RECONSTRUCTION OF BREAST OR AXILLARY LYMPH NODE TISSUE, EACH EXCISED SPECIMEN, 3-DIMENSIONAL AUTOMATIC SPECIMEN REORIENTATION, INTERPRETATION AND REPORT, REAL-TIME INTRAOPERATIVE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0710T NONINVASIVE ARTERIAL PLAQUE ANALYSIS USING SOFTWARE PROCESSING OF DATA FROM NON-CORONARY COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY; INCLUDING DATA PREPARATION AND TRANSMISSION, QUANTIFICATION OF THE STRUCTURE AND COMPOSITION OF THE VESSEL WALL AND ASSESSMENT FOR LIPID-RICH NECROTIC CORE PLAQUE TO ASSESS ATHEROSCLEROTIC PLAQUE STABILITY, DATA REVIEW, INTERPRETATION AND REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0711T NONINVASIVE ARTERIAL PLAQUE ANALYSIS USING SOFTWARE PROCESSING OF DATA FROM NON-CORONARY COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY; DATA PREPARATION AND TRANSMISSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0271U HEMATOLOGY (CONGENITAL NEUTROPENIA), GENOMIC SEQUENCE ANALYSIS OF 24 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0680T INSERTION OR REPLACEMENT OF PULSE GENERATOR ONLY, PERMANENT IMPLANTABLE SYNCHRONIZED DIAPHRAGMATIC STIMULATION SYSTEM FOR AUGMENTATION OF CARDIAC FUNCTION, WITH CONNECTION TO EXISTING LEAD(S) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0635T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, UNILATERAL; WITHOUT CONTRAST, FOLLOWED BY CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0624T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; DATA PREPARATION AND TRANSMISSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0625T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; COMPUTERIZED ANALYSIS OF DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0626T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; REVIEW OF COMPUTERIZED ANALYSIS OUTPUT TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0627T PERCUTANEOUS INJECTION OF ALLOGENEIC CELLULAR AND/OR TISSUE-BASED PRODUCT, INTERVERTEBRAL DISC, UNILATERAL OR BILATERAL INJECTION, WITH FLUOROSCOPIC GUIDANCE, LUMBAR; FIRST LEVEL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0628T PERCUTANEOUS INJECTION OF ALLOGENEIC CELLULAR AND/OR TISSUE-BASED PRODUCT, INTERVERTEBRAL DISC, UNILATERAL OR BILATERAL INJECTION, WITH FLUOROSCOPIC GUIDANCE, LUMBAR; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0629T PERCUTANEOUS INJECTION OF ALLOGENEIC CELLULAR AND/OR TISSUE-BASED PRODUCT, INTERVERTEBRAL DISC, UNILATERAL OR BILATERAL INJECTION, WITH CT GUIDANCE, LUMBAR; FIRST LEVEL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0630T PERCUTANEOUS INJECTION OF ALLOGENEIC CELLULAR AND/OR TISSUE-BASED PRODUCT, INTERVERTEBRAL DISC, UNILATERAL OR BILATERAL INJECTION, WITH CT GUIDANCE, LUMBAR; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0631T TRANSCUTANEOUS VISIBLE LIGHT HYPERSPECTRAL IMAGING MEASUREMENT OF OXYHEMOGLOBIN, DEOXYHEMOGLOBIN, AND TISSUE OXYGENATION, WITH INTERPRETATION AND REPORT, PER EXTREMITY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0661T REMOVAL AND REIMPLANTATION OF ANTERIOR SEGMENT INTRAOCULAR NONBIODEGRADABLE DRUG-ELUTING IMPLANT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0634T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, UNILATERAL; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0762 CRISIS STABILIZATION BED 23 HOUR - PSYCHIATRIC/SUBSTANCE USE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0636T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, BILATERAL; WITHOUT CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0637T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, BILATERAL; WITH CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0638T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, BILATERAL; WITHOUT CONTRAST, FOLLOWED BY CONTRAST MATERIAL(S) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0645T TRANSCATHETER IMPLANTATION OF CORONARY SINUS REDUCTION DEVICE INCLUDING VASCULAR ACCESS AND CLOSURE, RIGHT HEART CATHETERIZATION, VENOUS ANGIOGRAPHY, CORONARY SINUS ANGIOGRAPHY, IMAGING GUIDANCE, AND SUPERVISION AND INTERPRETATION, WHEN PERFORMED Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0650 HOSPICE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0651 HOSPICE, ROUTINE HOME CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0652 HOSPICE, CONTINUOUS HOME CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0656T ANTERIOR LUMBAR OR THORACOLUMBAR VERTEBRAL BODY TETHERING; UP TO 7 VERTEBRAL SEGMENTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0633T COMPUTED TOMOGRAPHY, BREAST, INCLUDING 3D RENDERING, WHEN PERFORMED, UNILATERAL; WITHOUT CONTRAST MATERIAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0824T TRANSCATHETER REMOVAL OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY), WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0712T NONINVASIVE ARTERIAL PLAQUE ANALYSIS USING SOFTWARE PROCESSING OF DATA FROM NON-CORONARY COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY; QUANTIFICATION OF THE STRUCTURE AND COMPOSITION OF THE VESSEL WALL AND ASSESSMENT FOR LIPID-RICH NECROTIC CORE PLAQUE TO ASSESS ATHEROSCLEROTIC PLAQUE STABILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0808T PULMONARY TISSUE VENTILATION ANALYSIS USING SOFTWARE-BASED PROCESSING OF DATA FROM SEPARATELY CAPTURED CINEFLUOROGRAPH IMAGES; IN COMBINATION WITH COMPUTED TOMOGRAPHY (CT) IMAGES TAKEN FOR THE PURPOSE OF PULMONARY TISSUE VENTILATION ANALYSIS, INCLUDING DATA PREPARATION AND TRANSMISSION, QUANTIFICATION OF PULMONARY TISSUE VENTILATION, DATA REVIEW, INTERPRETATION AND REPORT Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0816T OPEN INSERTION OR REPLACEMENT OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION INCLUDING ELECTRODE(S) (EG, ARRAY OR LEADLESS), AND PULSE GENERATOR OR RECEIVER, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBCUTANEOUS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0817T OPEN INSERTION OR REPLACEMENT OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION INCLUDING ELECTRODE(S) (EG, ARRAY OR LEADLESS), AND PULSE GENERATOR OR RECEIVER, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBFASCIAL Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0818T REVISION OR REMOVAL OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBCUTANEOUS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0819T REVISION OR REMOVAL OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBFASCIAL Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0820T CONTINUOUS IN-PERSON MONITORING AND INTERVENTION (EG, PSYCHOTHERAPY, CRISIS INTERVENTION), AS NEEDED, DURING PSYCHEDELIC MEDICATION THERAPY; FIRST PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, EACH HOUR Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0821T CONTINUOUS IN-PERSON MONITORING AND INTERVENTION (EG, PSYCHOTHERAPY, CRISIS INTERVENTION), AS NEEDED, DURING PSYCHEDELIC MEDICATION THERAPY; SECOND PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, CONCURRENT WITH FIRST PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, EACH HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0806T TRANSCATHETER SUPERIOR AND INFERIOR VENA CAVA PROSTHETIC VALVE IMPLANTATION (IE, CAVAL VALVE IMPLANTATION [CAVI]); OPEN FEMORAL VEIN APPROACH Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0823T TRANSCATHETER INSERTION OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0805T TRANSCATHETER SUPERIOR AND INFERIOR VENA CAVA PROSTHETIC VALVE IMPLANTATION (IE, CAVAL VALVE IMPLANTATION [CAVI]); PERCUTANEOUS FEMORAL VEIN APPROACH Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0825T TRANSCATHETER REMOVAL AND REPLACEMENT OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0826T PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, LEADLESS PACEMAKER SYSTEM IN SINGLE-CARDIAC CHAMBER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0859T NONCONTACT NEAR-INFRARED SPECTROSCOPY (EG, FOR MEASUREMENT OF DEOXYHEMOGLOBIN, OXYHEMOGLOBIN, AND RATIO OF TISSUE OXYGENATION), OTHER THAN FOR SCREENING FOR PERIPHERAL ARTERIAL DISEASE, IMAGE ACQUISITION, INTERPRETATION, AND REPORT; EACH ADDITIONAL ANATOMIC SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0860T NONCONTACT NEAR-INFRARED SPECTROSCOPY (EG, FOR MEASUREMENT OF DEOXYHEMOGLOBIN, OXYHEMOGLOBIN, AND RATIO OF TISSUE OXYGENATION), FOR SCREENING FOR PERIPHERAL ARTERIAL DISEASE, INCLUDING PROVOCATIVE MANEUVERS, IMAGE ACQUISITION, INTERPRETATION, AND REPORT, ONE OR BOTH LOWER EXTREMITIES Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0861T REMOVAL OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING; BOTH COMPONENTS (BATTERY AND TRANSMITTER) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0862T RELOCATION OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; BATTERY COMPONENT ONLY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0863T RELOCATION OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; TRANSMITTER COMPONENT ONLY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0864T LOW-INTENSITY EXTRACORPOREAL SHOCK WAVE THERAPY INVOLVING CORPUS CAVERNOSUM, LOW ENERGY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0822T CONTINUOUS IN-PERSON MONITORING AND INTERVENTION (EG, PSYCHOTHERAPY, CRISIS INTERVENTION), AS NEEDED, DURING PSYCHEDELIC MEDICATION THERAPY; CLINICAL STAFF UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, CONCURRENT WITH FIRST PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, EACH HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0796T TRANSCATHETER INSERTION OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; RIGHT ATRIAL PACEMAKER COMPONENT (WHEN AN EXISTING RIGHT VENTRICULAR SINGLE LEADLESS PACEMAKER EXISTS TO CREATE A DUAL-CHAMBER LEADLESS PACEMAKER SYSTEM) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0784T INSERTION OR REPLACEMENT OF PERCUTANEOUS ELECTRODE ARRAY, SPINAL, WITH INTEGRATED NEUROSTIMULATOR, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0785T REVISION OR REMOVAL OF NEUROSTIMULATOR ELECTRODE ARRAY, SPINAL, WITH INTEGRATED NEUROSTIMULATOR Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0786T INSERTION OR REPLACEMENT OF PERCUTANEOUS ELECTRODE ARRAY, SACRAL, WITH INTEGRATED NEUROSTIMULATOR, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0787T REVISION OR REMOVAL OF NEUROSTIMULATOR ELECTRODE ARRAY, SACRAL, WITH INTEGRATED NEUROSTIMULATOR Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0788T ELECTRONIC ANALYSIS WITH SIMPLE PROGRAMMING OF IMPLANTED INTEGRATED NEUROSTIMULATION SYSTEM (EG, ELECTRODE ARRAY AND RECEIVER), INCLUDING CONTACT GROUP(S), AMPLITUDE, PULSE WIDTH, FREQUENCY (HZ), ON/OFF CYCLING, BURST, DOSE LOCKOUT, PATIENT-SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED-LOOP PARAMETERS, AND PASSIVE PARAMETERS, WHEN PERFORMED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, SPINAL CORD OR SACRAL NERVE, 1-3 PARAMETERS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0789T ELECTRONIC ANALYSIS WITH COMPLEX PROGRAMMING OF IMPLANTED INTEGRATED NEUROSTIMULATION SYSTEM (EG, ELECTRODE ARRAY AND RECEIVER), INCLUDING CONTACT GROUP(S), AMPLITUDE, PULSE WIDTH, FREQUENCY (HZ), ON/OFF CYCLING, BURST, DOSE LOCKOUT, PATIENT-SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED-LOOP PARAMETERS, AND PASSIVE PARAMETERS, WHEN PERFORMED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, SPINAL CORD OR SACRAL NERVE, 4 OR MORE PARAMETERS Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     0790T REVISION (EG, AUGMENTATION, DIVISION OF TETHER), REPLACEMENT, OR REMOVAL OF THORACOLUMBAR OR LUMBAR VERTEBRAL BODY TETHERING, INCLUDING THORACOSCOPY, WHEN PERFORMED Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0791T MOTOR-COGNITIVE, SEMI-IMMERSIVE VIRTUAL REALITY-FACILITATED GAIT TRAINING, EACH 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0807T PULMONARY TISSUE VENTILATION ANALYSIS USING SOFTWARE-BASED PROCESSING OF DATA FROM SEPARATELY CAPTURED CINEFLUOROGRAPH IMAGES; IN COMBINATION WITH PREVIOUSLY ACQUIRED COMPUTED TOMOGRAPHY (CT) IMAGES, INCLUDING DATA PREPARATION AND TRANSMISSION, QUANTIFICATION OF PULMONARY TISSUE VENTILATION, DATA REVIEW, INTERPRETATION AND REPORT Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0795T TRANSCATHETER INSERTION OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; COMPLETE SYSTEM (IE, RIGHT ATRIAL AND RIGHT VENTRICULAR PACEMAKER COMPONENTS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0611T MAGNETIC RESONANCE SPECTROSCOPY, DETERMINATION AND LOCALIZATION OF DISCOGENIC PAIN (CERVICAL, THORACIC, OR LUMBAR); POSTPROCESSING FOR ALGORITHMIC ANALYSIS OF BIOMARKER DATA FOR DETERMINATION OF RELATIVE CHEMICAL DIFFERENCES BETWEEN DISCS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0797T TRANSCATHETER INSERTION OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; RIGHT VENTRICULAR PACEMAKER COMPONENT (WHEN PART OF A DUAL-CHAMBER LEADLESS PACEMAKER SYSTEM) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0798T TRANSCATHETER REMOVAL OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY), WHEN PERFORMED; COMPLETE SYSTEM (IE, RIGHT ATRIAL AND RIGHT VENTRICULAR PACEMAKER COMPONENTS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0799T TRANSCATHETER REMOVAL OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY), WHEN PERFORMED; RIGHT ATRIAL PACEMAKER COMPONENT Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0800T TRANSCATHETER REMOVAL OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY), WHEN PERFORMED; RIGHT VENTRICULAR PACEMAKER COMPONENT (WHEN PART OF A DUAL-CHAMBER LEADLESS PACEMAKER SYSTEM) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0801T TRANSCATHETER REMOVAL AND REPLACEMENT OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; DUAL-CHAMBER SYSTEM (IE, RIGHT ATRIAL AND RIGHT VENTRICULAR PACEMAKER COMPONENTS) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0802T TRANSCATHETER REMOVAL AND REPLACEMENT OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; RIGHT ATRIAL PACEMAKER COMPONENT Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0803T TRANSCATHETER REMOVAL AND REPLACEMENT OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; RIGHT VENTRICULAR PACEMAKER COMPONENT (WHEN PART OF A DUAL-CHAMBER LEADLESS PACEMAKER SYSTEM) Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0804T PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF IMPLANTABLE DEVICE TO TEST THE FUNCTION OF DEVICE AND TO SELECT OPTIMAL PERMANENT PROGRAMMED VALUES, WITH ANALYSIS, REVIEW, AND REPORT, BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, LEADLESS PACEMAKER SYSTEM IN DUAL CARDIAC CHAMBERS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0794T PATIENT-SPECIFIC, ASSISTIVE, RULES-BASED ALGORITHM FOR RANKING PHARMACO-ONCOLOGIC TREATMENT OPTIONS BASED ON THE PATIENT'S TUMOR-SPECIFIC CANCER MARKER INFORMATION OBTAINED FROM PRIOR MOLECULAR PATHOLOGY, IMMUNOHISTOCHEMICAL, OR OTHER PATHOLOGY RESULTS WHICH HAVE BEEN PREVIOUSLY INTERPRETED AND REPORTED SEPARATELY Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0308U CARDIOLOGY (CORONARY ARTERY DISEASE [CAD]), ANALYSIS OF 3 PROTEINS (HIGH SENSITIVITY [HS] TROPONIN, ADIPONECTIN, AND KIDNEY INJURY MOLECULE-1 [KIM-1]) WITH 3 CLINICAL PARAMETERS (AGE, SEX, HISTORY OF CARDIAC INTERVENTION), PLASMA, ALGORITHM REPORTED AS A RISK SCORE FOR OBSTRUCTIVE CAD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0623T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; DATA PREPARATION AND TRANSMISSION, COMPUTERIZED ANALYSIS OF DATA, WITH REVIEW OF COMPUTERIZED ANALYSIS OUTPUT TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0294U LONGEVITY AND MORTALITY RISK, MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 18 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0295U ONCOLOGY (BREAST DUCTAL CARCINOMA IN SITU), PROTEIN EXPRESSION PROFILING BY IMMUNOHISTOCHEMISTRY OF 7 PROTEINS (COX2, FOXA1, HER2, KI-67, P16, PR, SIAH2), WITH 4 CLINICOPATHOLOGIC FACTORS (SIZE, AGE, MARGIN STATUS, PALPABILITY), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS A RECURRENCE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0296U ONCOLOGY (ORAL AND/OR OROPHARYNGEAL CANCER), GENE EXPRESSION PROFILING BY RNA SEQUENCING OF AT LEAST 20 MOLECULAR FEATURES (EG, HUMAN AND/OR MICROBIAL MRNA), SALIVA, ALGORITHM REPORTED AS POSITIVE OR NEGATIVE FOR SIGNATURE ASSOCIATED WITH MALIGNANCY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0297U ONCOLOGY (PAN TUMOR), WHOLE GENOME SEQUENCING OF PAIRED MALIGNANT AND NORMAL DNA SPECIMENS, FRESH OR FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, BLOOD OR BONE MARROW, COMPARATIVE SEQUENCE ANALYSES AND VARIANT IDENTIFICATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0298U ONCOLOGY (PAN TUMOR), WHOLE TRANSCRIPTOME SEQUENCING OF PAIRED MALIGNANT AND NORMAL RNA SPECIMENS, FRESH OR FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, BLOOD OR BONE MARROW, COMPARATIVE SEQUENCE ANALYSES AND EXPRESSION LEVEL AND CHIMERIC TRANSCRIPT IDENTIFICATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0299U ONCOLOGY (PAN TUMOR), WHOLE GENOME OPTICAL GENOME MAPPING OF PAIRED MALIGNANT AND NORMAL DNA SPECIMENS, FRESH FROZEN TISSUE, BLOOD, OR BONE MARROW, COMPARATIVE STRUCTURAL VARIANT IDENTIFICATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0300I WHOLE GENOME SEQUENCING AND OPTICAL GENOME MAPPING OF PAIRED MALIGNANT AND NORMAL DNA SPECIMENS IN BLOOD SPECIMEN WITH COMPARATIVE SEQUENCE ANALYSES AND VARIANT IDENTIFICATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0292U PSYCHIATRY (STRESS DISORDERS), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 72 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0304U HEMATOLOGY, RED BLOOD CELL (RBC) ADHESION TO ENDOTHELIAL/SUBENDOTHELIAL ADHESION MOLECULES, FUNCTIONAL ASSESSMENT, WHOLE BLOOD, WITH ALGORITHMIC ANALYSIS AND RESULT REPORTED AS AN RBC ADHESION INDEX; NORMOXIC Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0291U PSYCHIATRY (MOOD DISORDERS), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 144 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0309U CARDIOLOGY (CARDIOVASCULAR DISEASE), ANALYSIS OF 4 PROTEINS (NT-PROBNP, OSTEOPONTIN, TISSUE INHIBITOR OF METALLOPROTEINASE-1 [TIMP-1], AND KIDNEY INJURY MOLECULE-1 [KIM-1]), PLASMA, ALGORITHM REPORTED AS A RISK SCORE FOR MAJOR ADVERSE CARDIAC EVENT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0310U PEDIATRICS (VASCULITIS, KAWASAKI DISEASE [KD]), ANALYSIS OF 3 BIOMARKERS (NT-PROBNP, C-REACTIVE PROTEIN, AND T-UPTAKE), PLASMA, ALGORITHM REPORTED AS A RISK SCORE FOR KD Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0313U ONCOLOGY (PANCREAS), DNA AND MRNA NEXT-GENERATION SEQUENCING ANALYSIS OF 74 GENES AND ANALYSIS OF CEA (CEACAM5) GENE EXPRESSION, PANCREATIC CYST FLUID, ALGORITHM REPORTED AS A CATEGORICAL RESULT (IE, NEGATIVE, LOW PROBABILITY OF NEOPLASIA OR POSITIVE, HIGH PROBABILITY OF NEOPLASIA) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0314U ONCOLOGY (CUTANEOUS MELANOMA), MRNA GENE EXPRESSION PROFILING BY RT-PCR OF 35 GENES (32 CONTENT AND 3 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS A CATEGORICAL RESULT (IE, BENIGN, INTERMEDIATE, MALIGNANT) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0315U ONCOLOGY (CUTANEOUS SQUAMOUS CELL CARCINOMA), MRNA GENE EXPRESSION PROFILING BY RT-PCR OF 40 GENES (34 CONTENT AND 6 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHM REPORTED AS A CATEGORICAL RISK RESULT (IE, CLASS 1, CLASS 2A, CLASS 2B) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0316U BORRELIA BURGDORFERI (LYME DISEASE), OSPA PROTEIN EVALUATION, URINE Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0519T REMOVAL AND REPLACEMENT OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; BOTH COMPONENTS (BATTERY AND TRANSMITTER) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0519U THERAPEUTIC DRUG MONITORING, MEDICATIONS SPECIFIC TO PAIN, DEPRESSION, AND ANXIETY, LC-MS/MS, PLASMA, 110 OR MORE DRUGS OR SUBSTANCES, QUALITATIVE AND QUANTITATIVE THERAPEUTIC MINIMALLY EFFECTIVE RANGE OF PRESCRIBED, NON-PRESCRIBED, AND ILLICIT MEDICATIONS IN CIRCULATION Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0300U ONCOLOGY (PAN TUMOR), WHOLE GENOME SEQUENCING AND OPTICAL GENOME MAPPING OF PAIRED MALIGNANT AND NORMAL DNA SPECIMENS, FRESH TISSUE, BLOOD, OR BONE MARROW, COMPARATIVE SEQUENCE ANALYSES AND VARIANT IDENTIFICATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0279U HEMATOLOGY (VON WILLEBRAND DISEASE [VWD]), VON WILLEBRAND FACTOR (VWF) AND COLLAGEN III BINDING BY ENZYME-LINKED IMMUNOSORBENT ASSAYS (ELISA), PLASMA, REPORT OF COLLAGEN III BINDING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     97551 CAREGIVER TRAINING IN STRATEGIES AND TECHNIQUES TO FACILITATE THE PATIENT'S FUNCTIONAL PERFORMANCE IN THE HOME OR COMMUNITY (EG, ACTIVITIES OF DAILY LIVING [ADLS], INSTRUMENTAL ADLS [IADLS], TRANSFERS, MOBILITY, COMMUNICATION, SWALLOWING, FEEDING, PROBLEM SOLVING, SAFETY PRACTICES) (WITHOUT THE PATIENT PRESENT), FACE TO FACE; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) Yes 9/1/2024   For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). Authorization required for all visits pertaining to Speech Therapy. InterQual® Evidence-Based Criteria & Guidelines     0273T INTERROGATION DEVICE EVALUATION (IN PERSON), CAROTID SINUS BAROREFLEX ACTIVATION SYSTEM, INCLUDING TELEMETRIC ITERATIVE COMMUNICATION WITH THE IMPLANTABLE DEVICE TO MONITOR DEVICE DIAGNOSTICS AND PROGRAMMED THERAPY VALUES, WITH INTERPRETATION AND REPORT (EG, BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY); WITH PROGRAMMING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0273U HEMATOLOGY (GENETIC HYPERFIBRINOLYSIS, DELAYED BLEEDING), ANALYSIS OF 9 GENES (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2 BY NEXT-GENERATION SEQUENCING, AND PLAU BY ARRAY COMPARATIVE GENOMIC HYBRIDIZATION), BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0274T PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; CERVICAL OR THORACIC Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0274U HEMATOLOGY (GENETIC PLATELET DISORDERS), GENOMIC SEQUENCE ANALYSIS OF 62 GENES AND DUPLICATION/DELETION OF PLAU, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0275T PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0276U HEMATOLOGY (INHERITED THROMBOCYTOPENIA), GENOMIC SEQUENCE ANALYSIS OF 42 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0277U HEMATOLOGY (GENETIC PLATELET FUNCTION DISORDER), GENOMIC SEQUENCE ANALYSIS OF 40 GENES AND DUPLICATION/DELETION OF PLAU, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0293U PSYCHIATRY (SUICIDAL IDEATION), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 54 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0278U HEMATOLOGY (GENETIC THROMBOSIS), GENOMIC SEQUENCE ANALYSIS OF 14 GENES, BLOOD, BUCCAL SWAB, OR AMNIOTIC FLUID Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0521T INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING, AND DISCONNECTION PER PATIENT ENCOUNTER, WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0281U HEMATOLOGY (VON WILLEBRAND DISEASE [VWD]), VON WILLEBRAND PROPEPTIDE, ENZYME-LINKED IMMUNOSORBENT ASSAYS (ELISA), PLASMA, DIAGNOSTIC REPORT OF VON WILLEBRAND FACTOR (VWF) PROPEPTIDE ANTIGEN LEVEL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0282U RED BLOOD CELL ANTIGEN TYPING, DNA, GENOTYPING OF 12 BLOOD GROUP SYSTEM GENES TO PREDICT 44 RED BLOOD CELL ANTIGEN PHENOTYPES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0285U ONCOLOGY, RESPONSE TO RADIATION, CELL-FREE DNA, QUANTITATIVE BRANCHED CHAIN DNA AMPLIFICATION, PLASMA, REPORTED AS A RADIATION TOXICITY SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0286U CEP72 (CENTROSOMAL PROTEIN, 72-KDA), NUDT15 (NUDIX HYDROLASE 15) AND TPMT (THIOPURINE S-METHYLTRANSFERASE) (EG, DRUG METABOLISM) GENE ANALYSIS, COMMON VARIANTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0287U ONCOLOGY (THYROID), DNA AND MRNA, NEXT-GENERATION SEQUENCING ANALYSIS OF 112 GENES, FINE NEEDLE ASPIRATE OR FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, ALGORITHMIC PREDICTION OF CANCER RECURRENCE, REPORTED AS A CATEGORICAL RISK RESULT (LOW, INTERMEDIATE, HIGH) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0288U ONCOLOGY (LUNG), MRNA, QUANTITATIVE PCR ANALYSIS OF 11 GENES (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) AND 3 REFERENCE GENES (ESD, TBP, YAP1), FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TUMOR TISSUE, ALGORITHMIC INTERPRETATION REPORTED AS A RECURRENCE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0289U NEUROLOGY (ALZHEIMER DISEASE), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 24 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0290U PAIN MANAGEMENT, MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 36 GENES, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0278T TRANSCUTANEOUS ELECTRICAL MODULATION PAIN REPROCESSING (EG, SCRAMBLER THERAPY), EACH TREATMENT SESSION (INCLUDES PLACEMENT OF ELECTRODES) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0556T BONE STRENGTH AND FRACTURE RISK USING FINITE ELEMENT ANALYSIS OF FUNCTIONAL DATA AND BONE-MINERAL DENSITY UTILIZING DATA FROM A COMPUTED TOMOGRAPHY SCAN; ASSESSMENT OF BONE STRENGTH AND FRACTURE RISK AND BONE-MINERAL DENSITY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0546U LOW-DENSITY LIPOPROTEIN RECEPTOR-RELATED PROTEIN 4 (LRP4), ANTIBODY IDENTIFICATION BY IMMUNOFLUORESCENCE, USING LIVE CELLS, REPORTED AS POSITIVE OR NEGATIVE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0547T BONE-MATERIAL QUALITY TESTING BY MICROINDENTATION(S) OF THE TIBIA(S), WITH RESULTS REPORTED AS A SCORE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0547U NEUROFILAMENT LIGHT CHAIN (NFL), CHEMILUMINESCENT ENZYME IMMUNOASSAY, PLASMA, QUANTITATIVE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0548U GLIAL FIBRILLARY ACIDIC PROTEIN (GFAP), CHEMILUMINESCENT ENZYME IMMUNOASSAY, USING PLASMA Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0549U ONCOLOGY (UROTHELIAL), DNA, QUANTITATIVE METHYLATED REAL-TIME PCR OF TRNA-CYS, SIM2, AND NKX1-1, USING URINE, DIAGNOSTIC ALGORITHM REPORTED AS A PROBABILITY INDEX FOR BLADDER CANCER AND/OR UPPER TRACT UROTHELIAL CARCINOMA (UTUC) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0550U ONCOLOGY (PROSTATE), ENZYME-LINKED IMMUNOSORBENT ASSAYS (ELISA) FOR TOTAL PROSTATE-SPECIFIC ANTIGEN (PSA) AND FREE PSA, SERUM, COMBINED WITH AGE, PREVIOUS NEGATIVE PROSTATE BIOPSY STATUS, DIGITAL RECTAL EXAMINATION FINDINGS, PROSTATE VOLUME, AND IMAGE AND DATA REPORTING OF THE PROSTATE, ALGORITHM REPORTED AS A RISK SCORE FOR THE PRESENCE OF HIGH-GRADE PROSTATE CANCER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0551U TAU, PHOSPHORYLATED, PTAU217, BY SINGLE-MOLECULE ARRAY (ULTRASENSITIVE DIGITAL PROTEIN DETECTION), USING PLASMA Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0553T PERCUTANEOUS TRANSCATHETER PLACEMENT OF ILIAC ARTERIOVENOUS ANASTOMOSIS IMPLANT, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0520T REMOVAL AND REPLACEMENT OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; BATTERY COMPONENT ONLY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0555T BONE STRENGTH AND FRACTURE RISK USING FINITE ELEMENT ANALYSIS OF FUNCTIONAL DATA AND BONE-MINERAL DENSITY UTILIZING DATA FROM A COMPUTED TOMOGRAPHY SCAN; RETRIEVAL AND TRANSMISSION OF THE SCAN DATA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0543U ONCOLOGY (SOLID TUMOR), NEXT-GENERATION SEQUENCING OF DNA FROM FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE OF 517 GENES, INTERROGATION FOR SINGLE- NUCLEOTIDE VARIANTS, MULTI-NUCLEOTIDE VARIANTS, INSERTIONS AND DELETIONS FROM DNA, FUSIONS IN 24 GENES AND SPLICE VARIANTS IN 1 GENE FROM RNA, AND TUMOR MUTATION BURDEN Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0557T BONE STRENGTH AND FRACTURE RISK USING FINITE ELEMENT ANALYSIS OF FUNCTIONAL DATA AND BONE-MINERAL DENSITY UTILIZING DATA FROM A COMPUTED TOMOGRAPHY SCAN; INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0558T COMPUTED TOMOGRAPHY SCAN TAKEN FOR THE PURPOSE OF BIOMECHANICAL COMPUTED TOMOGRAPHY ANALYSIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0563T EVACUATION OF MEIBOMIAN GLANDS, USING HEAT DELIVERED THROUGH WEARABLE, OPEN-EYE EYELID TREATMENT DEVICES AND MANUAL GLAND EXPRESSION, BILATERAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0567T PERMANENT FALLOPIAN TUBE OCCLUSION WITH DEGRADABLE BIOPOLYMER IMPLANT, TRANSCERVICAL APPROACH, INCLUDING TRANSVAGINAL ULTRASOUND Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0568T INTRODUCTION OF MIXTURE OF SALINE AND AIR FOR SONOSALPINGOGRAPHY TO CONFIRM OCCLUSION OF FALLOPIAN TUBES, TRANSCERVICAL APPROACH, INCLUDING TRANSVAGINAL ULTRASOUND AND PELVIC ULTRASOUND Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0609T MAGNETIC RESONANCE SPECTROSCOPY, DETERMINATION AND LOCALIZATION OF DISCOGENIC PAIN (CERVICAL, THORACIC, OR LUMBAR); ACQUISITION OF SINGLE VOXEL DATA, PER DISC, ON BIOMARKERS (IE, LACTIC ACID, CARBOHYDRATE, ALANINE, LAAL, PROPIONIC ACID, PROTEOGLYCAN, AND COLLAGEN) IN AT LEAST 3 DISCS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0610T MAGNETIC RESONANCE SPECTROSCOPY, DETERMINATION AND LOCALIZATION OF DISCOGENIC PAIN (CERVICAL, THORACIC, OR LUMBAR); TRANSMISSION OF BIOMARKER DATA FOR SOFTWARE ANALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0272T INTERROGATION DEVICE EVALUATION (IN PERSON), CAROTID SINUS BAROREFLEX ACTIVATION SYSTEM, INCLUDING TELEMETRIC ITERATIVE COMMUNICATION WITH THE IMPLANTABLE DEVICE TO MONITOR DEVICE DIAGNOSTICS AND PROGRAMMED THERAPY VALUES, WITH INTERPRETATION AND REPORT (EG, BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY); Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0554T BONE STRENGTH AND FRACTURE RISK USING FINITE ELEMENT ANALYSIS OF FUNCTIONAL DATA AND BONE-MINERAL DENSITY UTILIZING DATA FROM A COMPUTED TOMOGRAPHY SCAN; RETRIEVAL AND TRANSMISSION OF THE SCAN DATA, ASSESSMENT OF BONE STRENGTH AND FRACTURE RISK AND BONE-MINERAL DENSITY, INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0535U PERFLUOROALKYL SUBSTANCES (PFAS) (EG, PERFLUOROOCTANOIC ACID, PERFLUOROOCTANE SULFONIC ACID), BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS), PLASMA OR SERUM, QUANTITATIVE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0612T MAGNETIC RESONANCE SPECTROSCOPY, DETERMINATION AND LOCALIZATION OF DISCOGENIC PAIN (CERVICAL, THORACIC, OR LUMBAR); INTERPRETATION AND REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0522T PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING REVIEW AND REPORT, WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0524T ENDOVENOUS CATHETER DIRECTED CHEMICAL ABLATION WITH BALLOON ISOLATION OF INCOMPETENT EXTREMITY VEIN, OPEN OR PERCUTANEOUS, INCLUDING ALL VASCULAR ACCESS, CATHETER MANIPULATION, DIAGNOSTIC IMAGING, IMAGING GUIDANCE AND MONITORING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     0531U INFECTIOUS DISEASE (ACID-FAST BACTERIA AND INVASIVE FUNGI), DNA (673 ORGANISMS), NEXT-GENERATION SEQUENCING, PLASMA Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0532U RARE DISEASES (CONSTITUTIONAL DISEASE/HEREDITARY DISORDERS), RAPID WHOLE GENOME AND MITOCHONDRIAL DNA SEQUENCING FOR SINGLE-NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, COPY NUMBER VARIATIONS, PERIPHERAL BLOOD, BUFFY COAT, SALIVA, BUCCAL OR TISSUE SAMPLE, RESULTS REPORTED AS POSITIVE OR NEGATIVE Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   0533T RADIOSTEREOMETRIC ANALYSIS (RSA) - INCLUDES SET-UP, PATIENT TRAINING, CONFIGURATION OF MONITOR, DATA UPLOAD, ANALYSIS AND INITIAL REPORT CONFIGURATION, DOWNLOAD REVIEW, INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0533U DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), GENOTYPING OF 16 GENES (IE, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), REPORTED AS METABOLIZER STATUS AND TRANSPORTER FUNCTION Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0534T RADIOSTEREOMETRIC ANALYSIS (RSA) -SET-UP, PATIENT TRAINING, CONFIGURATION OF MONITOR Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0546T RADIOFREQUENCY SPECTROSCOPY, REAL TIME, INTRAOPERATIVE MARGIN ASSESSMENT, AT THE TIME OF PARTIAL MASTECTOMY, WITH REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0535T RADIOSTEREOMETRIC ANALYSIS (RSA) - -DATA UPLOAD, ANALYSIS AND INITIAL REPORT CONFIGURATION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0544U NEPHROLOGY (TRANSPLANT MONITORING), 48 VARIANTS BY DIGITAL PCR, USING CELL-FREE DNA FROM PLASMA, DONOR-DERIVED CELL-FREE DNA, PERCENTAGE REPORTED AS RISK FOR REJECTION Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0536T RADIOSTEREOMETRIC ANALYSIS (RSA) - DOWNLOAD REVIEW, INTERPRETATION AND REPORT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0536U RED BLOOD CELL ANTIGEN (FETAL RHD), PCR ANALYSIS OF EXON 4 OF RHD GENE AND HOUSEKEEPING CONTROL GENE GAPDH FROM WHOLE BLOOD IN PREGNANT INDIVIDUALS AT 10+ WEEKS GESTATION KNOWN TO BE RHD NEGATIVE, REPORTED AS FETAL RHD STATUS Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   0537U ONCOLOGY (COLORECTAL CANCER), ANALYSIS OF CELL-FREE DNA FOR EPIGENOMIC PATTERNS, NEXT-GENERATION SEQUENCING, >2500 DIFFERENTIALLY METHYLATED REGIONS (DMRS), PLASMA, ALGORITHM REPORTED AS POSITIVE OR NEGATIVE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0538U ONCOLOGY (SOLID TUMOR), NEXT-GENERATION TARGETED SEQUENCING ANALYSIS, FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TUMOR TISSUE, DNA ANALYSIS OF 600 GENES, INTERROGATION FOR SINGLE-NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, GENE REARRANGEMENTS, AND COPY NUMBER ALTERATIONS, MICROSATELLITE INSTABILITY, TUMOR MUTATION BURDEN, REPORTED AS ACTIONABLE VARIANT Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0539U ONCOLOGY (SOLID TUMOR), CELL-FREE CIRCULATING TUMOR DNA (CTDNA), 152 GENES, NEXT-GENERATION SEQUENCING, INTERROGATION FOR SINGLE-NUCLEOTIDE VARIANTS, INSERTIONS/DELETIONS, GENE REARRANGEMENTS, COPY NUMBER ALTERATIONS, AND MICROSATELLITE INSTABILITY, USING WHOLE-BLOOD SAMPLES, MUTATIONS WITH CLINICAL ACTIONABILITY REPORTED AS ACTIONABLE VARIANT Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0540U TRANSPLANTATION MEDICINE, QUANTIFICATION OF DONOR-DERIVED CELL-FREE DNA USING NEXT-GENERATION SEQUENCING ANALYSIS OF PLASMA, REPORTED AS PERCENTAGE OF DONOR-DERIVED CELL-FREE DNA TO DETERMINE PROBABILITY OF REJECTION Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines Evidence of Coverage (EOC, Plan coverage document)   0541U CARDIOVASCULAR DISEASE (HDL REVERSE CHOLESTEROL TRANSPORT), CHOLESTEROL EFFLUX CAPACITY, LC-MS/MS, QUANTITATIVE MEASUREMENT OF 5 DISTINCT HDL-BOUND APOLIPOPROTEINS (APOLIPOPROTEINS A1, C1, C2, C3, AND C4), SERUM, ALGORITHM REPORTED AS PREDICTION OF CORONARY ARTERY DISEASE (PCAD) SCORE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0542U NEPHROLOGY (RENAL TRANSPLANT), URINE, NUCLEAR MAGNETIC RESONANCE (NMR) SPECTROSCOPY MEASUREMENT OF 84 URINARY METABOLITES, COMBINED WITH PATIENT DATA, QUANTIFICATION OF BK VIRUS (HUMAN POLYOMAVIRUS 1) USING REAL-TIME PCR AND SERUM CREATININE, ALGORITHM REPORTED AS A PROBABILITY SCORE FOR ALLOGRAFT INJURY STATUS Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0520U THERAPEUTIC DRUG MONITORING, 200 OR MORE DRUGS OR SUBSTANCES, LC-MS/MS, PLASMA, QUALITATIVE AND QUANTITATIVE THERAPEUTIC MINIMALLY EFFECTIVE RANGE OF PRESCRIBED AND NON-PRESCRIBED MEDICATIONS Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   0534U ONCOLOGY (PROSTATE), MICRORNA, SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) ANALYSIS BY RT-PCR OF 32 VARIANTS, USING BUCCAL SWAB, ALGORITHM REPORTED AS A RISK SCORE Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L3891 ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3915 WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIV Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3762 ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3763 ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3764 ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3765 ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3766 ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3806 WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3807 WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3590 ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3809 WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, OFF-THE-SHELF, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3900 WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3901 WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3904 WRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, ELECTRIC, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3905 WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3906 WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3908 WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3912 HAND FINGER ORTHOSIS (HFO), FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3400 METATARSAL BAR WEDGE, ROCKER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3808 WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE MATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3485 HEEL, PAD, REMOVABLE FOR SPUR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2627 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, MOLDED TO PATIENT MODEL, RECIPROCATING HIP JOINT AND CABLES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3420 FULL SOLE AND HEEL WEDGE, BETWEEN SOLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3430 HEEL, COUNTER, PLASTIC REINFORCED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3440 HEEL, COUNTER, LEATHER REINFORCED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3450 HEEL, SACH CUSHION TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3455 HEEL, NEW LEATHER, STANDARD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3460 HEEL, NEW RUBBER, STANDARD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3465 HEEL, THOMAS WITH WEDGE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3595 ORTHOPEDIC SHOE ADDITION, MARCH BAR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3480 HEEL, PAD AND DEPRESSION FOR SPUR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3917 HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3500 ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3510 ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3520 ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3530 ORTHOPEDIC SHOE ADDITION, SOLE, HALF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3540 ORTHOPEDIC SHOE ADDITION, SOLE, FULL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3550 ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3560 ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3570 ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3470 HEEL, THOMAS EXTENDED TO BALL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3913 HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3999 UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4010 REPLACE TRILATERAL SOCKET BRIM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3980 UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3978 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4060 REPLACE HIGH ROLL CUFF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4030 REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3919 HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3921 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3923 HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3925 FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP), NON TORSION JOINT/SPRING, EXTENSION/FLEXION, MAY INCLUDE SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3927 FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP), WITHOUT JOINT/SPRING, EXTENSION/FLEXION (E.G., STATIC OR RING TYPE), MAY INCLUDE SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3929 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC P Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3931 WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3933 FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3982 UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3956 ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL; PER JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3390 OUTFLARE WEDGE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3961 SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3962 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERB'S PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3967 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3971 SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3973 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3975 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3976 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3977 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3935 FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3060 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3170 FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, PREFABRICATED, OFF-THE-SHELF, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3001 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3003 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3031 FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2861 ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3050 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3070 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3080 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3090 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3150 FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3160 FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3410 METATARSAL BAR WEDGE, BETWEEN SOLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2630 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, UNILATERAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2640 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, BILATERAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2650 ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL, GLUTEAL PAD, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2660 ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, THORACIC BAND Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2670 ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, PARASPINAL UPRIGHTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2680 ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, LATERAL SUPPORT UPRIGHTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3320 LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3161 FOOT, ADDUCTUS POSITIONING DEVICE, ADJUSTABLE Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L3252 FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3253 FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3254 NON-STANDARD SIZE OR WIDTH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3255 NON-STANDARD SIZE OR LENGTH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3260 SURGICAL BOOT/SHOE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3265 PLASTAZOTE SANDAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3330 LIFT, ELEVATION, METAL EXTENSION (SKATE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3334 LIFT, ELEVATION, HEEL, PER INCH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3340 HEEL WEDGE, SACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3350 HEEL WEDGE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3360 SOLE WEDGE, OUTSIDE SOLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3370 SOLE WEDGE, BETWEEN SOLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3380 CLUBFOOT WEDGE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3300 LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3214 BENESCH BOOT, PAIR, JUNIOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3207 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3208 SURGICAL BOOT, EACH, INFANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3209 SURGICAL BOOT, EACH, CHILD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3211 SURGICAL BOOT, EACH, JUNIOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3251 FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3213 BENESCH BOOT, PAIR, CHILD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3221 ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3222 ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3224 ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3225 ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L3212 BENESCH BOOT, PAIR, INFANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BAND Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5706 CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5684 ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5685 ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5686 ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5688 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5690 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5692 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5694 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5682 ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5681 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIAN BANDAGE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5699 ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5700 REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5701 REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5702 REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5703 ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5704 CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4130 REPLACE PRETIBIAL SHELL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5670 ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION ('PTS' OR SIMILAR) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5652 ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEE DISARTICULATION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5653 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5654 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5655 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5656 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5658 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5661 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5665 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5683 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIA Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5668 ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5707 CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING MECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5672 ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5673 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5676 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5677 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5678 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5679 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5680 ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NONMOLDED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5666 ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5705 CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5826 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5827 ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, ELECTROMECHANICAL SWING AND STANCE PHASE CONTROL, WITH OR WITHOUT SHOCK ABSORPTION AND STANCE EXTENSION DAMPING Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5814 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5841 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, PNEUMATIC SWING, AND STANCE PHASE CONTROL Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5848 ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEE EXTENSION ASSIST Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5855 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSION ASSIST Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5859 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5780 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5710 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5711 ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5712 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5714 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5716 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5718 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5722 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5724 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5728 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5781 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5782 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM, HEAVY DUTY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5783 ADDITION TO LOWER EXTREMITY, USER ADJUSTABLE, MECHANICAL, RESIDUAL LIMB VOLUME MANAGEMENT SYSTEM Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5795 ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5726 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5341 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5250 HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5270 HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5280 HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5312 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, SACH FOOT, ENDOSKELETAL SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5331 HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5160 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK' OR KNEE DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCL. FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, BELOW KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, ABOVE KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5500 INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5505 INITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4631 ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2624 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EXTENSION, ABDUCTION CONTROL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4350 ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4361 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4386 WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4392 REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH FOOT BLOCKS, NO ANKLE JOINTS, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4398 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5530 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5060 ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5150 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4396 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5640 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 'PTB' BRIM DESIGN SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5636 ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5510 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5642 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5643 ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5645 ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5646 ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5648 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5610 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5535 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, SACH FOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5540 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5560 PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5570 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5580 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5585 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5590 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5600 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5611 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5613 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5614 ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5615 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 4 BAR LINKAGE OR MULTIAXIAL, FLUID SWING AND STANCE PHASE CONTROL Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L5616 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5617 ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR BELOW KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5520 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5595 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0454 TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0480 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0170 CERVICAL, COLLAR, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0172 CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO-PIECE, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0174 CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0180 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0190 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE CERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0200 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE CERVICAL BARS, AND THORACIC EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0220 THORACIC, RIB BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0150 CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITH MANDIBULAR/OCCIPITAL PIECE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0452 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0456 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL AND SOFT ANTERIOR APRON, EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE, PRODUC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0458 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0460 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0462 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SO Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0464 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0466 TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS, PREFABRICATED ITEM TH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0470 TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO SCAPULA, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, AND LATERAL FRAME PIECES, ROTATIONAL STRENGT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0877 POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0450 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0900 CUSTOMIZED DURABLE MEDICAL EQUIPMENT, OTHER THAN WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L2628 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAME, RECIPROCATING HIP JOINT AND CABLES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0879 POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0880 POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0884 POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0885 POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0886 POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0890 POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0891 POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0160 CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0899 POWER MOBILITY DEVICE, NOT CODED BY DME PDAC OR DOES NOT MEET CRITERIA Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0482 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0901 KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0902 KNEE ORTHOSIS (KO), DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K1002 CRANIAL ELECTROTHERAPY STIMULATION (CES) SYSTEM, ANY TYPE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   K1004 LOW FREQUENCY ULTRASONIC DIATHERMY TREATMENT DEVICE FOR HOME USE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L0112 CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0113 CRANIAL CERVICAL ORTHOSIS, TORTICOLLIS TYPE, WITH OR WITHOUT JOINT, WITH OR WITHOUT SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0130 CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0898 POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0830 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0472 TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAME EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH WITH TWO ANTERIOR COMPONENTS (ONE PUBIC AND ONE STERNAL), POSTERIOR AND LATERAL PADS WITH STRAPS AND CLOSURES, LIMITS SPINAL FLEXION, R Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0637 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO R Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0638 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO R Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0639 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0640 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERAL CONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0710 CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIENT MODEL, WITH INTERFACE MATERIAL, (MINERVA TYPE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0720 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERAL CONTROL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item Evidence of Coverage (EOC, Plan coverage document)     L0635 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIOR FRAME/PANEL(S), LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0820 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0634 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOA Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0859 ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGS AND PINS, ANY MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0861 ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0970 TLSO, CORSET FRONT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0972 LSO, CORSET FRONT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0974 TLSO, FULL CORSET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0976 LSO, FULL CORSET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0978 AXILLARY CRUTCH EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0980 PERONEAL STRAPS, PREFABRICATED, OFF-THE-SHELF, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0810 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0625 LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, SHOULDER STR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0484 TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0486 TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0488 TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0490 TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVERLAPPING REINFORCED ANTERIOR, WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES AT OR BEFORE THE T-9 VERTEBRA, ANTERIOR EXTENDS FROM SYMP Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0491 TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE XIPHOID, SOF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0492 TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE XIPHOID, S Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0621 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0622 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0636 LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIOR FRAME/PANELS, LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERA Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0624 SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS PLACED OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0871 POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0626 LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0627 LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOU Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0628 LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE STAYS, SHOU Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0629 LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE STAYS, SHOU Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0630 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0631 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0632 LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0633 LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0623 SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0801 POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0816 POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0733 POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0738 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0739 REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT OTHER THAN OXYGEN EQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0740 REPAIR OR NONROUTINE SERVICE FOR OXYGEN EQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0743 SUCTION PUMP, HOME MODEL, PORTABLE, FOR USE ON WOUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0744 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE 16 SQUARE INCHES OR LESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0745 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE MORE THAN 16 SQUARE INCHES BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0669 WHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDAC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0800 POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0609 REPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0802 POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0806 POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0807 POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0808 POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0812 POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0813 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0814 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0878 POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0746 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE GREATER THAN 48 SQUARE INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0552 SUPPLIES FOR EXTERNAL NON-INSULIN DRUG INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     97546 WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0073 CASTER PIN LOCK, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0098 DRIVE BELT FOR POWER WHEELCHAIR, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0672 ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0462 TEMPORARY REPLACEMENT FOR PATIENT OWNED EQUIPMENT BEING REPAIRED, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0820 POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0601 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE, 1.5 VOLT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0602 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE, 3 VOLT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0603 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, ALKALINE, 1.5 VOLT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0604 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 3.6 VOLT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0605 REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 4.5 VOLT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0606 AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0607 REPLACEMENT BATTERY FOR AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0608 REPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0455 INFUSION PUMP USED FOR UNINTERRUPTED PARENTERAL ADMINISTRATION OF MEDICATION, (E.G., EPOPROSTENOL OR TREPROSTINOL) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0859 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0815 POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0850 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0851 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0852 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0853 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0854 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0855 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0856 POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0848 POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0858 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0843 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0860 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0861 POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0862 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0863 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0864 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0868 POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0869 POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0870 POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0857 POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0831 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0821 POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0822 POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0823 POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0824 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0825 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0826 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0827 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0828 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0849 POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0830 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0999 ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0835 POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0836 POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0837 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0838 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0839 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0840 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0841 POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0842 POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0829 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601 POUNDS OR MORE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2240 ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2126 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2128 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2132 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2134 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2136 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2188 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2200 ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2210 ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2220 ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2230 ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L0982 STOCKING SUPPORTER GRIPS, PREFABRICATED, OFF-THE-SHELF, SET OF FOUR (4) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2005 KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, ANY TYPE ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR 'AK' ORTHOSIS), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2034 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2040 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2050 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, HIP JOINT, PELVIC BAND/BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2060 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, BALL BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2070 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2080 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, HIP JOINT, PELVIC BAND/BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2090 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, BALL BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2035 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2530 ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM (BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2500 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2510 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2520 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2526 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2540 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2550 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2570 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE TWO POSITION JOINT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2580 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2600 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUST BEARING, FREE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2610 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS OR THRUST BEARING, LOCK, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2620 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, HEAVY DUTY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2622 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2525 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2260 ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2265 ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2270 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINED OR MALLEOLUS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2280 ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2300 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2310 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2335 ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2350 ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FOR 'PTB' 'AFO' ORTHOSES) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2360 ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2370 ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2375 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2380 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2387 ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1320 THORACIC, PECTUS CARINATUM ORTHOSIS, STERNAL COMPRESSION, RIGID CIRCUMFERENTIAL FRAME WITH ANTERIOR AND POSTERIOR RIGID PADS, CUSTOM FABRICATED Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1230 ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1240 ADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1250 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1260 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1270 ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1280 ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1290 ADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1210 ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1310 OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1499 SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1600 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WITH COVER, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INIDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1610 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER ONLY), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1620 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1630 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1640 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR SPREADER BAR, THIGH CUFFS, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1650 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFLED TYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1652 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICULATION, MANUAL LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1001 CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1006 SCOLIOSIS ORTHOSIS, SAGITTAL-CORONAL CONTROL PROVIDED BY A RIGID LATERAL FRAME, EXTENDS FROM AXILLA TO TROCHANTER, INCLUDES ALL ACCESSORY PADS, STRAPS AND INTERFACE, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZE Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L1010 ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS, AXILLA SLING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1020 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1220 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1680 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL, ADJUSTABLE HIP MOTION CONTROL, THIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1120 ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1847 KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1850 KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1860 KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM FABRICATED (SK) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1900 ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1902 ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1904 ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTOUS ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1907 ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1653 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT SIZE, PREFABRICATED, OFF THE SHELF Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1844 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1932 AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1933 ANKLE FOOT ORTHOSIS, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1950 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1951 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1952 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L0984 PROTECTIVE BODY SOCK, PREFABRICATED, OFF-THE-SHELF, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1820 KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1685 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1686 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1690 COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION AND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1700 LEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1710 LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1720 LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1730 LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1846 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1845 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, A Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1821 KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, OFF THE SHELF Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L1830 KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1832 KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1834 KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1840 KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1843 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, A Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1660 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L1755 LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4338 ARTACENT VELOS, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4347 RAMPART DL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4306 AMERICAN AMNION AC, PER SQUARE CENTIMETER Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4307 AMERICAN AMNION, PER SQUARE CENTIMETER Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4308 SANOPELLIS, PER SQUARE CENTIMETER Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4309 VIA MATRIX, PER SQUARE CENTIMETER Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4310 PROCENTA, PER 100 MG Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4334 AMNIOPLAST 1, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4335 AMNIOPLAST 2, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4304 GRAFIX PLUS, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4337 ARTACENT TRIDENT, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4303 COMPLETE AA, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4339 ARTACENT VERICLEN, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4340 SIMPLIGRAFT, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4341 SIMPLIMAX, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4342 THERAMEND, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4343 DERMACYTE AC MATRIX AMNIOTIC MEMBRANE ALLOGRAFT, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4344 TRI-MEMBRANE WRAP, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4345 MATRIX HD ALLOGRAFT DERMIS, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4280 XCELL AMNIO MATRIX, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4336 ARTACENT C, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4293 ACESSO DL, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4118 MATRISTEM MICROMATRIX, 1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4282 CYGNUS DUAL, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4283 BIOVANCE TRI-LAYER OR BIOVANCE 3L, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4284 DERMABIND SL, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4287 DERMABIND DL, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4288 DERMABIND CH, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4289 REVOSHIELD + AMNIOTIC BARRIER, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4290 MEMBRANE WRAP-HYDRO, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4305 AMERICAN AMNION AC TRI-LAYER, PER SQUARE CENTIMETER Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   Q4292 LAMELLAS, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4348 SENTRY SL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4294 AMNIO QUAD-CORE, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4295 AMNIO TRI-CORE AMNIOTIC, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4296 REBOUND MATRIX, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4297 EMERGE MATRIX, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4298 AMNICORE PRO, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4299 AMNICORE PRO+, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4301 ACTIVATE MATRIX, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4302 COMPLETE ACA, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4291 LAMELLAS XT, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q5104 INJECTION, INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q4346 SHELTER DM MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q5004 HOSPICE CARE PROVIDED IN SKILLED NURSING FACILITY (SNF) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5005 HOSPICE CARE PROVIDED IN INPATIENT HOSPITAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5006 HOSPICE CARE PROVIDED IN INPATIENT HOSPICE FACILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5007 HOSPICE CARE PROVIDED IN LONG TERM CARE FACILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5008 HOSPICE CARE PROVIDED IN INPATIENT PSYCHIATRIC FACILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5009 HOSPICE OR HOME HEALTH CARE PROVIDED IN PLACE NOT OTHERWISE SPECIFIED (NOS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5010 HOSPICE HOME CARE PROVIDED IN A HOSPICE FACILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5002 HOSPICE OR HOME HEALTH CARE PROVIDED IN ASSISTED LIVING FACILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5103 INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5001 HOSPICE OR HOME HEALTH CARE PROVIDED IN PATIENT'S HOME/RESIDENCE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5106 INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5107 INJECTION, BEVACIZUMAB-AWWB, BIOSIMILAR, (MVASI), 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required when billed charges exceed $500 per line item OncolHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5108 INJECTION, PEGFILGRASTIM-JMDB (FULPHILA), BIOSIMILAR, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q5109 INJECTION, INFLIXIMAB-QBTX, BIOSIMILAR, (IXIFI), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5110 INJECTION, FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5111 INJECTION, PEGFILGRASTIM-CBQV (UDENYCA), BIOSIMILAR, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q5112 INJECTION, TRASTUZUMAB-DTTB, BIOSIMILAR, (ONTRUZANT), 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses. OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5113 INJECTION, TRASTUZUMAB-PKRB, BIOSIMILAR, (HERZUMA), 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses. OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5101 INJECTION, FILGRASTIM-SNDZ, BIOSIMILAR, (ZARXIO), 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q4359 CHORIPLY, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4349 MANTLE DL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4350 PALISADE DM MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4351 ENCLOSE TL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4352 OVERLAY SL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4353 XCEED TL MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4354 PALINGEN DUAL-LAYER MEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4355 ABIOMEND XPLUS MEMBRANE AND ABIOMEND XPLUS HYDROMEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4356 ABIOMEND MEMBRANE AND ABIOMEND HYDROMEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q5003 HOSPICE CARE PROVIDED IN NURSING LONG TERM CARE FACILITY (LTC) OR NON-SKILLED NURSING FACILITY (NF) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4358 XWRAP DUAL, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4279 VENDAJE AC, PER SQUARE CENTIMETER Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4360 AMCHOPLAST FD, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4361 EPIXPRESS, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4362 CYGNUS DISK, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4363 AMNIO BURGEON MEMBRANE AND HYDROMEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4364 AMNIO BURGEON XPLUS MEMBRANE AND XPLUS HYDROMEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4365 AMNIO BURGEON DUAL-LAYER MEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4366 DUAL LAYER AMNIO BURGEON X-MEMBRANE, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4367 AMNIOCORE SL, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4357 XWRAP PLUS, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4203 DERMA-GIDE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4213 ASCENT, 0.5 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4193 COLL-E-DERM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4194 NOVACHOR, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4195 PURAPLY, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4196 PURAPLY AM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4197 PURAPLY XT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4198 GENESIS AMNIOTIC MEMBRANE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4200 SKIN TE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4149 EXCELLAGEN, 0.1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4202 KEROXX (2.5G/CC), 1CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4148 NEOX CORD 1K, NEOX CORD RT, OR CLARIX CORD 1K, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4204 XWRAP, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4205 MEMBRANE GRAFT OR MEMBRANE WRAP, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4206 FLUID FLOW OR FLUID GF, 1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4208 NOVAFIX, PER SQUARE CENITMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4209 SURGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4210 AXOLOTL GRAFT OR AXOLOTL DUALGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4211 AMNION BIO OR AXOBIOMEMBRANE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4281 BARRERA SL OR BARRERA DL, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4201 MATRION, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4138 BIODFENCE DRYFLEX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4123 ALLOSKIN RT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4125 ARTHROFLEX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4126 MEMODERM, DERMASPAN, TRANZGRAFT OR INTEGUPLY, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4127 TALYMED, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4130 STRATTICE TM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4134 HMATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4135 MEDISKIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4150 ALLOWRAP DS OR DRY, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4137 AMNIOEXCEL, AMNIOEXCEL PLUS OR BIODEXCEL, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4214 CELLESTA CORD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4139 AMNIOMATRIX OR BIODMATRIX, INJECTABLE, 1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4140 BIODFENCE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4141 ALLOSKIN AC, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4142 XCM BIOLOGIC TISSUE MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4143 REPRIZA, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4145 EPIFIX, INJECTABLE, 1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4146 TENSIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4147 ARCHITECT, ARCHITECT PX, OR ARCHITECT FX, EXTRACELLULAR MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4136 EZ-DERM, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4270 COMPLETE SL, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4212 ALLOGEN, PER CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4248 DERMACYTE AMNIOTIC MEMBRANE ALLOGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4262 DUAL LAYER IMPAX MEMBRANE, PER SQUARE CENTIMETER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4263 SURGRAFT TL, PER SQUARE CENTIMETER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4264 COCOON MEMBRANE, PER SQUARE CENTIMETER Yes 5/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4265 NEOSTIM TL, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4266 NEOSTIM MEMBRANE, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4267 NEOSTIM DL, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4246 CORETEXT OR PROTEXT, PER CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4269 SURGRAFT XT, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4245 AMNIOTEXT, PER CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4271 COMPLETE FT, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4272 ESANO A, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4273 ESANO AAA, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4274 ESANO AC, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4275 ESANO ACA, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4276 ORION, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4277 WOUNDPLUS MEMBRANE OR E-GRAFT, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4278 EPIEFFECT, PER SQUARE CENTIMETER Yes 7/1/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4268 SURGRAFT FT, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4234 XCELLERATE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4215 AXOLOTL AMBIENT OR AXOLOTL CRYO, 0.1 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4216 ARTACENT CORD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4217 WOUNDFIX, BIOWOUND, WOUNDFIX PLUS, BIOWOUND PLUS, WOUNDFIX XPLUS OR BIOWOUND XPLUS, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4218 SURGICORD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4219 SURGIGRAFT-DUAL, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4227 AMNIOCORE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4228 BIONEXTPATCH, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4229 COGENEX AMNIOTIC MEMBRANE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4247 AMNIOTEXT PATCH, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4233 SURFACTOR OR NUDYN, PER 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q5116 INJECTION, TRASTUZUMAB-QYYP, BIOSIMILAR, (TRAZIMERA), 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q4235 AMNIOREPAIR OR ALTIPLY, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4236 CAREPATCH, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4237 CRYO-CORD, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4239 AMNIO-MAXX OR AMNIO-MAXX LITE, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4240 CORECYTE, FOR TOPICAL USE ONLY, PER 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4241 POLYCYTE, FOR TOPICAL USE ONLY, PER 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4242 AMNIOCYTE PLUS, PER 0.5 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4244 PROCENTA, PER 200 MG Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4232 CORPLEX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9090 VERTEBRAL AXIAL DECOMPRESSION, PER SESSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9129 OCCUPATIONAL THERAPY, IN THE HOME, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8301 INFECTION CONTROL SUPPLIES, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S8930 ELECTRICAL STIMULATION OF AURICULAR ACUPUNCTURE POINTS; EACH 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S8940 EQUESTRIAN/HIPPOTHERAPY, PER SESSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S8990 PHYSICAL OR MANIPULATIVE THERAPY PERFORMED FOR MAINTENANCE RATHER THAN RESTORATION Yes 7/7/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     S9001 HOME UTERINE MONITOR WITH OR WITHOUT ASSOCIATED NURSING SERVICES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9002 INTRA-VAGINAL MOTION SENSOR SYSTEM, PROVIDES BIOFEEDBACK FOR PELVIC FLOOR MUSCLE REHABILITATION DEVICE Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   S9055 PROCUREN OR OTHER GROWTH FACTOR PREPARATION TO PROMOTE WOUND HEALING Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S8131 INTERFERENTIAL CURRENT STIMULATOR, 4 CHANNEL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9061 HOME ADMINISTRATION OF AEROSOLIZED DRUG THERAPY (E.G., PENTAMIDINE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8130 INTERFERENTIAL CURRENT STIMULATOR, 2 CHANNEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9097 HOME VISIT FOR WOUND CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9098 HOME VISIT, PHOTOTHERAPY SERVICES (E.G., BILI-LITE), INCLUDING EQUIPMENT RENTAL, NURSING SERVICES, BLOOD DRAW, SUPPLIES, AND OTHER SERVICES, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9110 TELEMONITORING OF PATIENT IN THEIR HOME, INCLUDING ALL NECESSARY EQUIPMENT; COMPUTER SYSTEM, CONNECTIONS, AND SOFTWARE; MAINTENANCE; PATIENT EDUCATION AND SUPPORT; PER MONTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9123 NURSING CARE, IN THE HOME; BY REGISTERED NURSE, PER HOUR (USE FOR GENERAL NURSING CARE ONLY, NOT TO BE USED WHEN CPT CODES 99500-99602 CAN BE USED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9124 NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, PER HOUR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9126 HOSPICE CARE, IN THE HOME, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9127 SOCIAL WORK VISIT, IN THE HOME, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5114 INJECTION, TRASTUZUMAB-DKST, BIOSIMILAR, (OGIVRI), 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses. OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   S9056 COMA STIMULATION PER DIEM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S5181 HOME HEALTH RESPIRATORY THERAPY, NOS, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3870 COMPARATIVE GENOMIC HYBRIDIZATION (CGH) MICROARRAY TESTING FOR DEVELOPMENTAL DELAY, AUTISM SPECTRUM DISORDER AND/OR INTELLECTUAL DISABILITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3900 SURFACE ELECTROMYOGRAPHY (EMG) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S5035 HOME INFUSION THERAPY, ROUTINE SERVICE OF INFUSION DEVICE (E.G., PUMP MAINTENANCE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S5036 HOME INFUSION THERAPY, REPAIR OF INFUSION DEVICE (E.G., PUMP REPAIR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S5108 HOME CARE TRAINING TO HOME CARE CLIENT, PER 15 MINUTES Yes 4/14/2020     InterQual® Evidence-Based Criteria & Guidelines     S5109 HOME CARE TRAINING TO HOME CARE CLIENT, PER SESSION Yes 4/14/2020     InterQual® Evidence-Based Criteria & Guidelines     S5110 HOME CARE TRAINING, FAMILY; PER 15 MINUTES Yes 4/14/2020     InterQual® Evidence-Based Criteria & Guidelines     S5111 HOME CARE TRAINING, FAMILY; PER SESSION Yes 4/14/2020     InterQual® Evidence-Based Criteria & Guidelines     S8270 ENURESIS ALARM, USING AUDITORY BUZZER AND/OR VIBRATION DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S5116 HOME CARE TRAINING, NON-FAMILY; PER SESSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9131 PHYSICAL THERAPY; IN THE HOME, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8035 MAGNETIC SOURCE IMAGING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8037 MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8040 TOPOGRAPHIC BRAIN MAPPING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8042 MAGNETIC RESONANCE IMAGING (MRI), LOW-FIELD Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8085 FLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD COINCIDENCE DETECTION SYSTEM (NON-DEDICATED PET SCAN) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8092 ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINE CT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S8120 OXYGEN CONTENTS, GASEOUS, 1 UNIT EQUALS 1 CUBIC FOOT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S8121 OXYGEN CONTENTS, LIQUID, 1 UNIT EQUALS 1 POUND Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S5115 HOME CARE TRAINING, NON-FAMILY; PER 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5080 GLASSES, BONE CONDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9128 SPEECH THERAPY, IN THE HOME, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V2626 REDUCTION OF OCULAR PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V2627 SCLERAL COVER SHELL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     V2628 FABRICATION AND FITTING OF OCULAR CONFORMER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     V2629 PROSTHETIC EYE, OTHER TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     V5030 HEARING AID, MONAURAL, BODY WORN, AIR CONDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5040 HEARING AID, MONAURAL, BODY WORN, BONE CONDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5050 HEARING AID, MONAURAL, IN THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     V5070 GLASSES, AIR CONDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V2623 PROSTHETIC EYE, PLASTIC, CUSTOM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     V5095 SEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   V5100 HEARING AID, BILATERAL, BODY WORN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5120 BINAURAL, BODY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5130 BINAURAL, IN THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5140 BINAURAL, BEHIND THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5150 BINAURAL, GLASSES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5170 HEARING AID, CROS, IN THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5290 ASSISTIVE LISTENING DEVICE, TRANSMITTER MICROPHONE, ANY TYPE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V5060 HEARING AID, MONAURAL, BEHIND THE EAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9485 CRISIS INTERVENTION MENTAL HEALTH SERVICES, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9208 HOME MANAGEMENT OF PRETERM LABOR, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9209 HOME MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM), INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9211 HOME MANAGEMENT OF GESTATIONAL HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USE THIS CODE WITH ANY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9212 HOME MANAGEMENT OF POSTPARTUM HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9213 HOME MANAGEMENT OF PREECLAMPSIA, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING SERVICES CODED SEPARATELY); PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFU Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9214 HOME MANAGEMENT OF GESTATIONAL DIABETES, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USE THIS CODE WITH ANY HOM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9370 HOME THERAPY, INTERMITTENT ANTI-EMETIC INJECTION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9372 HOME THERAPY; INTERMITTENT ANTICOAGULANT INJECTION THERAPY (E.G., HEPARIN); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     V2625 ENLARGEMENT OF OCULAR PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3861 GENETIC TESTING, SODIUM CHANNEL, VOLTAGE-GATED, TYPE V, ALPHA SUBUNIT (SCN5A) AND VARIANTS FOR SUSPECTED BRUGADA SYNDROME Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S9529 ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S), SINGLE HOME BOUND, NURSING HOME, OR SKILLED NURSING FACILITY PATIENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9537 HOME THERAPY; HEMATOPOIETIC HORMONE INJECTION THERAPY (E.G., ERYTHROPOIETIN, G-CSF, GM-CSF); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9560 HOME INJECTABLE THERAPY; HORMONAL THERAPY (E.G.; LEUPROLIDE, GOSERELIN), INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9562 HOME INJECTABLE THERAPY, PALIVIZUMAB OR OTHER MONOCLONAL ANTIBODY FOR RSV, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S9590 HOME THERAPY, IRRIGATION THERAPY (E.G., STERILE IRRIGATION OF AN ORGAN OR ANATOMICAL CAVITY); INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9810 HOME THERAPY; PROFESSIONAL PHARMACY SERVICES FOR PROVISION OF INFUSION, SPECIALTY DRUG ADMINISTRATION, AND/OR DISEASE STATE MANAGEMENT, NOT OTHERWISE CLASSIFIED, PER HOUR (DO NOT USE THIS CODE WITH ANY PER DIEM CODE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     T1000 PRIVATE DUTY / INDEPENDENT NURSING SERVICE(S) - LICENSED, UP TO 15 MINUTES Yes 8/15/2023     InterQual® Evidence-Based Criteria & Guidelines     T2004 NON-EMERGENCY TRANSPORT; COMMERCIAL CARRIER, MULTI-PASS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S9445 PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER, INDIVIDUAL, PER SESSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5150 INJECTION, AFLIBERCEPT-MRBB (AHZANTIVE), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S3866 GENETIC ANALYSIS FOR A SPECIFIC GENE MUTATION FOR HYPERTROPHIC CARDIOMYOPATHY (HCM) IN AN INDIVIDUAL WITH A KNOWN HCM MUTATION IN THE FAMILY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5141 INJECTION, ADALIMUMAB-AATY, BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5142 INJECTION, ADALIMUMAB-RYVK BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5143 INJECTION, ADALIMUMAB-ADBM, BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5144 INJECTION, ADALIMUMAB-AACF (IDACIO), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5145 INJECTION, ADALIMUMAB-AFZB (ABRILADA), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5146 INJECTION, TRASTUZUMAB-STRF (HERCESSI), BIOSIMILAR, 10 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5147 INJECTION, AFLIBERCEPT-AYYH (PAVBLU), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5139 INJECTION, ECULIZUMAB-AEEB (BKEMV), BIOSIMILAR, 10 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5149 INJECTION, AFLIBERCEPT-ABZV (ENZEEVU), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5136 INJECTION, DENOSUMAB-BBDZ (JUBBONTI/WYOST), BIOSIMILAR, 1 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5151 INJECTION, ECULIZUMAB-AAGH (EPYSQLI), BIOSIMILAR, 2 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5152 INJECTION, ECULIZUMAB-AEEB (BKEMV), BIOSIMILAR, 2 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q9980 HYALURONAN OR DERIVATIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q9996 INJECTION, USTEKINUMAB-TTWE (PYZCHIVA), SUBCUTANEOUS, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q9997 INJECTION, USTEKINUMAB-TTWE (PYZCHIVA), INTRAVENOUS, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q9998 INJECTION, USTEKINUMAB-AEKN (SELARSDI), 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q9999 INJECTION, USTEKINUMAB-AAUZ (OTULFI), BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S0145 INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5148 INJECTION, FILGRASTIM-TXID (NYPOZI), BIOSIMILAR, 1 MICROGRAM Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5127 INJECTION, PEGFILGRASTIM-FPGK (STIMUFEND), BIOSIMILAR, 0.5 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q4117 HYALOMATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q5117 INJECTION, TRASTUZUMAB-ANNS, BIOSIMILAR, (KANJINTI), 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5118 INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG Yes 1/1/2025   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required when billed charges exceed $500 per line item OncoHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5119 INJECTION, RITUXIMAB-PVVR, BIOSIMILAR, (RUXIENCE), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Rituximab: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5120 INJECTION, PEGFILGRASTIM-BMEZ (ZIEXTENZO), BIOSIMILAR, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5121 INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5122 INJECTION, PEGFILGRASTIM-APGF (NYVEPRIA), BIOSIMILAR, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q5123 INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses. OncoHealth Medical Policy, "Rituximab: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5140 INJECTION, ADALIMUMAB-FKJP, BIOSIMILAR, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5126 INJECTION, BEVACIZUMAB-MALY, BIOSIMILAR, (ALYMSYS), 10 MG Yes 5/15/2023   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required when billed charges exceed $500 per line item OncolHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   S0271 PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, HOSPICE MONTHLY CASE RATE (PER 30 DAYS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5128 INJECTION, RANIBIZUMAB-EQRN (CIMERLI), BIOSIMILAR, 0.1 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q5129 INJECTION, BEVACIZUMAB-ADCD (VEGZELMA), BIOSIMILAR, 10 MG Yes 8/15/2023   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required when billed charges exceed $500 per line item OncolHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   Q5130 INJECTION, PEGFILGRASTIM-PBBK (FYLNETRA), BIOSIMILAR, 0.5 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   Q5131 INJECTION, ADALIMUMAB-AACF (IDACIO), BIOSIMILAR, 20 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5132 INJECTION, ADALIMUMAB-AFZB (ABRILADA), BIOSIMILAR, 10 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5133 INJECTION, TOCILIZUMAB-BAVI (TOFIDENCE), BIOSIMILAR, 1 MG Yes 11/26/2024   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5134 INJECTION, NATALIZUMAB-SZTN (TYRUKO), BIOSIMILAR, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q5135 INJECTION, TOCILIZUMAB-AAZG (TYENNE), BIOSIMILAR, 1 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q5124 INJECTION, RANIBIZUMAB-NUNA, BIOSIMILAR, (BYOOVIZ), 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   S3842 GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2202 ECHOSCLEROTHERAPY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2235 IMPLANTATION OF AUDITORY BRAIN STEM IMPLANT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S2300 ARTHROSCOPY, SHOULDER, SURGICAL; WITH THERMALLY-INDUCED CAPSULORRHAPHY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S2348 DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, USING RADIOFREQUENCY ENERGY, SINGLE OR MULTIPLE LEVELS, LUMBAR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3650 SALIVA TEST, HORMONE LEVEL; DURING MENOPAUSE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S3652 SALIVA TEST, HORMONE LEVEL; TO ASSESS PRETERM LABOR RISK Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S3722 DOSE OPTIMIZATION BY AREA UNDER THE CURVE (AUC) ANALYSIS, FOR INFUSIONAL 5-FLUOROURACIL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S3800 GENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS (ALS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0148 INJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S3841 GENETIC TESTING FOR RETINOBLASTOMA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2112 ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CELLS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3844 DNA ANALYSIS OF THE CONNEXIN 26 GENE (GJB2) FOR SUSCEPTIBILITY TO CONGENITAL, PROFOUND DEAFNESS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3845 GENETIC TESTING FOR ALPHA-THALASSEMIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3846 GENETIC TESTING FOR HEMOGLOBIN E BETA-THALASSEMIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3849 GENETIC TESTING FOR NIEMANN-PICK DISEASE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3850 GENETIC TESTING FOR SICKLE CELL ANEMIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3853 GENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S3854 GENE EXPRESSION PROFILING PANEL FOR USE IN THE MANAGEMENT OF BREAST CANCER TREATMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q5115 INJECTION, RITUXIMAB-ABBS, BIOSIMILAR, (TRUXIMA), 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Rituximab: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   S3840 DNA ANALYSIS FOR GERMLINE MUTATIONS OF THE RET PROTO-ONCOGENE FOR SUSCEPTIBILITY TO MULTIPLE ENDOCRINE NEOPLASIA TYPE 2 Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S1036 TRANSMITTER; EXTERNAL, FOR USE WITH ARTIFICIAL PANCREAS DEVICE SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S3865 COMPREHENSIVE GENE SEQUENCE ANALYSIS FOR HYPERTROPHIC CARDIOMYOPATHY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S0272 PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, EPISODIC CARE MONTHLY CASE RATE (PER 30 DAYS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0273 PHYSICIAN VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0274 NURSE PRACTITIONER VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0280 MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, INITIAL PLAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0281 MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, MAINTENANCE OF PLAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S1030 CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE (FOR PHYSICIAN INTERPRETATION OF DATA, USE CPT CODE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S1031 CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, RENTAL, INCLUDING SENSOR, SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR (FOR PHYSICIAN INTERPRETATION OF DATA, USE CPT CODE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S2118 METAL-ON-METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORAL COMPONENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S1035 SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH ARTIFICIAL PANCREAS DEVICE SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S2117 ARTHROEREISIS, SUBTALAR Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S1037 RECEIVER (MONITOR); EXTERNAL, FOR USE WITH ARTIFICIAL PANCREAS DEVICE SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     S1040 CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     S1090 MOMETASONE FUROATE SINUS IMPLANT, 370 MICROGRAMS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   S2065 SIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2066 BREAST RECONSTRUCTION WITH GLUTEAL ARTERY PERFORATOR (GAP) FLAP, INCLUDING HARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO A BREAST, UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2067 BREAST RECONSTRUCTION OF A SINGLE BREAST WITH "STACKED" DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP(S) AND/OR GLUTEAL ARTERY PERFORATOR (GAP) FLAP(S), INCLUDING HARVESTING OF THE FLAP(S), MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE(S) AND SHAPING TH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2075 LAPAROSCOPY, SURGICAL; REPAIR INCISIONAL OR VENTRAL HERNIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S2077 LAPAROSCOPY, SURGICAL; IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL OR VENTRAL HERNIA REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR INCISIONAL OR VENTRAL HERNIA REPAIR) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S0270 PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, STANDARD MONTHLY CASE RATE (PER 30 DAYS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     S1034 ARTIFICIAL PANCREAS DEVICE SYSTEM (E.G., LOW GLUCOSE SUSPEND (LGS) FEATURE) INCLUDING CONTINUOUS GLUCOSE MONITOR, BLOOD GLUCOSE DEVICE, INSULIN PUMP AND COMPUTER ALGORITHM THAT COMMUNICATES WITH ALL OF THE DEVICES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6693 UPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6706 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6682 UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULATION OR ABOVE ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6684 UPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6687 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6688 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6689 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, SHOULDER DISARTICULATION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6690 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, INTERSCAPULAR-THORACIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6677 UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TERMINAL DEVICE AND ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6692 UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6676 UPPER EXTREMITY ADDITION, HARNESS, (E.G., FIGURE OF EIGHT TYPE), DUAL CABLE DESIGN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6694 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6695 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6696 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6697 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6698 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK MECHANISM, EXCLUDES SOCKET INSERT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6700 UPPER EXTREMITY ADDITION, EXTERNAL POWERED FEATURE, MYOELECTRONIC CONTROL MODULE, ADDITIONAL EMG INPUTS, PATTERN-RECOGNITION DECODING INTENT MOVEMENT Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6703 TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6629 UPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATION COLLAR WITH COUPLING PIECE, OTTO BOCK OR EQUAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6647 UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY POWERED ACTUATOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4121 THERASKIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6638 UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE WITH MANUALLY POWERED ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6642 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6680 UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULATION OR BELOW ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6646 UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION, ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNAL POWERED SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6707 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6648 UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATOR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6650 UPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6655 UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6660 UPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6665 UPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6672 UPPER EXTREMITY ADDITION, HARNESS, CHEST OR SHOULDER, SADDLE TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6675 UPPER EXTREMITY ADDITION, HARNESS, (E.G., FIGURE OF EIGHT TYPE), SINGLE CABLE DESIGN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6645 UPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION JOINT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6960 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6704 TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6915 HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED), REPLACEMENT GLOVE FOR ABOVE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6920 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6925 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6930 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6935 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6940 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6945 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6905 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, MULTIPLE FINGERS REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6900 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, THUMB OR ONE FINGER REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6965 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6970 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6975 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL D Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7008 ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7040 PREHENSILE ACTUATOR, SWITCH CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7045 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6810 ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6708 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6709 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6711 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6712 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6713 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6714 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6715 TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6721 TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6910 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, NO FINGERS REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6805 ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER, OTTO BOCK OR EQUAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6880 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, ANY GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6881 AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6882 MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6883 REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6884 REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6885 REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6890 ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6895 ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, CUSTOM FABRICATED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6722 TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6010 PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6050 WRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HINGES, TRICEPS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLON Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5986 ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5988 ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5990 ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6000 PARTIAL HAND, THUMB REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5979 ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6020 PARTIAL HAND, NO FINGER REMAINING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6028 PARTIAL HAND INCLUDING FINGERS, FLEXIBLE OR NON-FLEXIBLE INTERFACE, ENDOSKELETAL SYSTEM, MOLDED TO PATIENT MODEL, FOR USE WITHOUT EXTERNAL POWER, NOT INCLUDING INSERTS DESCRIBED BY L6692 Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6029 UPPER EXTREMITY ADDITION, TEST SOCKET/INTERFACE, PARTIAL HAND INCLUDING FINGERS Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6030 UPPER EXTREMITY ADDITION, EXTERNAL FRAME, PARTIAL HAND INCLUDING FINGERS Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6031 REPLACEMENT SOCKET/INTERFACE, PARTIAL HAND INCLUDING FINGERS, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6032 ADDITION TO UPPER EXTREMITY PROSTHESIS, PARTIAL HAND INCLUDING FINGERS, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6033 ADDITION TO UPPER EXTREMITY PROSTHESIS, PARTIAL HAND INCLUDING FINGERS, ACRYLIC MATERIAL Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6630 UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5999 LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5969 ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5926 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL, KNEE DISARTICULATION, ABOVE KNEE, HIP DISARTICULATION, POSITIONAL ROTATION UNIT, ANY TYPE Yes 4/1/2024   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5961 ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL, ROTATION CONTROL, WITH OR WITHOUT FLEXION AND/OR EXTENSION CONTROL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5968 ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6055 WRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOW HINGES, TRICEPS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5971 ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5972 ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE KEEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5973 ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5975 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6037 IMMEDIATE POST-SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, PARTIAL HAND INCLUDING FINGERS Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6580 PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6582 PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6584 PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6586 PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6588 PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6590 PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6450 ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6611 ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6615 UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6616 UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST UNIT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6620 UPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUT FRICTION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6621 UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6623 UPPER EXTREMITY ADDITION, SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATCH RELEASE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6624 UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6625 UPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE LOCK Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICEPS PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6110 BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN SUSPENSION TYPES) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP HINGES, HALF CUFF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED LOCKING HINGE, HALF CUFF Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6200 ELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING HINGE, FOREARM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6205 ELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE LOCKING HINGES, FOREARM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKING ELBOW, FOREARM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6300 SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6550 SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6320 SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP ONLY) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7181 ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6360 INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROSTHESIS) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6370 INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, WRIST DISARTICULATION OR BELOW ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, ELBOW DISARTICULATION OR ABOVE ELBOW Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6384 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF RIGID DRESSING ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6400 BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L6310 SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROSTHESIS) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8689 EXTERNAL RECHARGING SYSTEM FOR BATTERY (INTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8721 RECEPTOR SOLE FOR USE WITH L8720, REPLACEMENT, EACH Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8680 IMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8681 PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLE NEUROSTIMULATOR PULSE GENERATOR, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8682 IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8683 RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8684 RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE SACRAL ROOT NEUROSTIMULATOR RECEIVER FOR BOWEL AND BLADDER MANAGEMENT, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8685 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, RECHARGEABLE, INCLUDES EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8686 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, NON-RECHARGEABLE, INCLUDES EXTENSION Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8678 ELECTRICAL STIMULATOR SUPPLIES (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR, PER MONTH Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8688 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON-RECHARGEABLE, INCLUDES EXTENSION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8670 VASCULAR GRAFT MATERIAL, SYNTHETIC, IMPLANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8690 AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8691 AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, EXCLUDES TRANSDUCER/ACTUATOR, REPLACEMENT ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8692 AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUT OSSEOINTEGRATION, BODY WORN, INCLUDES HEADBAND OR OTHER MEANS OF EXTERNAL ATTACHMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8693 AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8695 EXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8696 ANTENNA (EXTERNAL) FOR USE WITH IMPLANTABLE DIAPHRAGMATIC/PHRENIC NERVE STIMULATION DEVICE, REPLACEMENT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8699 PROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8687 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, RECHARGEABLE, INCLUDES EXTENSION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8627 COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8615 HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8616 MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8617 TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8618 TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE OR AUDITORY OSSEOINTEGRATED DEVICE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8619 COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM, REPLACEMENT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8621 ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE AND AUDITORY OSSEOINTEGRATED SOUND PROCESSORS, REPLACEMENT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8622 ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8623 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, OTHER THAN EAR LEVEL, REPLACEMENT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8679 IMPLANTABLE NEUROSTIMULATOR, PULSE GENERATOR, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8625 EXTERNAL RECHARGING SYSTEM FOR BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8628 COCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8629 TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8630 METACARPOPHALANGEAL JOINT IMPLANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8631 METACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE PIECES, METAL (E.G., STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON), FOR SURGICAL IMPLANTATION (ALL SIZES, INCLUDES ENTIRE SYSTEM) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8641 METATARSAL JOINT IMPLANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8642 HALLUX IMPLANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8658 INTERPHALANGEAL JOINT SPACER, SILICONE OR EQUAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8659 INTERPHALANGEAL FINGER JOINT REPLACEMENT, 2 OR MORE PIECES, METAL (E.G., STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON) FOR SURGICAL IMPLANTATION, ANY SIZE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8624 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE SPEECH PROCESSOR, EAR LEVEL, REPLACEMENT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q4105 INTEGRA DERMAL REGENERATION TEMPLATE (DRT) OR INTEGRA OMNIGRAFT DERMAL REGENERATION MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L8720 EXTERNAL LOWER EXTREMITY SENSORY PROSTHETIC DEVICE, CUTANEOUS STIMULATION OF MECHANORECEPTORS PROXIMAL TO THE ANKLE, PER LEG Yes 3/1/2025   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q2057 AFAMITRESGENE AUTOLEUCEL, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines     Q3027 INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR USE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q3028 INJECTION, INTERFERON BETA-1A, 1 MCG FOR SUBCUTANEOUS USE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q3031 COLLAGEN SKIN TEST Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4074 ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q4101 APLIGRAF, PER SQUARE CENTIMETER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4102 OASIS WOUND MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q2055 IDECABTAGENE VICLEUCEL, UP TO 510 MILLION AUTOLOGOUS B-CELL MATURATION ANTIGEN (BCMA) DIRECTED CAR-POSITIVE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q4104 INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q2054 LISOCABTAGENE MARALEUCEL, UP TO 110 MILLION AUTOLOGOUS ANTI-CD19 CAR-POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     Q4106 DERMAGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4107 GRAFTJACKET, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4108 INTEGRA MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4110 PRIMATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4111 GAMMAGRAFT, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4112 CYMETRA, INJECTABLE, 1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4113 GRAFTJACKET XPRESS, INJECTABLE, 1 CC Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4115 ALLOSKIN, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q4103 OASIS BURN MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q0509 MISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH ANY IMPLANTED VENTRICULAR ASSIST DEVICE FOR WHICH PAYMENT WAS NOT MADE UNDER MEDICARE PART A Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     M0076 PROLOTHERAPY Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   M0224 INTRAVENOUS INFUSION, PEMIVIBART, FOR THE PRE-EXPOSURE PROPHYLAXIS ONLY, FOR CERTAIN ADULTS AND ADOLESCENTS (12 YEARS OF AGE AND OLDER WEIGHING AT LEAST 40 KG) WITH NO KNOWN SARS-COV-2 EXPOSURE, WHO EITHER HAVE MODERATE-TO-SEVERE IMMUNE COMPROMISE DUE TO Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     P9020 PLATELET RICH PLASMA, EACH UNIT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   Q0138 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q0139 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRD ON DIALYSIS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q0155 DRONABINOL (SYNDROS), 0.1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q0224 INJECTION, PEMIVIBART, FOR THE PRE-EXPOSURE PROPHYLAXIS ONLY, FOR CERTAIN ADULTS AND ADOLESCENTS (12 YEARS OF AGE AND OLDER WEIGHING AT LEAST 40 KG) WITH NO KNOWN SARS-COV-2 EXPOSURE, AND WHO EITHER HAVE MODERATE-TO-SEVERE IMMUNE COMPROMISE DUE TO A MEDIC Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     Q0249 INJECTION, TOCILIZUMAB, FOR HOSPITALIZED ADULTS AND PEDIATRIC PATIENTS (2 YEARS OF AGE AND OLDER) WITH COVID-19 WHO ARE RECEIVING SYSTEMIC CORTICOSTEROIDS AND REQUIRE SUPPLEMENTAL OXYGEN, NON-INVASIVE OR INVASIVE MECHANICAL VENTILATION, OR EXTRACORPOREAL Yes 1/1/2025   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   Q2056 CILTACABTAGENE AUTOLEUCEL, UP TO 100 MILLION AUTOLOGOUS B-CELL MATURATION ANTIGEN (BCMA) DIRECTED CAR-POSITIVE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     Q0508 MISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH AN IMPLANTED VENTRICULAR ASSIST DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8612 AQUEOUS SHUNT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     Q0516 PHARMACY SUPPLYING FEE FOR HIV PRE-EXPOSURE PROPHYLAXIS FDA APPROVED PRESCRIPTION ORAL DRUG, PER 30-DAYS Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q0517 PHARMACY SUPPLYING FEE FOR HIV PRE-EXPOSURE PROPHYLAXIS FDA APPROVED PRESCRIPTION ORAL DRUG, PER 60-DAYS Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q0518 PHARMACY SUPPLYING FEE FOR HIV PRE-EXPOSURE PROPHYLAXIS FDA APPROVED PRESCRIPTION ORAL DRUG, PER 90-DAYS Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q2041 AXICABTAGENE CILOLEUCEL, UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q2042 TISAGENLECLEUCEL, UP TO 600 MILLION CAR-POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q2043 SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER INFUSION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q2052 SERVICES, SUPPLIES AND ACCESSORIES USED IN THE HOME FOR THE ADMINISTRATION OF INTRAVENOUS IMMUNE GLOBULIN (IVIG) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     Q2053 BREXUCABTAGENE AUTOLEUCEL, UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     Q0507 MISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH AN EXTERNAL VENTRICULAR ASSIST DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8033 NIPPLE PROSTHESIS, CUSTOM FABRICATED, REUSABLE, ANY MATERIAL, ANY TYPE, EACH Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8614 COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7900 MALE VACUUM ERECTION SYSTEM Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7902 TENSION RING, FOR VACUUM ERECTION DEVICE, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8000 BREAST PROSTHESIS, MASTECTOMY BRA, WITHOUT INTEGRATED BREAST PROSTHESIS FORM, ANY SIZE, ANY TYPE Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL, ANY SIZE, ANY TYPE Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL, ANY SIZE, ANY TYPE Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8020 BREAST PROSTHESIS, MASTECTOMY FORM Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8030 BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8032 NIPPLE PROSTHESIS, PREFABRICATED, REUSABLE, ANY TYPE, EACH Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L7510 REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8035 CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8039 BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8031 BREAST PROSTHESIS, SILICONE OR EQUAL, WITH INTEGRAL ADHESIVE Yes 1/1/2022   Pays without authorization for breast-cancer related diagnoses: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C5 InterQual® Evidence-Based Criteria & Guidelines     L7368 LITHIUM ION BATTERY CHARGER, REPLACEMENT ONLY Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     K0065 SPOKE PROTECTORS, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7190 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7191 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7360 SIX VOLT BATTERY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7362 BATTERY CHARGER, SIX VOLT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7364 TWELVE VOLT BATTERY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7600 PROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7367 LITHIUM ION BATTERY, RECHARGEABLE, REPLACEMENT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8048 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7400 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7401 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7402 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7403 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYLIC MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7404 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7405 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ACRYLIC MATERIAL Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7406 ADDITION TO UPPER EXTREMITY, USER ADJUSTABLE, MECHANICAL, RESIDUAL LIMB VOLUME MANAGEMENT SYSTEM Yes 6/15/2025   Preauthorization required when purchase price exceeds $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L7499 UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L7366 BATTERY CHARGER, TWELVE VOLT, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8603 INJECTABLE BULKING AGENT, COLLAGEN IMPLANT, URINARY TRACT, 2.5 ML SYRINGE, INCLUDES SHIPPING AND NECESSARY SUPPLIES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8505 ARTIFICIAL LARYNX REPLACEMENT BATTERY / ACCESSORY, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8507 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PATIENT INSERTED, ANY TYPE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8509 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, INSERTED BY A LICENSED HEALTH CARE PROVIDER, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8510 VOICE AMPLIFIER Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8511 INSERT FOR INDWELLING TRACHEOESOPHAGEAL PROSTHESIS, WITH OR WITHOUT VALVE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8512 GELATIN CAPSULES OR EQUIVALENT, FOR USE WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, REPLACEMENT ONLY, PER 10 Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8513 CLEANING DEVICE USED WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, PIPET, BRUSH, OR EQUAL, REPLACEMENT ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8514 TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPLACEMENT ONLY, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8499 UNLISTED PROCEDURE FOR MISCELLANEOUS PROSTHETIC SERVICES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8604 INJECTABLE BULKING AGENT, DEXTRANOMER/HYALURONIC ACID COPOLYMER IMPLANT, URINARY TRACT, 1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     L8605 INJECTABLE BULKING AGENT, DEXTRANOMER/HYALURONIC ACID COPOLYMER IMPLANT, ANAL CANAL, 1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L8606 INJECTABLE BULKING AGENT, SYNTHETIC IMPLANT, URINARY TRACT, 1 ML SYRINGE, INCLUDES SHIPPING AND NECESSARY SUPPLIES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8607 INJECTABLE BULKING AGENT FOR VOCAL CORD MEDIALIZATION, 0.1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIES Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8608 MISCELLANEOUS EXTERNAL COMPONENT, SUPPLY OR ACCESSORY FOR USE WITH THE ARGUS II RETINAL PROSTHESIS SYSTEM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   L8609 ARTIFICIAL CORNEA Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8610 OCULAR IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L7180 ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8515 GELATIN CAPSULE, APPLICATION DEVICE FOR USE WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8420 PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8613 OSSICULA IMPLANT Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8049 REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE INCREMENTS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8300 TRUSS, SINGLE WITH STANDARD PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8310 TRUSS, DOUBLE WITH STANDARD PADS Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8320 TRUSS, ADDITION TO STANDARD PAD, WATER PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8330 TRUSS, ADDITION TO STANDARD PAD, SCROTAL PAD Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8400 PROSTHETIC SHEATH, BELOW KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8501 TRACHEOSTOMY SPEAKING VALVE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE OR ABOVE KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8500 ARTIFICIAL LARYNX, ANY TYPE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8430 PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8435 PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8470 PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8480 PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8485 PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     E0736 TRANSCUTANEOUS TIBIAL NERVE STIMULATOR Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     E0747 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0700 SAFETY EQUIPMENT, DEVICE OR ACCESSORY, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0721 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR FOR NERVES IN THE AURICULAR REGION Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0732 CRANIAL ELECTROTHERAPY STIMULATION (CES) SYSTEM, ANY TYPE Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0733 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR FOR ELECTRICAL STIMULATION OF THE TRIGEMINAL NERVE Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0693 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 6 FOOT PANEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0735 NON-INVASIVE VAGUS NERVE STIMULATOR Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0692 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 4 FOOT PANEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0737 TRANSCUTANEOUS TIBIAL NERVE STIMULATOR, CONTROLLED BY PHONE APPLICATION Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0738 UPPER EXTREMITY REHABILITATION SYSTEM PROVIDING ACTIVE ASSISTANCE TO FACILITATE MUSCLE RE-EDUCATION, INCLUDE MICROPROCESSOR, ALL COMPONENTS AND ACCESSORIES Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   E0739 REHABILITATION SYSTEM WITH INTERACTIVE INTERFACE PROVIDING ACTIVE ASSISTANCE IN REHABILITATION THERAPY, INCLUDES ALL COMPONENTS AND ACCESSORIES, MOTORS, MICROPROCESSORS, SENSORS Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   E0740 NON-IMPLANTED PELVIC FLOOR ELECTRICAL STIMULATOR, COMPLETE SYSTEM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0743 EXTERNAL LOWER EXTREMITY NERVE STIMULATOR FOR RESTLESS LEGS SYNDROME, EACH Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0744 NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0734 EXTERNAL UPPER LIMB TREMOR STIMULATOR OF THE PERIPHERAL NERVES OF THE WRIST Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0671 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0315 BED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0656 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0660 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0665 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0666 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0667 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0668 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0694 ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0748 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0672 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0673 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0675 PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE, FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0676 INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0677 NON-PNEUMATIC SEQUENTIAL COMPRESSION GARMENT, TRUNK Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0682 NON-PNEUMATIC SEQUENTIAL COMPRESSION GARMENT, FULL ARM Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0683 NON-PNEUMATIC, NON-SEQUENTIAL, PERISTALTIC WAVE COMPRESSION PUMP Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0691 ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0669 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0746 ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0849 TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0850 TRACTION STAND, FREE STANDING, CERVICAL TRACTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0855 CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0856 CERVICAL TRACTION DEVICE, WITH INFLATABLE AIR BLADDER(S) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0870 TRACTION FRAME, ATTACHED TO FOOTBOARD, EXTREMITY TRACTION, (E.G., BUCK'S) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0880 TRACTION STAND, FREE STANDING, EXTREMITY TRACTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0900 TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0791 PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI-CHANNEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0911 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0912 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0920 FRACTURE FRAME, ATTACHED TO BED, INCLUDES WEIGHTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0930 FRACTURE FRAME, FREE STANDING, INCLUDES WEIGHTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0935 CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE ON KNEE ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0936 CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE OTHER THAN KNEE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0941 GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0779 AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0749 OSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0755 ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRA-ORAL/NON-INVASIVE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0760 OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0761 NON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK POWER ELECTROMAGNETIC ENERGY TREATMENT DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0762 TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0764 FUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIAL MUSCLE GROUPS OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0765 FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF NAUSEA AND VOMITING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0766 ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, INCLUDES ALL ACCESSORIES, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0840 TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0769 ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0651 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0780 AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0781 AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0782 INFUSION PUMP, IMPLANTABLE, NON-PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, ETC.) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0783 INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, ETC.) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0784 EXTERNAL AMBULATORY INFUSION PUMP, INSULIN Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0785 IMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLE INFUSION PUMP, REPLACEMENT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0786 IMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLE INTRASPINAL CATHETER) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0787 EXTERNAL AMBULATORY INFUSION PUMP, INSULIN, DOSAGE RATE ADJUSTMENT USING THERAPEUTIC CONTINUOUS GLUCOSE SENSING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0767 INTRABUCCAL, SYSTEMIC DELIVERY OF AMPLITUDE-MODULATED, RADIOFREQUENCY ELECTROMAGNETIC FIELD DEVICE, FOR CANCER TREATMENT, INCLUDES ALL ACCESSORIES Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0467 HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0484 OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0445 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0446 TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0447 PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT, PRESCRIBED AMOUNT AT REST OR NIGHTTIME EXCEEDS 4 LITERS PER MINUTE (LPM) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0455 OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0457 CHEST SHELL (CUIRASS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0459 CHEST WRAP Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0462 ROCKING BED WITH OR WITHOUT SIDE RAILS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0443 PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0466 HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0442 STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0468 HOME VENTILATOR, DUAL-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ADDITIONAL FUNCTION OF COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0470 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0471 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0472 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0480 PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0481 INTRAPULMONARY PERCUSSIVE VENTILATION SYSTEM AND RELATED ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0482 COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0655 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0465 HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0425 STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2225 MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0328 HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0350 CONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0352 DISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM AND COLLECTION BAG/BOX) FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0370 AIR PRESSURE ELEVATOR FOR HEEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0444 PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0430 PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0433 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND CONTENTS GAUGE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0435 PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0440 STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0441 STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0635 PATIENT LIFT, ELECTRIC WITH SEAT OR SLING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0483 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM, WITH FULL ANTERIOR AND/OR POSTERIOR THORACIC REGION RECEIVING SIMULTANEOUS EXTERNAL OSCILLATION, INCLUDES ALL ACCESSORIES AND SUPPLIES, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0617 EXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0618 APNEA MONITOR, WITHOUT RECORDING FEATURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0619 APNEA MONITOR, WITH RECORDING FEATURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0620 SKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0621 SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0625 PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0627 SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0615 PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS, INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0630 PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0607 HOME BLOOD GLUCOSE MONITOR Yes 1/1/2022   No authorization required for a diagnosis of diabetes. All other diagnoses require preauthorization. InterQual® Evidence-Based Criteria & Guidelines     E0636 MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0637 COMBINATION SIT TO STAND FRAME/TABLE SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEAT LIFT FEATURE, WITH OR WITHOUT WHEELS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0638 STANDING FRAME/TABLE SYSTEM, ONE POSITION (E.G., UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0639 PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY, INCLUDES ALL COMPONENTS/ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0640 PATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0641 STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G., THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0642 STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0629 SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0565 COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF-CONTAINED OR CYLINDER DRIVEN Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0487 SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0492 POWER SOURCE AND CONTROL ELECTRONICS UNIT FOR ORAL DEVICE/APPLIANCE FOR NEUROMUSCULAR ELECTRICAL STIMULATION OF THE TONGUE MUSCLE, CONTROLLED BY PHONE APPLICATION Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0493 ORAL DEVICE/APPLIANCE FOR NEUROMUSCULAR ELECTRICAL STIMULATION OF THE TONGUE MUSCLE, USED IN CONJUNCTION WITH THE POWER SOURCE AND CONTROL ELECTRONICS UNIT, CONTROLLED BY PHONE APPLICATION, 90-DAY SUPPLY Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0500 IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC VALVES; INTERNAL OR EXTERNAL POWER SOURCE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0550 HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENTS OR OXYGEN DELIVERY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0560 HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENT OR OXYGEN DELIVERY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0616 IMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, ACTIVATOR AND PROGRAMMER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0562 HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0945 EXTREMITY BELT/HARNESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0570 NEBULIZER, WITH COMPRESSOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0572 AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0574 ULTRASONIC/ELECTRONIC AEROSOL GENERATOR WITH SMALL VOLUME NEBULIZER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0575 NEBULIZER, ULTRASONIC, LARGE VOLUME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0585 NEBULIZER, WITH COMPRESSOR AND HEATER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0605 VAPORIZER, ROOM TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0561 HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1812 DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1823 DYNAMIC ADJUSTABLE ANKLE FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1802 DYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1803 DYNAMIC ADJUSTABLE ELBOW EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1804 DYNAMIC ADJUSTABLE ELBOW FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1806 STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEXION AND/OR EXTENSION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1807 DYNAMIC ADJUSTABLE WRIST EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1808 DYNAMIC ADJUSTABLE WRIST FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1800 DYNAMIC ADJUSTABLE ELBOW EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1811 STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXTENSION AND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1702 REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 200 Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1813 DYNAMIC ADJUSTABLE KNEE EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1814 DYNAMIC ADJUSTABLE KNEE FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1815 DYNAMIC ADJUSTABLE ANKLE EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1816 STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEXION AND/OR EXTENSION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1818 STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1820 REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1821 REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0942 CERVICAL HEAD HARNESS/HALTER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1810 DYNAMIC ADJUSTABLE KNEE EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1615 DEIONIZER WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1405 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1406 OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1570 ADJUSTABLE CHAIR, FOR ESRD PATIENTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1575 TRANSDUCER PROTECTORS/FLUID BARRIERS, FOR HEMODIALYSIS, ANY SIZE, PER 10 Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1580 UNIPUNCTURE CONTROL SYSTEM FOR HEMODIALYSIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1590 HEMODIALYSIS MACHINE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1801 STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXTENSION AND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1825 DYNAMIC ADJUSTABLE FINGER EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1629 TABLO HEMODIALYSIS SYSTEM FOR THE BILLABLE DIALYSIS SERVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1632 WEARABLE ARTIFICIAL KIDNEY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1635 COMPACT (PORTABLE) TRAVEL HEMODIALYZER SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1636 SORBENT CARTRIDGES, FOR HEMODIALYSIS, PER 10 Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1699 DIALYSIS EQUIPMENT, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1700 JAW MOTION REHABILITATION SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1701 REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 6 Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1594 CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2215 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1822 DYNAMIC ADJUSTABLE ANKLE EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2212 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2214 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2216 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2217 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2218 MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2219 MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2220 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2221 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2222 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2213 MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE), ANY TYPE, ANY SIZE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1905 VIRTUAL REALITY COGNITIVE BEHAVIORAL THERAPY DEVICE (CBT), INCLUDING PRE-PROGRAMMED THERAPY SOFTWARE Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1826 DYNAMIC ADJUSTABLE FINGER EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1827 DYNAMIC ADJUSTABLE FINGER FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1828 DYNAMIC ADJUSTABLE TOE EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1829 DYNAMIC ADJUSTABLE TOE FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1830 DYNAMIC ADJUSTABLE TOE EXTENSION AND FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1831 STATIC PROGRESSIVE STRETCH TOE DEVICE, EXTENSION AND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1832 STATIC PROGRESSIVE STRETCH FINGER DEVICE, EXTENSION AND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document)     E1840 DYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION DEVICE, INCLUDES SOFT INTERFACE MATERIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC OR CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1902 COMMUNICATION BOARD, NON-ELECTRONIC AUGMENTATIVE OR ALTERNATIVE COMMUNICATION DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1372 IMMERSION EXTERNAL HEATER FOR NEBULIZER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2000 GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2001 SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC, ANY TYPE, FOR USE WITH EXTERNAL URINE AND/OR FECAL MANAGEMENT SYSTEM Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2100 BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2101 BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2103 NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR OR RECEIVER Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2120 PULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER EAR ENDOLYMPHATIC FLUID Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 INCHES AND LESS THAN 24 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1841 STATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1391 OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0980 SAFETY VEST, WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0983 MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0984 MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0988 MANUAL WHEELCHAIR ACCESSORY, LEVER-ACTIVATED, WHEEL DRIVE, PAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0994 ARM REST, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0986 MANUAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER ASSIST SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0958 MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0310 BED SIDE RAILS, FULL LENGTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0946 FRACTURE, FRAME, DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G., BALKEN, 4 POSTER) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0947 FRACTURE FRAME, ATTACHMENTS FOR COMPLEX PELVIC TRACTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0948 FRACTURE FRAME, ATTACHMENTS FOR COMPLEX CERVICAL TRACTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0950 WHEELCHAIR ACCESSORY, TRAY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0953 WHEELCHAIR ACCESSORY, LATERAL THIGH OR KNEE SUPPORT, ANY TYPE INCLUDING FIXED MOUNTING HARDWARE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0954 WHEELCHAIR ACCESSORY, FOOT BOX, ANY TYPE, INCLUDES ATTACHMENT AND MOUNTING HARDWARE, EACH FOOT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0974 MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0957 WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0959 MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0960 WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0966 MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0967 MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0968 COMMODE SEAT, WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0969 NARROWING DEVICE, WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0970 NO. 2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0956 WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1298 SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDTH, BY CONSTRUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1240 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL LENGTH) SWING AWAY DETACHABLE, ELEVATING LEGREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1250 LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1260 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1270 LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1280 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1285 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1295 HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEGREST Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1297 SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1035 MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY CARE GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1352 OXYGEN ACCESSORY, FLOW REGULATOR CAPABLE OF POSITIVE INSPIRATORY PRESSURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1353 REGULATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1354 OXYGEN ACCESSORY, WHEELED CART FOR PORTABLE CYLINDER OR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1355 STAND/RACK Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1356 OXYGEN ACCESSORY, BATTERY PACK/CARTRIDGE FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1357 OXYGEN ACCESSORY, BATTERY CHARGER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1358 OXYGEN ACCESSORY, DC POWER ADAPTER FOR PORTABLE CONCENTRATOR, ANY TYPE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0944 PELVIC BELT/HARNESS/BOOT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1022 WHEELCHAIR TRANSPORTATION SECUREMENT SYSTEM, ANY TYPE INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document)     E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1011 MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1012 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1239 POWER WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1023 WHEELCHAIR TRANSIT SECUREMENT SYSTEM, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document)     E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTERS 5" OR GREATER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1032 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE USED WITH JOYSTICK OR OTHER DRIVE CONTROL INTERFACE Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1033 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR HEADREST, CUSHIONED, ANY TYPE Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1034 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR LATERAL TRUNK OR HIP SUPPORT, ANY TYPE Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1776 JOINT DEVICE (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1818 INTEGRATED KERATOPROSTHESIS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B9002 ENTERAL NUTRITION INFUSION PUMP, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B9004 PARENTERAL NUTRITION INFUSION PUMP, PORTABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B9006 PARENTERAL NUTRITION INFUSION PUMP, STATIONARY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1721 CARDIOVERTER-DEFIBRILLATOR, DUAL CHAMBER (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1722 CARDIOVERTER-DEFIBRILLATOR, SINGLE CHAMBER (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1749 ENDOSCOPE, RETROGRADE IMAGING/ILLUMINATION COLONOSCOPE DEVICE (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1760 CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, ANY TYPE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1767 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4083 STOMACH TUBE - LEVINE TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1780 LENS, INTRAOCULAR (NEW TECHNOLOGY) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1783 OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1784 OCULAR DEVICE, INTRAOPERATIVE, DETACHED RETINA Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1787 PATIENT PROGRAMMER, NEUROSTIMULATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1789 PROSTHESIS, BREAST (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1813 PROSTHESIS, PENILE, INFLATABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1816 RECEIVER AND/OR TRANSMITTER, NEUROSTIMULATOR (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6511 COMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1764 EVENT RECORDER, CARDIAC (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9285 INVERSION/EVERSION CORRECTION DEVICE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A7023 MECHANICAL ALLERGEN PARTICLE BARRIER/INHALATION FILTER, CREAM, NASAL, TOPICAL Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A8000 HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A8001 HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A8002 HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A8003 HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A8004 SOFT INTERFACE FOR HELMET, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9274 EXTERNAL AMBULATORY INSULIN DELIVERY SYSTEM, DISPOSABLE, EACH, INCLUDES ALL SUPPLIES AND ACCESSORIES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9279 MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1820 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9606 RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4081 NASOGASTRIC TUBING WITH STYLET Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     B4082 NASOGASTRIC TUBING WITHOUT STYLET Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A9275 HOME GLUCOSE DISPOSABLE MONITOR, INCLUDES TEST STRIPS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C8907 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C1817 SEPTAL DEFECT IMPLANT SYSTEM, INTRACARDIAC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C8003 IMPLANTATION OF MEDIAL KNEE EXTRAARTICULAR IMPLANTABLE SHOCK ABSORBER SPANNING THE KNEE JOINT FROM DISTAL FEMUR TO PROXIMAL TIBIA, OPEN, INCLUDES MEASUREMENTS, POSITIONING AND ADJUSTMENTS, WITH IMAGING GUIDANCE (E.G., FLUOROSCOPY) Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines     C8005 BRONCHOSCOPY, RIGID OR FLEXIBLE, NON-THERMAL TRANSBRONCHIAL ABLATION OF LESION(S) BY PULSED ELECTRIC FIELD (PEF) ENERGY, INCLUDING FLUOROSCOPIC AND/OR ULTRASOUND GUIDANCE, WHEN PERFORMED, WITH COMPUTED TOMOGRAPHY ACQUISITION(S) AND 3D RENDERING, COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION, AND ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (E.G., ASPIRATION[S]/BIOPSY[IES]) OF ALL MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES, AND THERAPEUTIC INTER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C8900 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8901 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8902 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, ABDOMEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8903 MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8904 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8001 3D ANATOMICAL SEGMENTATION IMAGING FOR PREOPERATIVE PLANNING, DATA PREPARATION AND TRANSMISSION, OBTAINED FROM PREVIOUS DIAGNOSTIC COMPUTED TOMOGRAPHIC OR MAGNETIC RESONANCE EXAMINATION OF THE SAME ANATOMY Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C8906 MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C7508 PERCUTANEOUS VERTEBRAL AUGMENTATIONS, FIRST LUMBAR AND ANY ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODIES, INCLUDING CAVITY CREATIONS (FRACTURE REDUCTIONS AND BONE BIOPSIES INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (E.G., KYPHOPLASTY), UNILATERAL O Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C8908 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; BILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8909 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8910 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8911 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8912 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8913 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8914 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, LOWER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8918 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8905 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; UNILATERAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C1891 INFUSION PUMP, NON-PROGRAMMABLE, PERMANENT (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1821 INTERSPINOUS PROCESS DISTRACTION DEVICE (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C1822 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), HIGH FREQUENCY, WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1823 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE, WITH TRANSVENOUS SENSING AND STIMULATION LEADS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C1824 GENERATOR, CARDIAC CONTRACTILITY MODULATION (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1825 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE WITH CAROTID SINUS BARORECEPTOR STIMULATION LEAD(S) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1826 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), INCLUDES CLOSED FEEDBACK LOOP LEADS AND ALL IMPLANTABLE COMPONENTS, WITH RECHARGEABLE BATTERY AND CHARGING SYSTEM Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1827 GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE, WITH IMPLANTABLE STIMULATION LEAD AND EXTERNAL PAIRED STIMULATION CONTROLLER Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C1833 MONITOR, CARDIAC, INCLUDING INTRACARDIAC LEAD AND ALL SYSTEM COMPONENTS (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C8002 PREPARATION OF SKIN CELL SUSPENSION AUTOGRAFT, AUTOMATED, INCLUDING ALL ENZYMATIC PROCESSING AND DEVICE COMPONENTS (DO NOT REPORT WITH MANUAL SUSPENSION PREPARATION) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C1889 IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A6510 COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD), CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C2622 PROSTHESIS, PENILE, NON-INFLATABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C2623 CATHETER, TRANSLUMINAL ANGIOPLASTY, DRUG-COATED, NON-LASER Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C2626 INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C7501 PERCUTANEOUS BREAST BIOPSIES USING STEREOTACTIC GUIDANCE, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (E.G., CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, ALL LESIONS UNILATERAL AND BILATERAL (FOR SINGLE L Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C7502 PERCUTANEOUS BREAST BIOPSIES USING MAGNETIC RESONANCE GUIDANCE, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (E.G., CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, ALL LESIONS UNILATERAL OR BILATERAL (FOR SIN Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C7504 PERCUTANEOUS VERTEBROPLASTIES (BONE BIOPSIES INCLUDED WHEN PERFORMED), FIRST CERVICOTHORACIC AND ANY ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODIES, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C7505 PERCUTANEOUS VERTEBROPLASTIES (BONE BIOPSIES INCLUDED WHEN PERFORMED), FIRST LUMBOSACRAL AND ANY ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODIES, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C7507 PERCUTANEOUS VERTEBRAL AUGMENTATIONS, FIRST THORACIC AND ANY ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODIES, INCLUDING CAVITY CREATIONS (FRACTURE REDUCTIONS AND BONE BIOPSIES INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (E.G., KYPHOPLASTY), UNILATERAL Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     C1840 LENS, INTRAOCULAR (TELESCOPIC) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A0435 FIXED WING AIR MILEAGE, PER STATUTE MILE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A2029 MIROTRACT WOUND MATRIX SHEET, PER CUBIC CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A0140 NON-EMERGENCY TRANSPORTATION AND AIR TRAVEL (PRIVATE OR COMMERCIAL) INTRA OR INTER STATE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0425 GROUND MILEAGE, PER STATUTE MILE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0426 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0432 PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY A VOLUNTEER AMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTY PAYERS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99601 HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0434 SPECIALTY CARE TRANSPORT (SCT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99600 UNLISTED HOME VISIT SERVICE OR PROCEDURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A0999 UNLISTED AMBULANCE SERVICE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A2019 KERECIS OMEGA3 MARIGEN SHIELD, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2020 AC5 ADVANCED WOUND SYSTEM (AC5) Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2021 NEOMATRIX, PER SQUARE CENTIMETER Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2026 RESTRATA MINIMATRIX, 5 MG Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     A2027 MATRIDERM, PER SQUARE CENTIMETER Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A6512 COMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99503 HOME VISIT FOR RESPIRATORY THERAPY CARE (EG, BRONCHODILATOR, OXYGEN THERAPY, RESPIRATORY ASSESSMENT, APNEA EVALUATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     97552 GROUP CAREGIVER TRAINING IN STRATEGIES AND TECHNIQUES TO FACILITATE THE PATIENT'S FUNCTIONAL PERFORMANCE IN THE HOME OR COMMUNITY (EG, ACTIVITIES OF DAILY LIVING [ADLS], INSTRUMENTAL ADLS [IADLS], TRANSFERS, MOBILITY, COMMUNICATION, SWALLOWING, FEEDING, PROBLEM SOLVING, SAFETY PRACTICES) (WITHOUT THE PATIENT PRESENT), FACE TO FACE WITH MULTIPLE SETS OF CAREGIVERS Yes 9/1/2024   For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). Authorization required for all visits pertaining to Speech Therapy. InterQual® Evidence-Based Criteria & Guidelines     97610 LOW FREQUENCY, NON-CONTACT, NON-THERMAL ULTRASOUND, INCLUDING TOPICAL APPLICATION(S), WHEN PERFORMED, WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER DAY Yes 7/1/2019     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   97760 ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT AND FITTING WHEN NOT OTHERWISE REPORTED), UPPER EXTREMITY(IES), LOWER EXTREMITY(IES) AND/OR TRUNK, INITIAL ORTHOTIC(S) ENCOUNTER, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97761 PROSTHETIC(S) TRAINING, UPPER AND/OR LOWER EXTREMITY(IES), INITIAL PROSTHETIC(S) ENCOUNTER, EACH 15 MINUTES Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97763 ORTHOTIC(S)/PROSTHETIC(S) MANAGEMENT AND/OR TRAINING, UPPER EXTREMITY(IES), LOWER EXTREMITY(IES), AND/OR TRUNK, SUBSEQUENT ORTHOTIC(S)/PROSTHETIC(S) ENCOUNTER, EACH 15 MINUTES Yes 8/15/2018   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     97799 UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE Yes 7/27/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     98978 REMOTE THERAPEUTIC MONITORING (EG, THERAPY ADHERENCE, THERAPY RESPONSE, DIGITAL THERAPEUTIC INTERVENTION); DEVICE(S) SUPPLY FOR DATA ACCESS OR DATA TRANSMISSIONS TO SUPPORT MONITORING OF COGNITIVE BEHAVIORAL THERAPY, EACH 30 DAYS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   99500 HOME VISIT FOR PRENATAL MONITORING AND ASSESSMENT TO INCLUDE FETAL HEART RATE, NON-STRESS TEST, UTERINE MONITORING, AND GESTATIONAL DIABETES MONITORING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99602 HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99502 HOME VISIT FOR NEWBORN CARE AND ASSESSMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A2030 MIRO3D FIBERS, PER MILLIGRAM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   99504 HOME VISIT FOR MECHANICAL VENTILATION CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99505 HOME VISIT FOR STOMA CARE AND MAINTENANCE INCLUDING COLOSTOMY AND CYSTOSTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99506 HOME VISIT FOR INTRAMUSCULAR INJECTIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99507 HOME VISIT FOR CARE AND MAINTENANCE OF CATHETER(S) (EG, URINARY, DRAINAGE, AND ENTERAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99509 HOME VISIT FOR ASSISTANCE WITH ACTIVITIES OF DAILY LIVING AND PERSONAL CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99510 HOME VISIT FOR INDIVIDUAL, FAMILY, OR MARRIAGE COUNSELING Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99511 HOME VISIT FOR FECAL IMPACTION MANAGEMENT AND ENEMA ADMINISTRATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99512 HOME VISIT FOR HEMODIALYSIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     99501 HOME VISIT FOR POSTNATAL ASSESSMENT AND FOLLOW-UP CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A5512 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OF SHORE A 35 DUROMETER O Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A2028 MICROMATRIX FLEX, PER MG Yes 3/1/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A4650 IMPLANTABLE RADIATION DOSIMETER, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A5500 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A5501 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF SHOE MOLDED FROM CAST(S) OF PATIENT'S FOOT (CUSTOM MOLDED SHOE), PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A5503 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A5504 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A5505 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A5506 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A4648 TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A5508 FOR DIABETICS ONLY, DELUXE FEATURE OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A4614 PEAK EXPIRATORY FLOW RATE METER, HAND HELD Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A5513 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT'S FOOT, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER (OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPIN Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A6231 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6501 COMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6502 COMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6503 COMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6507 COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6508 COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A6509 COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST), CUSTOM FABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A5507 FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE Yes 1/1/2022   Effective 6/15/2025 Preauthorization required when billed charges exceed $500 per line item (Previously was $250) InterQual® Evidence-Based Criteria & Guidelines     A4541 MONTHLY SUPPLIES FOR USE OF DEVICE CODED AT E0733 Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2031 MIRODRY WOUND MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2032 MYRIAD MATRIX, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2033 MYRIAD MORCELLS, 4 MILLIGRAMS Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2034 FOUNDATION DRS SOLO, PER SQUARE CENTIMETER Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A2035 CORPLEX P OR THERACOR P OR ALLACOR P, PER MILLIGRAM Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   A4220 REFILL KIT FOR IMPLANTABLE INFUSION PUMP Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4305 DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR GREATER PER HOUR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4306 DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4649 SURGICAL SUPPLY; MISCELLANEOUS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4540 DISTAL TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR, STIMULATES PERIPHERAL NERVES OF THE UPPER ARM Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     C8931 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     A4542 SUPPLIES AND ACCESSORIES FOR EXTERNAL UPPER LIMB TREMOR STIMULATOR OF THE PERIPHERAL NERVES OF THE WRIST Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4560 NEUROMUSCULAR ELECTRICAL STIMULATOR (NMES), DISPOSABLE, REPLACEMENT ONLY Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4593 NEUROMODULATION STIMULATOR SYSTEM, ADJUNCT TO REHABILITATION THERAPY REGIME, CONTROLLER Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4594 NEUROMODULATION STIMULATOR SYSTEM, ADJUNCT TO REHABILITATION THERAPY REGIME, MOUTHPIECE EACH Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4611 BATTERY, HEAVY DUTY; REPLACEMENT FOR PATIENT OWNED VENTILATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4612 BATTERY CABLES; REPLACEMENT FOR PATIENT-OWNED VENTILATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4613 BATTERY CHARGER; REPLACEMENT FOR PATIENT-OWNED VENTILATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     A4483 MOISTURE EXCHANGER, DISPOSABLE, FOR USE WITH INVASIVE MECHANICAL VENTILATION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7945 OSTEOTOMY – BODY OF MANDIBLE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7991 CORONOIDECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7877 ARTHROSCOPY – SURGICAL: DEBRIDEMENT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7899 UNSPECIFIED TMD THERAPY, BY REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7911 COMPLICATED SUTURE - UP TO 5 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7912 COMPLICATED SUTURE — GREATER THAN 5 CM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7940 OSTEOPLASTY — FOR ORTHOGNATHIC DEFORMITIES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7941 OSTEOTOMY – MANDIBULAR RAMI Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7875 ARTHROSCOPY – SURGICAL: SYNOVECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7944 OSTEOTOMY – SEGMENTED OR SUBAPICAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7874 ARTHROSCOPY – SURGICAL: DISC REPOSITIONING AND STABILIZATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7946 LEFORT I (MAXILLA – TOTAL) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7947 LEFORT I (MAXILLA – SEGMENTED) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7948 LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION)-WITHOUT BONE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7949 LEFORT II OR LEFORT III – WITH BONE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7950 OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR FACIAL BONES — AUTOGENEOUS OR NONAUTOGENEOUS, BY REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7951 SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7952 SINUS AUGUMENTATION VIA A VERTICAL APPROACH. Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8919 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7943 OSTEOTOMY – MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7854 SYNOVECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7750 MALAR AND/OR ZYGOMATIC ARCH — OPEN REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7760 MALAR AND/OR ZYGOMATIC ARCH — CLOSED REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7770 ALVEOLUS — OPEN REDUCTION STABILIZATION OF TEETH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7771 ALVEOLUS — CLOSED REDUCTION STABILIZATION OF TEETH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7780 FACIAL BONES — COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE APPROACHES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7810 OPEN REDUCTION OF DISLOCATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7820 CLOSED REDUCTION OF DISLOCATION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7830 MANIPULATION UNDER ANESTHESIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7876 ARTHROSCOPY – SURGICAL: DISCECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7852 DISC REPAIR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7995 SYNTHETIC GRAFT - MANDIBLE OR FACIAL BONES, BY REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7856 MYOTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7858 JOINT RECONSTRUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7860 ARTHROTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7865 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7870 ARTHROCENTESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7871  NON-ARTHROSCOPIC LYSIS AND LAVAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7872 ARTHROSCOPY – DIAGNOSIS, WITH OR WITHOUT BIOPSY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7873 ARTHROSCOPY – SURGICAL: LAVAGE AND LYSIS OF ADHESIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7840 CONDYLECTOMY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E0295 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7955 REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E0261 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0266 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0270 HOSPITAL BED, INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKER FRAME, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0290 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0291 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0256 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0294 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0255 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0296 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0297 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0305 BED SIDE RAILS, HALF LENGTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0196 GEL PRESSURE MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7996 IMPLANT-MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR RIDGE), BY REPORT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D9210 LOCAL ANESTHESIA NOT IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D9211 REGIONAL BLOCK ANESTHESIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D9212 TRIGEMINAL DIVISION BLOCK ANESTHESIA Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D9215 LOCAL ANESTHESIA IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E0181 POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0182 PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0187 WATER PRESSURE MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0260 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0194 AIR FLUIDIZED BED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7720 MAXILLA — CLOSED REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0198 WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0236 PUMP FOR WATER CIRCULATING PAD Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0239 HYDROCOLLATOR UNIT, PORTABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0249 PAD FOR WATER CIRCULATING HEAT UNIT, FOR REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0251 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9352 MICROPOROUS COLLAGEN IMPLANTABLE TUBE (NEURAGEN NERVE GUIDE), PER CENTIMETER LENGTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7740 MANDIBLE — CLOSED REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C9169 INJECTION, NOGAPENDEKIN ALFA INBAKICEPT-PMLN, FOR INTRAVESICAL USE, 1 MICROGRAM Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9170 INJECTION, TARLATAMAB-DLLE, 1 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9172 INJECTION, FIDANACOGENE ELAPARVOVEC-DZKT, PER THERAPEUTIC DOSE Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9173 INJECTION, FILGRASTIM-TXID (NYPOZI), BIOSIMILAR, 1 MICROGRAM Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9257 INJECTION, BEVACIZUMAB, 0.25 MG Yes 1/1/2022   Pays without authorization for Ophthalmic condition Dx codes listed here when delivered by Providers in the Sendero network. Requires preauthorization for any other condition when billed charges exceed $500 per line item or when administered by a provider OncoHealth global Medical Necessity Criteria for oncology indications. InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   C9301 OBECABTAGENE AUTOLEUCEL, UP TO 410 MILLION CD19 CAR-POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines     C9302 INJECTION, ZANIDATAMAB-HRII, 2 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9167 INJECTION, ADAMTS13, RECOMBINANT-KRHN, 10 IU Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9304 INJECTION, MARSTACIMAB-HNCQ, 0.5 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9166 INJECTION, SECUKINUMAB, INTRAVENOUS, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   C9353 MICROPOROUS COLLAGEN IMPLANTABLE SLIT TUBE (NEURAWRAP NERVE PROTECTOR), PER CENTIMETER LENGTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9354 ACELLULAR PERICARDIAL TISSUE MATRIX OF NON-HUMAN ORIGIN (VERITAS), PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9356 TENDON, POROUS MATRIX OF CROSS-LINKED COLLAGEN AND GLYCOSAMINOGLYCAN MATRIX (TENOGLIDE TENDON PROTECTOR SHEET), PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9358 DERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN, FETAL BOVINE ORIGIN (SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE CENTIMETERS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9360 DERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN, NEONATAL BOVINE ORIGIN (SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE CENTIMETERS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9363 SKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9364 PORCINE IMPLANT, PERMACOL, PER SQUARE CENTIMETER Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9303 INJECTION, ZOLBETUXIMAB-CLZB, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9096 INJECTION, FILGRASTIM-AYOW, BIOSIMILAR, (RELEUKO), 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2226 MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C8932 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8933 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8934 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C9047 INJECTION, CAPLACIZUMAB-YHDP, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9072 INJECTION, IMMUNE GLOBULIN (ASCENIV), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9168 INJECTION, MIRIKIZUMAB-MRKZ, 1 MG Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     C9095 INJ, TEBENTAFUSP-TEBN, 1 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9745 NASAL ENDOSCOPY, SURGICAL; BALLOON DILATION OF EUSTACHIAN TUBE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9097 INJ, FARICIMAB-SVOA, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9098 CILTACABTAGENE AUTOLEUCEL, UP TO 100 MILLION AUTOLOGOUS B-CELL MATURATION ANTIGEN (BCMA) DIRECTED CAR-POSITIVE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER THERAPEUTIC DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9160 INJECTION, DAXIBOTULINUMTOXINA-LANM, 1 UNIT Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     C9161 INJECTION, AFLIBERCEPT HD, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9162 INJECTION, AVACINCAPTAD PEGOL, 0.1 MG Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9163 INJECTION, TALQUETAMAB-TGVS, 0.25 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9164 CANTHARIDIN FOR TOPICAL ADMINISTRATION, 0.7%, SINGLE UNIT DOSE APPLICATOR (3.2 MG) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     C9165 INJECTION, ELRANATAMAB-BCMM, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     C9094 INJ, SUTIMLIMAB-JOME, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     D7630 MANDIBLE — OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D5916 OCULAR PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D6050 SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7272 TOOTH TRANSPLANTATION (INCLUDES RE-IMPLANTATION FROM ONE SITE TO ANOTHER AND SPLINTING AND/OR STABILIZATION) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7296 CORTICOTOMY - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7297 CORTICOTOMY - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7530 REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7540 REMOVAL OF REACTION PRODUCING FOREIGN BODIES, MUSCULOSKELETAL SYSTEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C9610 CATHETER, TRANSLUMINAL DRUG DELIVERY WITH OR WITHOUT ANGIOPLASTY, CORONARY, NON-LASER (INSERTABLE) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   D7620 MAXILLA — CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D5911 FACIAL MOULAGE, SECTIONAL Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7640 MANDIBLE — CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7650 MALAR AND/OR ZYGOMATIC ARCH — OPEN REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7660 MALAR AND/OR ZYGOMATIC ARCH — CLOSED REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7670 ALVEOLUS — CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7671 ALVEOLUS — OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7680 FACIAL BONES — COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7710 MAXILLA — OPEN REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C8920 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, PELVIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7610 MAXILLA — OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D7730 MANDIBLE — OPEN REDUCTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C9747 ABLATION OF PROSTATE, TRANSRECTAL, HIGH INTENSITY FOCUSED ULTRASOUND (HIFU), INCLUDING IMAGING GUIDANCE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9749 REPAIR OF NASAL VESTIBULAR LATERAL WALL STENOSIS WITH IMPLANT(S) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9794 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX, INCLUDING ACQUISITION OF PET AND CT IMAGING DATA REQUIRED FOR RADIOPHARMACEUTICAL-DIRECTED RADIATION THERAPY TREATMENT PLANNING (I.E., MODELING) Yes 4/1/2024     InterQual® Evidence-Based Criteria & Guidelines     C9795 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE AND REAL-TIME POSITRON EMISSIONS-BASED DELIVERY ADJUSTMENTS TO 1 OR MORE LESIONS, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS Yes 4/1/2024     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9807 NERVE STIMULATOR, PERCUTANEOUS, PERIPHERAL (E.G., SPRINT PERIPHERAL NERVE STIMULATION SYSTEM), INCLUDING ELECTRODE AND ALL DISPOSABLE SYSTEM COMPONENTS, NON-OPIOID MEDICAL DEVICE (MUST BE A QUALIFYING MEDICARE NON-OPIOID MEDICAL DEVICE FOR POST-SURGICAL P Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   C9808 NERVE CRYOABLATION PROBE (E.G., CRYOICE, CRYOSPHERE, CRYOSPHERE MAX, CRYOICE CRYOSPHERE, CRYOICE CRYO2), INCLUDING PROBE AND ALL DISPOSABLE SYSTEM COMPONENTS, NON-OPIOID MEDICAL DEVICE (MUST BE A QUALIFYING MEDICARE NON-OPIOID MEDICAL DEVICE FOR POST-SURGICAL PAIN RELIEF IN ACCORDANCE WITH SECTION 4135 OF THE CAA, 2023) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   C9809 CRYOABLATION NEEDLE (E.G., IOVERA SYSTEM), INCLUDING NEEDLE/TIP AND ALL DISPOSABLE SYSTEM COMPONENTS, NON-OPIOID MEDICAL DEVICE (MUST BE A QUALIFYING MEDICARE NON-OPIOID MEDICAL DEVICE FOR POST-SURGICAL PAIN RELIEF IN ACCORDANCE WITH SECTION 4135 OF THE CAA, 2023) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   D5914 AURICULAR PROSTHESIS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D5912 FACIAL MOULAGE, COMPLETE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0250 EXTRAORAL - 2D PROJECTION RADIOGRAPHIC IMAGE CREATED USING A STATIONARY RADIATION SOURCE, AND DETECTO Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0260 EXTRAORAL – EACH ADDITIONAL RADIOGRAPHIC IMAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0272 BITEWINGS – FOUR RADIOGRAPHIC IMAGES – LIMIT TO 1 SERIES EVERY 6 MONTHS. Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0273 BITEWINGS - THREE FILMS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0274 BITEWINGS – FOUR RADIOGRAPHIC IMAGES – LIMIT TO 1 SERIES EVERY 6 MONTHS. Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     D0277 VERTICAL BITEWINGS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     C9727 INSERTION OF IMPLANTS INTO THE SOFT PALATE; MINIMUM OF THREE IMPLANTS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   D0210 INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J7635 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7647 ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7622 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7626 BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7627 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG Yes 1/1/2022   Pays without authorization for age 6 through 17 for Dx J45.40-J45.52 Pys without authorization for ages 12 through 17 years for Dx. L50.8 Pays without authorization for ages 18 yrs and older for Dx. D47.02, J33.0 - J33.9, J45.40 - J45.52, L50.8 Otherwi Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7628 BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considere Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7629 BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7631 CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7632 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS Yes 1/1/2022   Pays without auth for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered nvestigat Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7615 LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7634 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7610 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7636 ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization or Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Expe Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7639 DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7640 FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 12 MICROGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7641 FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7642 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7643 GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Expe Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7644 IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Expe Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7323 HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7633 BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Pasy without authori Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7355 INJECTION, TRAVOPROST, INTRACAMERAL IMPLANT, 1 MICROGRAM Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     J2505 INJECTION, PEGFILGRASTIM, 6 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7325 HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7326 HYALURONAN OR DERIVATIVE, GEL-ONE, FOR INTRA-ARTICULAR INJECTION, PER DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7327 HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7328 HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7329 HYALURONAN OR DERIVATIVE, TRIVISC, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7330 AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J7331 HYALURONAN OR DERIVATIVE, SYNOJOYNT, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7620 ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME Yes 1/1/2022   Pays without authorization or Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered n Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7354 CANTHARIDIN FOR TOPICAL ADMINISTRATION, 0.7%, SINGLE UNIT DOSE APPLICATOR (3.2 MG) Yes 9/1/2024   Topical drug authorized through the Pharmacy benefit. Submit request to Navitus PBM. InterQual® Evidence-Based Criteria & Guidelines     J7648 ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7376 INJECTION, POZELIMAB-BBFG, 1 MG Yes 11/26/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7514 MYCOPHENOLATE MOFETIL (MYHIBBIN), ORAL SUSPENSION, 100 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7601 ENSIFENTRINE, INHALATION SUSPENSION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 3 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7605 ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7606 FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7607 LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7608 ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7609 ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Otherwise considered Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7332 HYALURONAN OR DERIVATIVE, TRILURON, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J9028 INJECTION, NOGAPENDEKIN ALFA INBAKICEPT-PMLN, FOR INTRAVESICAL USE, 1 MICROGRAM Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7645 IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization or Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exper Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J9017 INJECTION, ARSENIC TRIOXIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9019 INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9020 INJECTION, ASPARAGINASE, NOT OTHERWISE SPECIFIED, 10,000 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9022 INJECTION, ATEZOLIZUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9023 INJECTION, AVELUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9024 INJECTION, ATEZOLIZUMAB, 5 MG AND HYALURONIDASE-TQJS Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9025 INJECTION, AZACITIDINE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9027 INJECTION, CLOFARABINE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J8700 TEMOZOLOMIDE, ORAL, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9029 INTRAVESICAL INSTILLATION, NADOFARAGENE FIRADENOVEC-VNCG, PER THERAPEUTIC DOSE Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9031 BCG (INTRAVESICAL) PER INSTILLATION Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9032 INJECTION, BELINOSTAT, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9033 INJECTION, BENDAMUSTINE HYDROCHLORIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9034 INJECTION, BENDAMUSTINE HCL (BENDEKA), 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9035 INJECTION, BEVACIZUMAB, 10 MG Yes 1/1/2022   Pays without authorization for Ophthalmic condition Dx codes listed here when delivered by Providers in the Sendero network. Requires preauthorization for any other condition when billed charges exceed $500 per line item or when administered by a provider OncolHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9036 INJECTION, BENDAMUSTINE HYDROCHLORIDE, (BELRAPZO/BENDAMUSTINE), 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9037 INJECTION, BELANTAMAB MAFODOTIN-BLMF, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9026 INJECTION, TARLATAMAB-DLLE, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7683 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7649 ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7650 ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7657 ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7659 ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7660 ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7667 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED FORM, PER 10 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7669 METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7670 METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Exp Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J9015 INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7682 TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Expe Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7322 HYALURONAN OR DERIVATIVE, HYMOVIS, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7684 TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7685 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MILLIGRAMS Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7686 TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Expe Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7999  COMPOUNDED DRUG, NOT OTHERWISE CLASSIFIED Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J8522 CAPECITABINE, ORAL, 50 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J8611 METHOTREXATE (JYLAMVO), ORAL, 2.5 MG Yes 7/1/2024   Submit request through Navitus OncoHealth global Medical Necessity Criteria InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J8612 METHOTREXATE (XATMEP), ORAL, 2.5 MG Yes 7/1/2024   Submit request through Navitus OncoHealth global Medical Necessity Criteria InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J7676 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Investigational /Ex Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J3392 INJECTION, EXAGAMGLOGENE AUTOTEMCEL, PER TREATMENT Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines     J3590 UNCLASSIFIED BIOLOGICS Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Depends on which drug is requested. Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases"; OncolHealth medical policy, "Bevacizumab: Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev"; InterQual InterQual® Evidence-Based Criteria & Guidelines   J3247 INJECTION, SECUKINUMAB, INTRAVENOUS, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3262 INJECTION, TOCILIZUMAB, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J3263 INJECTION, TORIPALIMAB-TPZI, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3285 INJECTION, TREPROSTINIL, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3357 USTEKINUMAB, FOR SUBCUTANEOUS INJECTION, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J3358 USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J3241 INJECTION, TEPROTUMUMAB-TRBW, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3385 INJECTION, VELAGLUCERASE ALFA, 100 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3145 INJECTION, TESTOSTERONE UNDECANOATE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3393 INJECTION, BETIBEGLOGENE AUTOTEMCEL, PER TREATMENT Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines InterQual® Evidence-Based Criteria & Guidelines   J3394 INJECTION, LOVOTIBEGLOGENE AUTOTEMCEL, PER TREATMENT Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3397 INJECTION, VESTRONIDASE ALFA-VJBK, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3398 INJECTION, VORETIGENE NEPARVOVEC-RZYL, 1 BILLION VECTOR GENOMES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3399 INJECTION, ONASEMNOGENE ABEPARVOVEC-XIOI, PER TREATMENT, UP TO 5X10^15 VECTOR GENOMES Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     J3401 BEREMAGENE GEPERPAVEC-SVDT FOR TOPICAL ADMINISTRATION, CONTAINING NOMINAL 5 X 10^9 PFU/ML VECTOR GENOMES, PER 0.1 ML Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3489 INJECTION, ZOLEDRONIC ACID, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7324 HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3380 INJECTION, VEDOLIZUMAB, INTRAVENOUS, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2224 MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2507 INJECTION, PEGLOTICASE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2508 INJECTION, PEGUNIGALSIDASE ALFA-IWXJ, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2545 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG Yes 1/1/2022   Pays without authorization for Dx B20, B59, B96.5, E84.0 - E84.9, I27.0, I27.20 - I27.29, J05.0, J15.1, J40 - J47.9, J95.00 - J95.09, Q33.4, R09.3, T86.00 - T86.99, Z43.0, Z93.0, E75.242, J98.11, J98.19, R05.1 - R05.9, Z43.0, Z94.2. Pays without authoriz Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J2778 INJECTION, RANIBIZUMAB, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2779 INJECTION, RANIBIZUMAB, VIA INTRAVITREAL IMPLANT (SUSVIMO), 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2786 INJECTION, RESLIZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2798 INJECTION, RISPERIDONE, (PERSERIS), 0.5 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3245 INJECTION, TILDRAKIZUMAB, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2802 INJECTION, ROMIPLOSTIM, 1 MICROGRAM Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7170 INJECTION, EMICIZUMAB-KXWH, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2840 INJECTION, SEBELIPASE ALFA, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2941 INJECTION, SOMATROPIN, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2998 INJECTION, PLASMINOGEN, HUMAN-TVMH, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3010 INJECTION, FENTANYL CITRATE, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3032 INJECTION, EPTINEZUMAB-JJMR, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3060 INJECTION, TALIGLUCERASE ALFA, 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3110 INJECTION, TERIPARATIDE, 10 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3111 INJECTION, ROMOSOZUMAB-AQQG, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2799 INJECTION, RISPERIDONE (UZEDY), 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7207 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PEGYLATED, 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J3490 UNCLASSIFIED DRUGS Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Policy/Guideline depends on the specific drug being requested.Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases"; OncoHealth policies; InterQual     J7197 ANTITHROMBIN III (HUMAN), PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7198 ANTI-INHIBITOR, PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7199 HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7200 INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), RIXUBIS, PER IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7201 INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINANT), ALPROLIX, 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7202 INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (RECOMBINANT), IDELVION, 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7203 INJECTION FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), GLYCOPEGYLATED, (REBINYN), 1 IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7195 INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER IU, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7205 INJECTION, FACTOR VIII FC FUSION PROTEIN (RECOMBINANT), PER IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7194 FACTOR IX, COMPLEX, PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7208 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PEGYLATED-AUCL, (JIVI), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7209 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NUWIQ), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7210 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (AFSTYLA), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7211 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (KOVALTRY), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7212 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT)-JNCW (SEVENFACT), 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7318 HYALURONAN OR DERIVATIVE, DUROLANE, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 7/1/2025   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7320 HYALURONAN OR DERIVITIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J7321 HYALURONAN OR DERIVATIVE, HYALGAN, SUPARTZ OR VISCO-3, FOR INTRA-ARTICULAR INJECTION, PER DOSE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7204 INJECTION, FACTOR VIII, ANTIHEMOPHILIC FACTOR (RECOMBINANT), (ESPEROCT), GLYCOPEGYLATED-EXEI, PER IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7185 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7171 INJECTION, ADAMTS13, RECOMBINANT-KRHN, 10 IU Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     J7175 INJECTION, FACTOR X, (HUMAN), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7177 INJECTION, HUMAN FIBRINOGEN CONCENTRATE (FIBRYGA), 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7178 INJECTION, HUMAN FIBRINOGEN CONCENTRATE, NOT OTHERWISE SPECIFIED, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7179 INJECTION, VON WILLEBRAND FACTOR (RECOMBINANT), (VONVENDI), 1 I.U. VWF:RCO Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7180 INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7181 INJECTION, FACTOR XIII A-SUBUNIT, (RECOMBINANT), PER IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7182 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOEIGHT), PER IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7196 INJECTION, ANTITHROMBIN RECOMBINANT, 50 I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7184 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU VWF:RCO Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9040 INJECTION, BLEOMYCIN SULFATE, 15 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7186 INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN), PER FACTOR VIII I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7187 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7188 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (OBIZUR), PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7189 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOSEVEN RT), 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7191 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7192 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7193 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U. Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J7183 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I.U. VWF:RCO Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9357 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9390 INJECTION, VINORELBINE TARTRATE, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9347 INJECTION, TREMELIMUMAB-ACTL, 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9348 INJECTION, NAXITAMAB-GQGK, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9349 INJECTION, TAFASITAMAB-CXIX, 2 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9350 INJECTION, MOSUNETUZUMAB-AXGB, 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9351 INJECTION, TOPOTECAN, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9353 INJECTION, MARGETUXIMAB-CMKB, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9354 INJECTION, ADO-TRASTUZUMAB EMTANSINE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9334 INJECTION, EFGARTIGIMOD ALFA, 2 MG AND HYALURONIDASE-QVFC Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9356 INJECTION, TRASTUZUMAB, 10 MG AND HYALURONIDASE-OYSK Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9333 INJECTION, ROZANOLIXIZUMAB-NOLI, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9358 INJECTION, FAM-TRASTUZUMAB DERUXTECAN-NXKI, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9360 INJECTION, VINBLASTINE SULFATE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9361 INJECTION, EFBEMALENOGRASTIM ALFA-VUXW, 0.5 MG Yes 9/1/2024     OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines   J9370 VINCRISTINE SULFATE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9371 INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9376 INJECTION, POZELIMAB-BBFG, 1 MG Yes 11/26/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9380 INJECTION, TECLISTAMAB-CQYV, 0.5 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9038 INJECTION, AXATILIMAB-CSFR, 0.1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9355 INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9322 INJECTION, PEMETREXED (BLUEPOINT), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9310 INJECTION, RITUXIMAB, 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9311 INJECTION, RITUXIMAB 10 MG AND HYALURONIDASE Yes 2/28/2021   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Rituximab: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9312 INJECTION, RITUXIMAB, 10 MG Yes 2/28/2021   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Rituximab: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9313 INJECTION, MOXETUMOMAB PASUDOTOX-TDFK, 0.01 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9314 INJECTION, PEMETREXED (TEVA), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9315 INJECTION, ROMIDEPSIN, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9316 INJECTION, PERTUZUMAB, TRASTUZUMAB, AND HYALURONIDASE-ZZXF, PER 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9317 INJECTION, SACITUZUMAB GOVITECAN-HZIY, 2.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9340 INJECTION, THIOTEPA, 15 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9321 INJECTION, EPCORITAMAB-BYSP, 0.16 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9393 INJECTION, FULVESTRANT (TEVA), NOT THERAPEUTICALLY EQUIVALENT TO J9395, 25 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9323 INJECTION, PEMETREXED DITROMETHAMINE, 10 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9324 INJECTION, PEMETREXED (PEMRYDI RTU), 10 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9325 INJECTION, TALIMOGENE LAHERPAREPVEC, PER 1 MILLION PLAQUE FORMING UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9328 INJECTION, TEMOZOLOMIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9329 INJECTION, TISLELIZUMAB-JSGR, 1MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J9330 INJECTION, TEMSIROLIMUS, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9331 INJECTION, SIROLIMUS PROTEIN-BOUND PARTICLES, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9332 INJECTION, EFGARTIGIMOD ALFA-FCAB, 2MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9320 INJECTION, STREPTOZOCIN, 1 GRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0044 FOOTREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9381 INJECTION, TEPLIZUMAB-MZWV, 5 MCG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0019 ARM PAD, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0038 LEG STRAP, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0039 LEG STRAP, H STYLE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0041 LARGE SIZE FOOTPLATE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0043 FOOTREST, LOWER EXTENSION TUBE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0045 FOOTREST, COMPLETE ASSEMBLY, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0050 RATCHET ASSEMBLY, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0052 SWINGAWAY, DETACHABLE FOOTRESTS, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0042 STANDARD SIZE FOOTPLATE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0006 HEAVY DUTY WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9394 INJECTION, FULVESTRANT (FRESENIUS KABI) NOT THERAPEUTICALLY EQUIVALENT TO J9395, 25 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9395 INJECTION, FULVESTRANT, 25 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9400 INJECTION, ZIV-AFLIBERCEPT, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9600 INJECTION, PORFIMER SODIUM, 75 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS Yes 2/28/2021   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per Depends on the drug being requested: OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU"; OncoHealth Medical Policy, "Trastuzumab: Herceptin, Herceptin Hylecta, Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera"; InterQual InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   K0001 STANDARD WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0003 LIGHTWEIGHT WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0005 ULTRALIGHTWEIGHT WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9307 INJECTION, PRALATREXATE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0007 EXTRA HEAVY DUTY WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0008 CUSTOM MANUAL WHEELCHAIR/BASE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0009 OTHER MANUAL WHEELCHAIR/BASE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0010 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0011 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND BRAKING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0013 CUSTOM MOTORIZED/POWER WHEELCHAIR BASE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9209 INJECTION, MESNA, 200 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9309 INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9181 INJECTION, ETOPOSIDE, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9190 INJECTION, FLUOROURACIL, 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9200 INJECTION, FLOXURIDINE, 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9206 INJECTION, IRINOTECAN, 20 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9178 INJECTION, EPIRUBICIN HCL, 2 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9208 INJECTION, IFOSFAMIDE, 1 GRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9177 INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9212 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9213 INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9214 INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9215 INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9216 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9218 LEUPROLIDE ACETATE, PER 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9207 INJECTION, IXABEPILONE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9052 INJECTION, CARMUSTINE (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9050, 100 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2504 INJECTION, PEGADEMASE BOVINE, 25 IU Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9041 INJECTION, BORTEZOMIB, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9042 INJECTION, BRENTUXIMAB VEDOTIN, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9043 INJECTION, CABAZITAXEL, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9045 INJECTION, CARBOPLATIN, 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9046 INJECTION, BORTEZOMIB (DR. REDDY'S), NOT THERAPEUTICALLY EQUIVALENT TO J9041, 0.1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9047 INJECTION, CARFILZOMIB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9048 INJECTION, BORTEZOMIB (FRESENIUS KABI), NOT THERAPEUTICALLY EQUIVALENT TO J9041, 0.1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9050 INJECTION, CARMUSTINE, 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9054 INJECTION, BORTEZOMIB (BORUZU), 0.1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9055 INJECTION, CETUXIMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9165 INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9171 INJECTION, DOCETAXEL, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Paclitaxel Protein Bound: Abraxane" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9172 INJECTION, DOCETAXEL (DOCIVYX), 1 MG Yes 4/1/2024   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Prequthorization required for all uses. OncoHealth Medical Policy, "Paclitaxel Protein Bound: Abraxane" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9173 INJECTION, DURVALUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9175 INJECTION, ELLIOTTS' B SOLUTION, 1 ML Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9176 INJECTION, ELOTUZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9049 INJECTION, BORTEZOMIB (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J9041, 0.1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9297 INJECTION, PEMETREXED (SANDOZ), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9271 INJECTION, PEMBROLIZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9272 INJECTION, DOSTARLIMAB-GXLY, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9280 INJECTION, MITOMYCIN, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9281 MITOMYCIN PYELOCALYCEAL INSTILLATION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9285 INJECTION, OLARATUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9286 INJECTION, GLOFITAMAB-GXBM, 2.5 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9292 INJECTION, PEMETREXED (AVYXA), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9293 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9219 LEUPROLIDE ACETATE IMPLANT, 65 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9296 INJECTION, PEMETREXED (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9267 INJECTION, PACLITAXEL, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Paclitaxel Protein Bound: Abraxane" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9299 INJECTION, NIVOLUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9301 INJECTION, OBINUTUZUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9302 INJECTION, OFATUMUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9303 INJECTION, PANITUMUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9304 INJECTION, PEMETREXED (PEMFEXY), 10 MG Yes 1/1/2025   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Prequthorization required for all uses. Sendero Internal medical policy InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9305 INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9306 INJECTION, PERTUZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9039 INJECTION, BLINATUMOMAB, 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9294 INJECTION, PEMETREXED (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J9305, 10 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item OncoHealth Medical Policy, "Pemetrexed: Alimta, Pemfexy, Pemrydi RTU" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9255 INJECTION, METHOTREXATE (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J9260, 50 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9308 INJECTION, RAMUCIRUMAB, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9227 INJECTION, ISATUXIMAB-IRFC, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9228 INJECTION, IPILIMUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9229 INJECTION, INOTUZUMAB OZOGAMICIN, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9230 INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9245 INJECTION, MELPHALAN HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9247 INJECTION, MELPHALAN FLUFENAMIDE, 1MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9248 INJECTION, MELPHALAN (HEPZATO), 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines   J9270 INJECTION, PLICAMYCIN, 2.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9250 METHOTREXATE SODIUM, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9268 INJECTION, PENTOSTATIN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9258 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES (TEVA), NOT THERAPEUTICALLY EQUIVALENT TO J9264, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9259 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES (AMERICAN REGENT), NOT THERAPEUTICALLY EQUIVALENT TO J9264, 1 MG Yes 7/1/2023   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Prequthorization required for all uses. Sendero Internal medical policy InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9260 INJECTION, METHOTREXATE SODIUM, 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9261 INJECTION, NELARABINE, 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9262 INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9263 INJECTION, OXALIPLATIN, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9264 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG Yes 1/1/2022   Includes step therapy requirements through either biosimilars or therapeutically similar medications for the below medications only when used for cancer/chemotherapy indications. Preauthorization required for all uses when billed charges exceed $500 per OncoHealth Medical Policy, "Paclitaxel Protein Bound: Abraxane" InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J9266 INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9225 HISTRELIN IMPLANT (VANTAS), 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J9249 INJECTION, MELPHALAN (APOTEX), 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0151 SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0161 SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE SPEECH-LANGUAGE PATHOLOGY MAINTENANCE PROGRAM, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E2630 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2631 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2632 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2633 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E3200 GAIT MODULATION SYSTEM, RHYTHMIC AUDITORY STIMULATION, INCLUDING RESTRICTED THERAPY SOFTWARE, ALL COMPONENTS AND ACCESSORIES, PRESCRIPTION ONLY Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E8000 GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E8001 GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2628 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0138 INTRAVENOUS INFUSION OF CIPAGLUCOSIDASE ALFA-ATGA, INCLUDING PROVIDER/SUPPLIER ACQUISITION AND CLINICAL SUPERVISION OF ORAL ADMINISTRATION OF MIGLUSTAT IN PREPARATION OF RECEIPT OF CIPAGLUCOSIDASE ALFA-ATGA Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2627 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0152 SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0153 SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0155 SERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH OR HOSPICE SETTINGS, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0156 SERVICES OF HOME HEALTH/HOSPICE AIDE IN HOME HEALTH OR HOSPICE SETTINGS, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0157 SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST ASSISTANT IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0158 SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST ASSISTANT IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0159 SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE PHYSICAL THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E8002 GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2617 CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2506 INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2608 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2609 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2610 WHEELCHAIR SEAT CUSHION, POWERED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2611 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2612 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2613 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2614 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2629 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2616 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E2619 REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2620 POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2621 POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2622 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2623 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2624 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2625 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2626 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2615 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G9147 OUTPATIENT INTRAVENOUS INSULIN TREATMENT (OIVIT) EITHER PULSATILE OR CONTINUOUS, BY ANY MEANS, GUIDED BY THE RESULTS OF MEASUREMENTS FOR: RESPIRATORY QUOTIENT; AND/OR, URINE UREA NITROGEN (UUN); AND/OR, ARTERIAL, VENOUS OR CAPILLARY GLUCOSE; AND/OR POTASS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0160 SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST, IN THE HOME HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE OCCUPATIONAL THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0460 AUTOLOGOUS PLATELET RICH PLASMA OR OTHER BLOOD-DERIVED PRODUCT FOR NON-DIABETIC CHRONIC WOUNDS/ULCERS, INCLUDING AS APPLICABLE PHLEBOTOMY, CENTRIFUGATION OR MIXING, AND ALL OTHER PREPARATORY PROCEDURES, ADMINISTRATION AND DRESSINGS, PER TREATMENT Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0465 AUTOLOGOUS PLATELET RICH PLASMA (PRP) OR OTHER BLOOD-DERIVED PRODUCT FOR DIABETIC CHRONIC WOUNDS/ULCERS, USING AN FDA-CLEARED DEVICE FOR THIS INDICATION, (INCLUDES AS APPLICABLE ADMINISTRATION, DRESSINGS, PHLEBOTOMY, CENTRIFUGATION OR MIXING, AND ALL OTHE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0493 SKILLED SERVICES OF A REGISTERED NURSE (RN) FOR THE OBSERVATION AND ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (THE CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TO IDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE M Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0533 MEDICATION ASSISTED TREATMENT, BUPRENORPHINE (INJECTABLE) ADMINISTERED ON A WEEKLY BASIS; WEEKLY BUNDLE INCLUDING DISPENSING AND/OR ADMINISTRATION, SUBSTANCE USE COUNSELING, INDIVIDUAL AND GROUP THERAPY, AND TOXICOLOGY TESTING IF PERFORMED (PROVISION OF T Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0555 PROVISION OF REPLACEMENT PATIENT ELECTRONICS SYSTEM (E.G., SYSTEM PILLOW, HANDHELD READER) FOR HOME PULMONARY ARTERY PRESSURE MONITORING Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0562 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX, INCLUDING ACQUISITION OF PET AND CT IMAGING DATA REQUIRED FOR RADIOPHARMACEUTICAL-DIRECTED RADIATION THERAPY TREATMENT PLANNING (I.E., MODELING) Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document)     G0563 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE AND REAL-TIME POSITRON EMISSIONS-BASED DELIVERY ADJUSTMENTS TO 1 OR MORE LESIONS, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS Yes 6/15/2025     Evidence of Coverage (EOC, Plan coverage document)     G0343 LAPAROTOMY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND INFUSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9143 WARFARIN RESPONSIVENESS TESTING BY GENETIC TECHNIQUE USING ANY METHOD, ANY NUMBER OF SPECIMEN(S) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0342 LAPAROSCOPY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND INFUSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9473 SERVICES PERFORMED BY CHAPLAIN IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9474 SERVICES PERFORMED BY DIETARY COUNSELOR IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9475 SERVICES PERFORMED BY OTHER COUNSELOR IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9476 SERVICES PERFORMED BY VOLUNTEER IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9477 SERVICES PERFORMED BY CARE COORDINATOR IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9478 SERVICES PERFORMED BY OTHER QUALIFIED THERAPIST IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9479 SERVICES PERFORMED BY QUALIFIED PHARMACIST IN THE HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9524 PATIENT WAS REFERRED TO HOSPICE CARE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G9012 OTHER SPECIFIED CASE MANAGEMENT SERVICE NOT ELSEWHERE CLASSIFIED Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     G0282 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281 Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0181 PHYSICIAN OR ALLOWED PRACTITIONER SUPERVISION OF A PATIENT RECEIVING MEDICARE-COVERED SERVICES PROVIDED BY A PARTICIPATING HOME HEALTH AGENCY (PATIENT NOT PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN OR ALLO Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0182 PHYSICIAN SUPERVISION OF A PATIENT UNDER A MEDICARE-APPROVED HOSPICE (PATIENT NOT PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIE Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0219 PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0235 PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0252 PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G., INITIAL STAGING OF AXILLARY LYMPH NODES) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0255 CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDUCTION TEST, (SNCT) PER LIMB, ANY NERVE Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0259 INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0260 INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0428 COLLAGEN MENISCUS IMPLANT PROCEDURE FOR FILLING MENISCAL DEFECTS (E.G., CMI, COLLAGEN SCAFFOLD, MENAFLEX) Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0281 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS STASIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE, AS Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE Yes 7/7/2020   Effective 1/27/2025 For Physical or Occupational Therapy only, authorization required when visits exceed 12 per calendar year (initial evaluation excluded). InterQual® Evidence-Based Criteria & Guidelines     G0295 ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0329 OR FOR OTHER USES Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0299 DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0300 DIRECT SKILLED NURSING SERVICES OF A LICENSED PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0329 ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS AND VENOUS STASIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE AS PART OF A THERA Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   G0330 FACILITY SERVICES FOR DENTAL REHABILITATION PROCEDURE(S) PERFORMED ON A PATIENT WHO REQUIRES MONITORED ANESTHESIA (E.G., GENERAL, INTRAVENOUS SEDATION (MONITORED ANESTHESIA CARE) AND USE OF AN OPERATING ROOM Yes 5/15/2023     InterQual® Evidence-Based Criteria & Guidelines     G0337 HOSPICE EVALUATION AND COUNSELING SERVICES, PRE-ELECTION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0341 PERCUTANEOUS ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND INFUSION Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     G0276 BLINDED PROCEDURE FOR LUMBAR STENOSIS, PERCUTANEOUS IMAGE-GUIDED LUMBAR DECOMPRESSION (PILD) OR PLACEBO-CONTROL, PERFORMED IN AN APPROVED COVERAGE WITH EVIDENCE DEVELOPMENT (CED) CLINICAL TRIAL Yes 1/1/2022     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON-SEALED LEAD ACID BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2367 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2328 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2329 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2330 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2340 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 20-23 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2341 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2342 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 OR 21 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2351 POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2325 POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2359 POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2360 POWER WHEELCHAIR ACCESSORY, 22NF NON-SEALED LEAD ACID BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2361 POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G., GEL CELL, ABSORBED GLASSMAT) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2363 POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2365 POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2607 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2343 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22-25 INCHES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2301 WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM, ANY TYPE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2230 MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2231 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), INCLUDES ANY TYPE MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2291 BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2292 SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2293 BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2294 SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2327 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2298 COMPLEX REHABILITATIVE POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM, ANY TYPE Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2310 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2311 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2312 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2321 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2322 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2295 MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING FRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2508 SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2366 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2394 POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2395 POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2398 WHEELCHAIR ACCESSORY, DYNAMIC POSITIONING HARDWARE FOR BACK Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2500 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2502 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2391 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2506 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2390 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2510 SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2511 SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2512 ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2599 ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2504 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2381 POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2370 POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2371 POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G., GEL CELL, ABSORBED GLASSMAT), EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2372 POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2373 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2374 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2375 POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2376 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2392 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2378 POWER WHEELCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     H0010 ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM INPATIENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     E2382 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2383 POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2385 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2386 POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     E2377 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1557 INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1573 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 ML Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1449 INJECTION, EFLAPEGRASTIM-XNST, 0.1 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1456 INJECTION, FOSAPREPITANT (TEVA), NOT THERAPEUTICALLY EQUIVALENT TO J1453, 1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1458 INJECTION, GALSULFASE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1459 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1551 INJECTION, IMMUNE GLOBULIN (CUTAQUIG), 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1552 INJECTION, IMMUNE GLOBULIN (ALYGLO), 500 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1447 INJECTION, TBO-FILGRASTIM, 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1442 INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J1558 INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1560 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), NOT OTHERWISE SPECIFIED, 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G9525 DOCUMENTATION OF PATIENT REASON(S) FOR NOT REFERRING TO HOSPICE CARE (E.G., PATIENT DECLINED, OTHER PATIENT REASONS) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J1555 INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1412 INJECTION, VALOCTOCOGENE ROXAPARVOVEC-RVOX, PER ML, CONTAINING NOMINAL 2 X 10^13 VECTOR GENOMES Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1301 INJECTION, EDARAVONE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1303 INJECTION, RAVULIZUMAB-CWVZ, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1304 INJECTION, TOFERSEN, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1305 INJECTION, EVINACUMAB-DGNB, 5MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1306 INJECTION, INCLISIRAN, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1307 INJECTION, CROVALIMAB-AKKZ, 10 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1322 INJECTION, ELOSULFASE ALFA, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1323 INJECTION, ELRANATAMAB-BCMM, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item OncoHealth Global Medical Necessity Review criteria InterQual® Evidence-Based Criteria & Guidelines for non-cancer indications   J1448 INJECTION, TRILACICLIB, 1MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1411 INJECTION, ETRANACOGENE DEZAPARVOVEC-DRLB, PER THERAPEUTIC DOSE Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1574 INJECTION, GANCICLOVIR SODIUM (EXELA), NOT THERAPEUTICALLY EQUIVALENT TO J1570, 500 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1413 INJECTION, DELANDISTROGENE MOXEPARVOVEC-ROKL, PER THERAPEUTIC DOSE Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1414 INJECTION, FIDANACOGENE ELAPARVOVEC-DZKT, PER THERAPEUTIC DOSE Yes 6/15/2025     InterQual® Evidence-Based Criteria & Guidelines     J1426 INJECTION, CASIMERSEN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1427 INJECTION, VILTOLARSEN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1428 INJECTION, ETEPLIRSEN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1429 INJECTION, GOLODIRSEN, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1438 INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J1439 INJECTION, FERRIC CARBOXYMALTOSE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1325 INJECTION, EPOPROSTENOL, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2182 INJECTION, MEPOLIZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2267 INJECTION, MIRIKIZUMAB-MRKZ, 1 MG Yes 9/1/2024     InterQual® Evidence-Based Criteria & Guidelines     J2320 INJECTION, NANDROLONE DECANOATE, UP TO 50 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2323 INJECTION, NATALIZUMAB, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J2326 INJECTION, NUSINERSEN, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2327 INJECTION, RISANKIZUMAB-RZAA, INTRAVENOUS, 1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J2329 INJECTION, UBLITUXIMAB-XIIY, 1MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1954 INJECTION, LEUPROLIDE ACETATE FOR DEPOT SUSPENSION (CIPLA), 7.5 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2351 INJECTION, OCRELIZUMAB, 1 MG AND HYALURONIDASE-OCSQ Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1952 LEUPROLIDE INJECTABLE, CAMCEVI, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2354 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2356 INJECTION, TEZEPELUMAB-EKKO, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2357 INJECTION, OMALIZUMAB, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2427 INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE (INVEGA HAFYERA, OR INVEGA TRINZA), 1 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2428 INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE (ERZOFRI), 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2469 INJECTION, PALONOSETRON HCL, 25 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2502 INJECTION, PASIREOTIDE LONG ACTING, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2350 INJECTION, OCRELIZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1747 INJECTION, SPESOLIMAB-SBZO, 1 MG Yes 8/15/2023     Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   J1575 INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1576 INJECTION, IMMUNE GLOBULIN (PANZYGA), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG Yes 7/1/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1599 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1602 INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J1628 INJECTION, GUSELKUMAB, 1 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases"     J1675 INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1740 INJECTION, IBANDRONATE SODIUM, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1743 INJECTION, IDURSULFASE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J2021 INJECTION, LINEZOLID (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J2020, 200 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1745 INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J1290 INJECTION, ECALLANTIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1748 INJECTION, INFLIXIMAB-DYYB (ZYMFENTRA), 10 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1749 INJECTION, ILOPROST, 0.1 MCG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1786 INJECTION, IMIGLUCERASE, 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1823 INJECTION, INEBILIZUMAB-CDON, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1826 INJECTION, INTERFERON BETA-1A, 30 MCG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1830 INJECTION, INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1930 INJECTION, LANREOTIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1931 INJECTION, LARONIDASE, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1744 INJECTION, ICATIBANT, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0225 INJECTION, VUTRISIRAN, 1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1300 INJECTION, ECULIZUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0180 INJECTION, AGALSIDASE BETA, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0202 INJECTION, ALEMTUZUMAB, 1 MG Yes 8/15/2018   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0217 INJECTION, VELMANASE ALFA-TYCV, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0218 INJECTION, OLIPUDASE ALFA-RPCP, 1 MG Yes 8/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0220 INJECTION, ALGLUCOSIDASE ALFA, 10 MG, NOT OTHERWISE SPECIFIED Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0221 INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0222 INJECTION, PATISIRAN, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0178 INJECTION, AFLIBERCEPT, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0224 INJECTION, LUMASIRAN, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0177 INJECTION, AFLIBERCEPT HD, 1 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0364 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0402 INJECTION, ARIPIPRAZOLE (ABILIFY ASIMTUFII), 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0490 INJECTION, BELIMUMAB, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0491 INJECTION, ANIFROLUMAB-FNIA, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0517 INJECTION, BENRALIZUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0567 INJECTION, CERLIPONASE ALFA, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0223 INJECTION, GIVOSIRAN, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     H2014 SKILLS TRAINING AND DEVELOPMENT, PER 15 MINUTES Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     V5298 HEARING AID, NOT OTHERWISE CLASSIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0011 ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM INPATIENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0012 ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION PROGRAM OUTPATIENT) Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0015 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT (TREATMENT PROGRAM THAT OPERATES AT LEAST 3 HOURS/DAY AND AT LEAST 3 DAYS/WEEK AND IS BASED ON AN INDIVIDUALIZED TREATMENT PLAN), INCLUDING ASSESSMENT, COUNSELING; CRISIS INTERVENTION, AND ACTIVITY THERAP Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0017 BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM), WITHOUT ROOM AND BOARD, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0018 BEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENT PROGRAM), WITHOUT ROOM AND BOARD, PER DIEM Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     H0031 MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     H0032 MENTAL HEALTH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIAN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0179 INJECTION, BROLUCIZUMAB-DBLL, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     H0047 ALCOHOL AND/OR OTHER DRUG ABUSE SERVICES, NOT OTHERWISE SPECIFIED Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS Yes 1/1/2022     Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   H2019 THERAPEUTIC BEHAVIORAL SERVICES, PER 15 MINUTES Yes 4/15/2020     InterQual® Evidence-Based Criteria & Guidelines     H2035 ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER HOUR Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0129 INJECTION, ABATACEPT, 10 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J0135 INJECTION, ADALIMUMAB, 20 MG Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J0139 INJECTION, ADALIMUMAB, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0172 INJECTION, ADUCANUMAB-AVWA, 2 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0174 INJECTION, LECANEMAB-IRMB, 1 MG Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0175 INJECTION, DONANEMAB-AZBT, 2 MG Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item Evidence of Coverage (EOC, Plan coverage document) InterQual® Evidence-Based Criteria & Guidelines   H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0896 INJECTION, LUSPATERCEPT-AAMT, 0.25 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0877 INJECTION, DAPTOMYCIN (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J0878, 1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0881 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0882 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0885 INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0887 INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0888 INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0890 INJECTION, PEGINESATIDE, 0.1 MG (FOR ESRD ON DIALYSIS) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0891 INJECTION, ARGATROBAN (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J0883, 1 MG (FOR NON-ESRD USE) Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0584 INJECTION, BUROSUMAB-TWZA 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0893 INJECTION, DECITABINE (SUN PHARMA), NOT THERAPEUTICALLY EQUIVALENT TO J0894, 1 MG Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0799 FDA APPROVED PRESCRIPTION DRUG, ONLY FOR USE AS HIV PRE-EXPOSURE PROPHYLAXIS (NOT FOR USE AS TREATMENT OF HIV), NOT OTHERWISE CLASSIFIED Yes 4/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0897 INJECTION, DENOSUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J0898 INJECTION, ARGATROBAN (AUROMEDICS), NOT THERAPEUTICALLY EQUIVALENT TO J0883, 1 MG (FOR NON-ESRD USE) Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0899 INJECTION, ARGATROBAN (AUROMEDICS), NOT THERAPEUTICALLY EQUIVALENT TO J0884, 1 MG (FOR ESRD ON DIALYSIS) Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0901 VADADUSTAT, ORAL, 1 MG (FOR ESRD ON DIALYSIS) Yes 3/1/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1202 MIGLUSTAT, ORAL, 65 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1203 INJECTION, CIPAGLUCOSIDASE ALFA-ATGA, 5 MG Yes 9/1/2024   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1260 INJECTION, DOLASETRON MESYLATE, 10 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     G9526 PATIENT WAS NOT REFERRED TO HOSPICE CARE, REASON NOT GIVEN Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0892 INJECTION, ARGATROBAN (ACCORD), NOT THERAPEUTICALLY EQUIVALENT TO J0884, 1 MG (FOR ESRD ON DIALYSIS) Yes 5/15/2023   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0630 INJECTION, CALCITONIN SALMON, UP TO 400 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J1299 INJECTION, DENILEUKIN DIFTITOX-CXDL, 1 MCG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   j0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS Yes 1/1/2022     Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT Yes 1/1/2022     InterQual® Evidence-Based Criteria & Guidelines     J0589 INJECTION, DAXIBOTULINUMTOXINA-LANM, 1 UNIT Yes 9/1/2024     Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J0593 INJECTION, LANADELUMAB-FLYO, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF-ADMINISTERED) Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0596 INJECTION, C1 ESTERASE INHIBITOR (RECOMBINANT), RUCONEST, 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0597 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0598 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0870 INJECTION, IMETELSTAT, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0606 INJECTION, ETELCALCETIDE, 0.1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0638 INJECTION, CANAKINUMAB, 1 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0641 INJECTION, LEVOLEUCOVORIN, NOT OTHERWISE SPECIFIED, 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0642 INJECTION, LEVOLEUCOVORIN (KHAPZORY), 0.5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0666 INJECTION, BUPIVACAINE LIPOSOME, 1 MG Yes 6/15/2025   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0717 INJECTION, CERTOLIZUMAB PEGOL, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Yes 2/28/2021   Preauthorization required when billed charges exceed $500 per line item Sendero internal medical policy RX.001 "Biologic and Specialty Treatments for Autoimmune Diseases" InterQual® Evidence-Based Criteria & Guidelines   J0725 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0775 INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0791 INJECTION, CRIZANLIZUMAB-TMCA, 5 MG Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines     J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT Yes 1/1/2022     Effective 7/1/25: Sendero internal medical policy RX.002 "Medical Step Therapy" InterQual® Evidence-Based Criteria & Guidelines   J0599 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), (HAEGARDA), 10 UNITS Yes 1/1/2022   Preauthorization required when billed charges exceed $500 per line item InterQual® Evidence-Based Criteria & Guidelines