PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE …
Transcript of PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE …
Service
Elective or Emergency Inpatient
Dialysis Treatment (Out-of-network services only)
Home Health, Hospice Care
Home Infusion
Elective surgery at a Hospital or Ambulatory Surgical Facility
(Out-of-Network services only)
Other Procedures Requiring Prior Authorization
Specialty Pharmacy
Service Category Procedure Code Code DescriptionMedical Policy No/
GuidelineMedical Policy Title Updates
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77021 Mri Guidance Ndl Plmt Rs&I AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77022 Mri Gdn Parnchyma Tiss Abltj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
S8042Magnetic Resonance Imaging (Mri)
Low-FieldAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
S8085
Fluorine-18 Fluorodeoxyglucose (F-
18 Fdg) Imaging Using Dual-Head
Coincidence Detection System
(Non-Dedicated Pet Scan)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
S8092
Electron Beam Computed
Tomography (Also Known As
Ultrafast Ct Cine Ct)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Orthopedic Prodecures - Functional Neuromuscular
Electrical Stimulation (FNMES)/Percutaneous and Implanted
Nerve Stimulation and Neuromodulation
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
MED201.033 Functional Neuromuscular Electrical StimulationRetire effective
01/01/2022
MEDICAL SURGICAL SERVICES
2021 Commercial Outpatient Benefit Preauthorization Procedure Code List
This list includes Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes related to services/categories for which benefit preauthorization may be
required as of 01/01/2021 for commercial, fully insured, standard plans/networks,
This is not an exhaustive listing of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member
benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.
Benefit preauthorization for some services/categories must be obtained through Blue Cross and Blue Shield of Montana (BCBSMT). Benefit preauthorization for other services/categories must be obtained
through a utilization management vendor.
It is imperative that providers check eligibility and benefits for each patient prior to rendering services to confirm benefits, benefit preauthorization/pre-notification requirements and utilization management
vendors that must be used, if applicable. Providers may submit online eligibility and benefits inquiries (electronic 270 transactions) via the Availity® Provider Portal or other preferred web vendor portal.
Services performed without benefit preauthorization, if required, may be denied for payment and providers may not seek reimbursement from BCBSMT members. Obtaining benefit preauthorization/pre-
notification is not a substitute for confirming eligibility and benefits.
PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.
Dialysis Treatment provided by an Out-of-network provider.
Skilled home health care provided by a licensed home health or hospice agency.
Outpatient Infusion therapy provided by a licensed home infusion agency.
Outpatient elective surgery performed at an out of network hospital or ambulatory surgery facility. Specific service requiring
preauthorization are listed in the table below.
Specific service requiring preauthorization are listed in the table below.
Refer to 2021 Specialty Drugs Preauthorization List for Infusion Site of Care on Claims and Eligibility, Predetermination and
Preauthorization section on bcbsmt.com/provider.
PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE 01/01/2021Updated November 2021 to reference changes that will be effective January 2022
• Preauthorization is required by BCBSMT for certain services to determine in advance the Medical Necessity or Experiment Investigational and/or Unproven nature of certain care and services based on MCG
Criteria, Medical Policy and Member benefits. The list below describes the services that require preauthorization.
• Predetermination is a process used to submit requests for review of coverage decisions in accordance with medical policy and member contracts for a service (i.e., procedure, supply, drug or device) used to
diagnose or treat an illness or condition. A predetermination is recommended if a provider is uncertain if the service meets medical policy criteria. Contact Provider Customer Service to determine if a service not
on this list is subject to medical necessity review.
• Not all requirements apply to each product in these networks (Blue Preferred PPOSM
, Blue OptionsSM
, Blue Focus POSSM
, Managed CareSM
or TraditionalSM
). It is imperative that providers check eligibility and
benefits and verify preauthorization requirements through Availity®.
Medical/Surgical Services Requiring Preauthorization
Description
Admission to a licensed Acute Care Facility, Skilled Nursing Facility, Long Term Care Facility inpatient Admissions.
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 1/41
Orthopedic Prodecures - Functional Neuromuscular
Electrical Stimulation (FNMES)/Percutaneous and Implanted
Nerve Stimulation and Neuromodulation
E0770
Functional Electrical Stimulator
Transcutaneous Stimulation Of
Nerve And/Or Muscle Groups Any
Type Complete System Not
Otherwise Specified
MED201.033 Functional Neuromuscular Electrical StimulationRetire effective
01/01/2022
Radiation Therapy 77401 Radiation Treatment Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77423 Neutron Beam Tx Complex AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77600 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77605 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77610 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77615 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Radiation Therapy 77620 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Molecular Genetic Lab Testing 0168UFtl Aneuploidy Trisomy 21 18 13
Dna Mat Plsm AlgAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
01/01/2022
Add effective 04/01/2021
Molecular Genetic Lab Testing 0250UOnc Sld Org Neo Trgt Gen Seq Dna
Alys 505 GenesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0258U Ai Psor Mrna 50-100 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0260U Rare Ds Id Opt Genome Mapg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0262U Onc Sld Tum Rt-Pcr 7 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0264U Rare Ds Id Opt Genome Mapg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0265U Rar Do Whl Gn&Mtcdrl Dna Als AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0266U Unxpl Cnst Hrtbl Do Gn Xprs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0267U Rare Do Id Opt Gen Mapg&Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0268U Hem Ahus Gen Seq Alys 15 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0269U Hem Aut Dm Cgen Trmbctpna 14 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0270U Hem Cgen Coagj Do 20 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0271U Hem Cgen Neutropenia 23 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0272U Hem Genetic Bld Do 51 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0273U Hem Gen Hyprfibrnlysis 8 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0274U Hem Gen Pltlt Do 43 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0276U Hem Inh Thrombocytopenia 23 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0277U Hem Gen Pltlt Funcj Do 31 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Molecular Genetic Lab Testing 0278U Hem Gen Pltlt Funcj Do 31 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 01/01/2022
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70336 Magnetic Image Jaw Joint AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70450 Ct Head/Brain W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70460 Ct Head/Brain W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70470 Ct Head/Brain W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70480 Ct Orbit/Ear/Fossa W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70481 Ct Orbit/Ear/Fossa W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70482 Ct Orbit/Ear/Fossa W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70486 Ct Maxillofacial W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70487 Ct Maxillofacial W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70488 Ct Maxillofacial W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 2/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70490 Ct Soft Tissue Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70491 Ct Soft Tissue Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70492 Ct Sft Tsue Nck W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70496 Ct Angiography Head AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70498 Ct Angiography Neck AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70540 Mri Orbit/Face/Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70542 Mri Orbit/Face/Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70543 Mri Orbt/Fac/Nck W/O &W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70544 Mr Angiography Head W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70545 Mr Angiography Head W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70546 Mr Angiograph Head W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70547 Mr Angiography Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70548 Mr Angiography Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70549 Mr Angiograph Neck W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70551 Mri Brain Stem W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70552 Mri Brain Stem W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70553 Mri Brain Stem W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70554 Fmri Brain By Tech AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
70555 Fmri Brain By Phys/Psych AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71250 Ct Thorax W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71260 Ct Thorax W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71270 Ct Thorax W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71271 Ct Thorax Lung Cancer Scr C- AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71275 Ct Angiography Chest AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71550 Mri Chest W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71551 Mri Chest W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71552 Mri Chest W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
71555 Mri Angio Chest W Or W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72125 Ct Neck Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72126 Ct Neck Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 3/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72127 Ct Neck Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72128 Ct Chest Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72129 Ct Chest Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72130 Ct Chest Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72131 Ct Lumbar Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72132 Ct Lumbar Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72133 Ct Lumbar Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72141 Mri Neck Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72142 Mri Neck Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72146 Mri Chest Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72147 Mri Chest Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72148 Mri Lumbar Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72149 Mri Lumbar Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72156 Mri Neck Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72157 Mri Chest Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72158 Mri Lumbar Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72159 Mr Angio Spine W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72191 Ct Angiograph Pelv W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72192 Ct Pelvis W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72193 Ct Pelvis W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72194 Ct Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72195 Mri Pelvis W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72196 Mri Pelvis W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72197 Mri Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
72198 Mr Angio Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73200 Ct Upper Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73201 Ct Upper Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73202 Ct Uppr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73206 Ct Angio Upr Extrm W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73218 Mri Upper Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 4/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73219 Mri Upper Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73220 Mri Uppr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73221 Mri Joint Upr Extrem W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73222 Mri Joint Upr Extrem W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73223 Mri Joint Upr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73225 Mr Angio Upr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73700 Ct Lower Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73701 Ct Lower Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73702 Ct Lwr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73706 Ct Angio Lwr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73718 Mri Lower Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73719 Mri Lower Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73720 Mri Lwr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73721 Mri Jnt Of Lwr Extre W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73722 Mri Joint Of Lwr Extr W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73723 Mri Joint Lwr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
73725 Mr Ang Lwr Ext W Or W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74150 Ct Abdomen W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74160 Ct Abdomen W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74170 Ct Abdomen W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74174 Ct Angio Abd&Pelv W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74175 Ct Angio Abdom W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74176 Ct Abd & Pelvis W/O Contrast AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74177 Ct Abd & Pelv W/Contrast AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74178 Ct Abd & Pelv 1/> Regns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74181 Mri Abdomen W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74182 Mri Abdomen W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74183 Mri Abdomen W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74185 Mri Angio Abdom W Orw/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74261 Ct Colonography Dx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 5/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74262 Ct Colonography Dx W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74263 Ct Colonography Screening AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74712 Mri Fetal Sngl/1St Gestation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
74713 Mri Fetal Ea Addl Gestation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
75635 Ct Angio Abdominal Arteries AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76376 3D Render W/Intrp Postproces AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76377 3D Render W/Intrp Postproces AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76380 Cat Scan Follow-Up Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76390 Mr Spectroscopy AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76391 Mr Elastography AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76497 Ct Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76498 Mri Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
76975 Gi Endoscopic Ultrasound AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
07/01/2021
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77046 Mri Breast C- Unilateral AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77047 Mri Breast C- Bilateral AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77048 Mri Breast C-+ W/Cad Uni AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77049 Mri Breast C-+ W/Cad Bi AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77078 Ct Bone Density Axial AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
77084 Magnetic Image Bone Marrow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78012 Thyroid Uptake Measurement AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78013 Thyroid Imaging W/Blood Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78014 Thyroid Imaging W/Blood Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78015 Thyroid Met Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78016 Thyroid Met Imaging/Studies AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78018 Thyroid Met Imaging Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78020 Thyroid Met Uptake AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78070 Parathyroid Planar Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78071 Parathyrd Planar W/Wo Subtrj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78072 Parathyrd Planar W/Spect&Ct AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78075 Adrenal Cortex & Medulla Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 6/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78102 Bone Marrow Imaging Ltd AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78103 Bone Marrow Imaging Mult AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78104 Bone Marrow Imaging Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78185 Spleen Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78195 Lymph System Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78201 Liver Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78202 Liver Imaging With Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78215 Liver And Spleen Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78216 Liver & Spleen Image/Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78226 Hepatobiliary System Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78227 Hepatobil Syst Image W/Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78230 Salivary Gland Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78231 Serial Salivary Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78232 Salivary Gland Function Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78258 Esophageal Motility Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78261 Gastric Mucosa Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78262 Gastroesophageal Reflux Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78264 Gastric Emptying Imag Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78265 Gastric Emptying Imag Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78266 Gastric Emptying Imag Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78278 Acute Gi Blood Loss Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78290 Meckels Divert Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78291 Leveen/Shunt Patency Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78300 Bone Imaging Limited Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78305 Bone Imaging Multiple Areas AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78306 Bone Imaging Whole Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78315 Bone Imaging 3 Phase AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78445 Vascular Flow Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78456 Acute Venous Thrombus Image AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78457 Venous Thrombosis Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 7/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78458 Ven Thrombosis Images Bilat AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78579 Lung Ventilation Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78580 Lung Perfusion Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78582 Lung Ventilat&Perfus Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78597 Lung Perfusion Differential AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78598 Lung Perf&Ventilat Diferentl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78600 Brain Image < 4 Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78601 Brain Image W/Flow < 4 Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78605 Brain Image 4+ Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78606 Brain Image W/Flow 4 + Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78608 Brain Imaging (Pet) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78609 Brain Imaging (Pet) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78610 Brain Flow Imaging Only AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78630 Cerebrospinal Fluid Scan AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78635 Csf Ventriculography AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78645 Csf Shunt Evaluation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78650 Csf Leakage Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78660 Nuclear Exam Of Tear Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78700 Kidney Imaging Morphol AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78701 Kidney Imaging With Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78707 K Flow/Funct Image W/O Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78708 K Flow/Funct Image W/Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78709 K Flow/Funct Image Multiple AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78725 Kidney Function Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78730 Urinary Bladder Retention AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78740 Ureteral Reflux Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78761 Testicular Imaging W/Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78800 Rp Loclzj Tum 1 Area 1 D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78801 Rp Loclzj Tum 2+Area 1+D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78802 Rp Loclzj Tum Whbdy 1 D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 8/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78803 Rp Loclzj Tum Spect 1 Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78804 Rp Loclzj Tum Whbdy 2+D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78811 Pet Image Ltd Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78812 Pet Image Skull-Thigh AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78813 Pet Image Full Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78814 Pet Image W/Ct Lmtd AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78815 Pet Image W/Ct Skull-Thigh AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78816 Pet Image W/Ct Full Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78830 Rp Loclzj Tum Spect W/Ct 1 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78831 Rp Loclzj Tum Spect 2 Areas AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78832 Rp Loclzj Tum Spect W/Ct 2 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
78999 Nuclear Diagnostic Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retired effective
01/01/2021
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
0042T Ct Perfusion W/Contrast Cbf AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8900Magnetic Resonance Angiography
With Contrast AbdomenAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8901Magnetic Resonance Angiography
Without Contrast AbdomenAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8902
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Abdomen
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8903Magnetic Resonance Imaging With
Contrast Breast; UnilateralAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8905
Magnetic Resonance Imaging
Without Contrast Followed By With
Contrast Breast; Unilateral
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8906Magnetic Resonance Imaging With
Contrast Breast; BilateralAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8908
Magnetic Resonance Imaging
Without Contrast Followed By With
Contrast Breast; Bilateral
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8909
Magnetic Resonance Angiography
With Contrast Chest (Excluding
Myocardium)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8910
Magnetic Resonance Angiography
Without Contrast Chest (Excluding
Myocardium)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8911
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Chest (Excluding
Myocardium)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8912Magnetic Resonance Angiography
With Contrast Lower ExtremityAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8913Magnetic Resonance Angiography
Without Contrast Lower ExtremityAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8914
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Lower Extremity
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8918Magnetic Resonance Angiography
With Contrast PelvisAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8919Magnetic Resonance Angiography
Without Contrast PelvisAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 9/41
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8920
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Pelvis
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8931
Magnetic Resonance Angiography
With Contrast Spinal Canal And
Contents
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8932
Magnetic Resonance Angiography
Without Contrast Spinal Canal And
Contents
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8933
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Spinal Canal And Contents
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8934Magnetic Resonance Angiography
With Contrast Upper ExtremityAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8935Magnetic Resonance Angiography
Without Contrast Upper ExtremityAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
C8936
Magnetic Resonance Angiography
Without Contrast Followed By With
Contrast Upper Extremity
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
G0219
Pet Imaging Whole Body;
Melanoma For Non-Covered
Indications
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
G0235Pet Imaging Any Site Not
Otherwise SpecifiedAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
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)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
G0297Low Dose Ct Scan (Ldct) For Lung
Cancer ScreeningAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Advanced Imaging- Advanced Imaging Services: MRI, MRA,
PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac
Advanced Imaging)
S8037Magnetic Resonance
Cholangiopancreatography (Mrcp)AIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Home Health, Hospice Care 99500 Home Visit PrenatalMCG
OB401.017
Clinical Guidelines
Home Uterine Activity Monitoring_
Home Health, Hospice Care 99501 Home Visit Postnatal MCG Clinical Guidelines _Home Health, Hospice Care 99502 Home Visit Nb Care MCG Clinical Guidelines _Home Health, Hospice Care 99503 Home Visit Resp Therapy MCG Clinical Guidelines _Home Health, Hospice Care 99504 Hhome Visit Mech Ventilator MCG Clinical Guidelines _Home Health, Hospice Care 99505 Home Visit Stoma Care MCG Clinical Guidelines _
Home Health, Hospice Care 99506 Home Visit Im InjectionMCG
RX501.062
Clinical Guidelines
Progesterone Therapy as a Technique to Reduce
Preterm Delivery in High-Risk Pregnancies
_
Home Health, Hospice Care 99507 Home Visit Cath Maintain MCG Clinical Guidelines _
Home Health, Hospice Care 99509 Home Visit Day Life ActivityMCG
ADM1001.014
Clinical Guidelines
Custodial Care_
Home Health, Hospice Care 99511 Home Visit Fecal/Enema Mgmt MCG Clinical Guidelines _Home Health, Hospice Care 99600 Home Visit Nos MCG Clinical Guidelines _
Home Health, Hospice Care G0151
Services Performed By A Qualified
Physical Therapist In The Home
Health Or Hospice Setting Each 15
Minutes
MCG
PSY301.014
THE803.010
Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
Home Health, Hospice Care G0152
Services Performed By A Qualified
Occupational Therapist In The
Home Health Or Hospice Setting
Each 15 Minutes
MCG
PSY301.014
THE803.010
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
Home Health, Hospice Care G0153
Services Performed By A Qualified
Speech-Language Pathologist In
The Home Health Or Hospice
Setting Each 15 Minutes
MCG
PSY301.014
THE803.014
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Speech-Language Therapy (SLT)
_
Home Health, Hospice Care G0155
Services Of Clinical Social Worker
In Home Health Or Hospice
Settings, Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G0156 HHCP-svs of aide,ea 15 min MCG _ _
Home Health, Hospice Care G0157
Services Performed By A Qualified
Physical Therapist Assistant In The
Home Health Or Hospice Setting
Each 15 Minutes
MCG
PSY301.014
THE803.010
Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
Home Health, Hospice Care G0158
Services Performed By A Qualified
Occupational Therapist Assistant In
The Home Health Or Hospice
Setting Each 15 Minutes
MCG
PSY301.014
THE803.010
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 10/41
Home Health, Hospice Care 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
MCG
PSY301.014
THE803.010
Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
Home Health, Hospice Care 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
MCG
PSY301.014
THE803.010
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Physical Therapy (PT) and Occupational Therapy
(OT) Services
_
Home Health, Hospice Care 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
MCG
PSY301.014
THE803.014
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Speech-Language Therapy (SLT)
_
Home Health, Hospice Care G0162
Skilled Services By A Registered
Nurse (Rn) In The Delivery Of
Management & Evaluation Of The
Plan Of Care; Each 15 Minutes (The
Patient'S Underlying Condition Or
Complication Requires An Rn To
Ensure That Essential Non-Skilled
Care Achieve Its Purpose In The
Home Health Or Hospice Setting)
MCG Clinical Guidelines _
Home Health, Hospice Care G0299
Direct Skilled Nursing Services Of A
Registered Nurse (Rn) In The Home
Health Or Hospice Setting Each 15
Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G0300
Direct Skilled Nursing Services Of A
License Practical Nurse (Lpn) In The
Home Health Or Hospice Setting
Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G0490
Face-To-Face Home Health Nursing
Visit By A Rural Health Clinic (Rhc)
Or Federally Qualified Health
Center (Fqhc) In An Area With A
Shortage Of Home Health
Agencies. (Services Limited To Rn
Or Lpn Only).
MCG Clinical Guidelines _
Home Health, Hospice Care 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
Modification Of Treatment In The
Home Health Or Hospice Setting)
MCG Clinical Guidelines _
Home Health, Hospice Care G0494
Skilled Services Of A Licensed
Practical Nurse (Lpn) 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 Modification Of
Treatment In The Home Health Or
Hospice Setting)
MCG Clinical Guidelines _
Home Health, Hospice Care G0495
Skilled Services Of A Registered
Nurse (Rn) In The Training And/Or
Education Of A Patient Or Family
Member In The Home Health Or
Hospice Setting Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G0496
Skilled Services Of A Licensed
Practical Nurse (Lpn) In The
Training And/Or Education Of A
Patient Or Family Member In The
Home Health Or Hospice Setting
Each 15 Minutes
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 11/41
Home Health, Hospice Care G9473
Services Performed By Chaplain In
The Hospice Setting Each 15
Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G9474
Services Performed By Dietary
Counselor In The Hospice Setting
Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G9475
Services Performed By Other
Counselor In The Hospice Setting
Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care G9478
Services Performed By Other
Qualified Therapist In The Hospice
Setting Each 15 Minutes
MCG Clinical Guidelines _
Home Health, Hospice Care Q5001
Hospice Or Home Health Care
Provided In Patient'S
Home/Residence
MCG Clinical Guidelines _
Home Health, Hospice Care Q5002Hospice Or Home Health Care
Provided In Assisted Living FacilityMCG Clinical Guidelines _
Home Health, Hospice Care Q5003
Hospice Care Provided In Nursing
Long Term Care Facility (Ltc) Or
Non-Skilled Nursing Facility (Nf)
MCG Clinical Guidelines _
Home Health, Hospice Care Q5004Hospice Care Provided In Skilled
Nursing Facility (Snf)MCG Clinical Guidelines _
Home Health, Hospice Care Q5005Hospice Care Provided In Inpatient
HospitalMCG Clinical Guidelines _
Home Health, Hospice Care Q5006Hospice Care Provided In Inpatient
Hospice FacilityMCG Clinical Guidelines _
Home Health, Hospice Care Q5007Hospice Care Provided In Long
Term Care FacilityMCG Clinical Guidelines _
Home Health, Hospice Care Q5008Hospice Care Provided In Inpatient
Psychiatric FacilityMCG Clinical Guidelines _
Home Health, Hospice Care Q5009
Hospice Or Home Health Care
Provided In Place Not Otherwise
Specified (Nos)
MCG Clinical Guidelines _
Home Health, Hospice Care Q5010Hospice Home Care Provided In A
Hospice FacilityMCG Clinical Guidelines _
Home Health, Hospice Care S5108Home Care Training To Home Care
Client, Per 15 Minutes
MCG
PSY301.021
Clinical Guidelines
Applied Behavior Analysis (ABA) for Autism
Spectrum Disorder (ASD) Diagnosis
_
Home Health, Hospice Care S5109Home Care Training To Home Care
Client, Per SessionMCG Clinical Guidelines _
Home Health, Hospice Care S5110Home Care Training, Family; Per 15
Minutes
MCG
PSY301.021
Clinical Guidelines
Applied Behavior Analysis (ABA) for Autism
Spectrum Disorder (ASD) Diagnosis
_
Home Health, Hospice Care S5111Home Care Training, Family; Per
Session
MCG
PSY301.021
Clinical Guidelines
Applied Behavior Analysis (ABA) for Autism
Spectrum Disorder (ASD) Diagnosis
_
Home Health, Hospice Care S5115Home Care Training, Non-Family;
Per 15 MinutesMCG Clinical Guidelines _
Home Health, Hospice Care S5116Home Care Training, Non-Family;
Per SessionMCG Clinical Guidelines _
Home Health, Hospice Care S5125Attendant Care Services; Per 15
MinutesMCG Clinical Guidelines _
Home Health, Hospice Care S5126 Attendant Care Services; Per Diem MCG Clinical Guidelines _
Home Health, Hospice Care S5180Home Health Respiratory Therapy,
Initial EvaluationMCG Clinical Guidelines _
Home Health, Hospice Care S5181Home Health Respiratory Therapy,
Nos, Per DiemMCG Clinical Guidelines _
Home Health, Hospice Care S9097 Home Visit Wound Care MCG Clinical Guidelines _
Home Health, Hospice Care S9098
Home Visit Phototherapy Services
(E. G. Bili-Lite) Including
Equipment Rental Nursing Services
Blood Draw Supplies And Other
Services Per Diem
MCG Clinical Guidelines _
Home Health, Hospice Care S9122
Home Health Aide Or Certified
Nurse Assistant, Providing Care In
The Home; Per Hour
MCG Clinical Guidelines _
Home Health, Hospice Care 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)
MCG
RX501.062
Clinical Guidelines
Progesterone Therapy as a Technique to Reduce
Preterm Delivery in High-Risk Pregnancies
_
Home Health, Hospice Care S9124Nursing Care In The Home; By
Licensed Practical Nurse Per Hour
MCG
RX501.062
Clinical Guidelines
Progesterone Therapy as a Technique to Reduce
Preterm Delivery in High-Risk Pregnancies
_
Home Health, Hospice Care S9126Hospice Care, In The Home, Per
DiemMCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 12/41
Home Health, Hospice Care 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 Infusion Per Diem Code)
MCG
RX501.062
Clinical Guidelines
Progesterone Therapy as a Technique to Reduce
Preterm Delivery in High-Risk Pregnancies
_
Home Health, Hospice Care 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 Use This Code With Any
Home Infusion Per Diem Code)
MCG Clinical Guidelines _
Home Health, Hospice Care T1004Services Of A Qualified Nursing
Aide, Up To 15 MinutesMCG Clinical Guidelines _
Home Health, Hospice Care T1030 RN home care per diem MCG _ Add effective 3/1/2021Home Health, Hospice Care T1031 LPN home care per diem MCG _ Add effective 3/1/2021
Home Health, Hospice Care T1502
Administration Of Oral,
Intramuscular And/Or
Subcutaneous Medication By
Health Care Agency/Professional,
Per Visit
MCG Clinical Guidelines _
Home Health, Hospice Care T1503
Administration Of Medication,
Other Than Oral And/Or Injectable,
By A Health Care
Agency/Professional, Per Visit
MCG Clinical Guidelines _
Home Hemodialysis 99512 Home Visit For Hemodialysis THE802.002Daily Hemodialysis and Hemodialysis in the Home
Setting_
Home Hemodialysis S9335
Home Therapy Hemodialysis;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Services Coded
Separately) Per Diem
THE802.002Daily Hemodialysis and Hemodialysis in the Home
Setting_
Home Infusion Therapy (HIT) 99601 Home Infusion/Visit 2 Hrs MCG Clinical Guidelines _Home Infusion Therapy (HIT) 99602 Home Infusion Each Addtl Hr MCG Clinical Guidelines _
Home Infusion Therapy (HIT) B4034
Enteral Feeding Supply Kit; Syringe
Fed Per Day Includes But Not
Limited To Feeding/Flushing
Syringe Administration Set Tubing
Dressings Tape
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4035
Enteral Feeding Supply Kit; Pump
Fed Per Day Includes But Not
Limited To Feeding/Flushing
Syringe Administration Set Tubing
Dressings Tape
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4036
Enteral Feeding Supply Kit; Gravity
Fed Per Day Includes But Not
Limited To Feeding/Flushing
Syringe Administration Set Tubing
Dressings Tape
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4102
Enteral Formula For Adults Used
To Replace Fluids And Electrolytes
(E.G. Clear Liquids) 500 Ml = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4103
Enteral Formula For Pediatrics
Used To Replace Fluids And
Electrolytes (E.G. Clear Liquids)
500 Ml = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4104Additive For Enteral Formula (E.G.
Fiber)
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4149
Enteral Formula Manufactured
Blenderized Natural Foods With
Intact Nutrients Includes Proteins
Fats Carbohydrates Vitamins And
Minerals May Include Fiber
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 13/41
Home Infusion Therapy (HIT) B4150
Enteral Formula Nutritionally
Complete With Intact Nutrients
Includes Proteins Fats
Carbohydrates Vitamins And
Minerals May Include Fiber
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4152
Enteral Formula Nutritionally
Complete Calorically Dense (Equal
To Or Greater Than 1. 5 Kcal/Ml)
With Intact Nutrients Includes
Proteins Fats Carbohydrates
Vitamins And Minerals May
Include Fiber Administered
Through An Enteral Feeding Tube
100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4153
Enteral Formula Nutritionally
Complete Hydrolyzed Proteins
(Amino Acids And Peptide Chain)
Includes Fats Carbohydrates
Vitamins And Minerals May
Include Fiber Administered
Through An Enteral Feeding Tube
100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4154
Enteral Formula Nutritionally
Complete For Special Metabolic
Needs Excludes Inherited Disease
Of Metabolism Includes Altered
Composition Of Proteins Fats
Carbohydrates Vitamins And/Or
Minerals May Include Fiber
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4155
Enteral Formula Nutritionally
Incomplete/Modular Nutrients
Includes Specific Nutrients
Carbohydrates (E. G. Glucose
Polymers) Proteins/Amino Acids
(E. G. Glutamine Arginine) Fat (E.
G. Medium Chain Triglycerides) Or
Combination Administered
Through An Enteral Feeding Tube
100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4158
Enteral Formula For Pediatrics
Nutritionally Complete With Intact
Nutrients Includes Proteins Fats
Carbohydrates Vitamins And
Minerals May Include Fiber
And/Or Iron Administered
Through An Enteral Feeding Tube
100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4159
Enteral Formula For Pediatrics
Nutritionally Complete Soy Based
With Intact Nutrients Includes
Proteins Fats Carbohydrates
Vitamins And Minerals May
Include Fiber And/Or Iron
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4160
Enteral Formula For Pediatrics
Nutritionally Complete Calorically
Dense (Equal To Or Greater Than
0.7 Kcal/Ml) With Intact Nutrients
Includes Proteins Fats
Carbohydrates Vitamins And
Minerals May Include Fiber
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4161
Enteral Formula For Pediatrics
Hydrolyzed/Amino Acids And
Peptide Chain Proteins Includes
Fats Carbohydrates Vitamins And
Minerals May Include Fiber
Administered Through An Enteral
Feeding Tube 100 Calories = 1 Unit
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4164
Parenteral Nutrition Solution:
Carbohydrates (Dextrose) 50% Or
Less (500 Ml = 1 Unit) - Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 14/41
Home Infusion Therapy (HIT) B4168
Parenteral Nutrition Solution;
Amino Acid 3. 5% (500 Ml = 1
Unit) - Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4172
Parenteral Nutrition Solution;
Amino Acid 5. 5% Through 7%
(500 Ml = 1 Unit) - Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4176
Parenteral Nutrition Solution;
Amino Acid 7% Through 8. 5%
(500 Ml = 1 Unit) - Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4178
Parenteral Nutrition Solution:
Amino Acid Greater Than 8. 5%
(500 Ml = 1 Unit) - Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4180
Parenteral Nutrition Solution;
Carbohydrates (Dextrose) Greater
Than 50% (500 Ml=1 Unit) -
Homemix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4185
Parenteral Nutrition Solution Not
Otherwise Specified 10 Grams
Lipids
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4189
Parenteral Nutrition Solution;
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength 10 To 51 Grams Of
Protein - Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4193
Parenteral Nutrition Solution;
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength 52 To 73 Grams Of
Protein - Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4197
Parenteral Nutrition Solution;
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength 74 To 100 Grams Of
Protein - Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4199
Parenteral Nutrition Solution;
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength Over 100 Grams Of
Protein - Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4216
Parenteral Nutrition; Additives
(Vitamins Trace Elements Heparin
Electrolytes) Homemix Per Day
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4220Parenteral Nutrition Supply Kit;
Premix Per Day
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4222Parenteral Nutrition Supply Kit;
Home Mix Per Day
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B4224Parenteral Nutrition
Administration Kit Per Day
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B5000
Parenteral Nutrition Solution
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength Renal-Aminosyn-Rf
Nephramine Renamine-Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B5100
Parenteral Nutrition Solution
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength Hepatic Hepatamine-
Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B5200
Parenteral Nutrition Solution
Compounded Amino Acid And
Carbohydrates With Electrolytes
Trace Elements And Vitamins
Including Preparation Any
Strength Stress-Branch Chain
Amino Acids-Freamine-Hbc-Premix
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B9002Enteral Nutrition Infusion Pump
Any Type
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B9004Parenteral Nutrition Infusion Pump
Portable
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B9006Parenteral Nutrition Infusion Pump
Stationary
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) B9998 Noc For Enteral SuppliesMCG
MED201.011
Clinical Guidelines
Nutritional Support_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 15/41
Home Infusion Therapy (HIT) B9999 Noc For Parenteral SuppliesMCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) E0779
Ambulatory Infusion Pump
Mechanical Reusable For Infusion
8 Hours Or Greater
MCG
RX504.015
RX501.056
Clinical Guidelines
Levodopa-Carbidopa Enteral Suspension (e.g.
Duopa) for The Treatment of Parkinson Disease
Advanced Therapies for Pharmacologic Treatment
of Pulmonary Hypertension
_
Home Infusion Therapy (HIT) E0780
Ambulatory Infusion Pump
Mechanical Reusable For Infusion
Less Than 8 Hours
MCG
RX501.056
Clinical Guidelines
Advanced Therapies for Pharmacologic Treatment
of Pulmonary Hypertension
_
Home Infusion Therapy (HIT) E0781
Ambulatory Infusion Pump Single
Or Multiple Channels Electric Or
Battery Operated With
Administrative Equipment Worn
By Patient
MCG
SUR702.013
RX504.015
Clinical Guidelines
Delivery of Anesthesia for Postoperative Pain
Control by Continuous Infusion Using Elastomeric
Infusion Pump
Levodopa-Carbidopa Enteral Suspension (e.g.
Duopa) for The Treatment of Parkinson Disease.
_
Home Infusion Therapy (HIT) E0782
Infusion Pump Implantable Non-
Programmable (Includes All
Components E. G. Pump
Catheter Connectors Etc. )
MCG
SUR707.008
Clinical Guidelines
Implantable Infusion Pump for Pain and Spasticity_
Home Infusion Therapy (HIT) E0783
Infusion Pump System Implantable
Programmable (Includes All
Components E. G. Pump
Catheter Connectors Etc. )
MCG
SUR707.008
Clinical Guidelines
Implantable Infusion Pump for Pain and Spasticity_
Home Infusion Therapy (HIT) E0784External Ambulatory Infusion
Pump Insulin
MCG
DME101.005
Clinical Guidelines
Glucose Monitoring and Insulin Delivery Devices
for Managing Diabetes
_
Home Infusion Therapy (HIT) E0791Parenteral Infusion Pump
Stationary Single Or Multi-Channel
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) K0455
Infusion Pump Used For
Uninterrupted Parenteral
Administration Of Medication (E.
G. Epoprostenol Or Treprostinol)
MCG
RX501.056
Clinical Guidelines
Advanced Therapies for Pharmacologic Treatment
of Pulmonary Hypertension
_
Home Infusion Therapy (HIT) Q0081Infusion Therapy Using Other Than
Chemotherapeutic Drugs Per VisitMCG Clinical Guidelines _
Home Infusion Therapy (HIT) Q0083
Chemotherapy Administration By
Other Than Infusion Technique
Only (Eg Subcutaneous
Intramuscular Push) Per Visit
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) Q0084Chemotherapy Administration By
Infusion Technique Only Per VisitMCG Clinical Guidelines _
Home Infusion Therapy (HIT) Q0085
Chemotherapy Administration By
Both Infusion Technique And Other
Techique(S) (Eg Subcutaneous
Intramuscular Push) Per Visit
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5035
Home Infusion Therapy, Routine
Service Of Infusion Device (Eg.
Pump Maintenance)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5036Home Infusion Therapy, Repair Of
Infusion Device (Eg. Pump Repair)MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5497
Home Infusion Therapy Catheter
Care / Maintenance Not
Otherwise Classified; Includes
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5498
Home Infusion Therapy, Catheter
Care / Maintenance, Simple (Single
Lumen), Includes Administrative
Services, Professional Pharmacy
Services, Care Coordination And All
Necessary Supplies And
Equipment, (Drugs And Nursing
Visits Coded Separately), Per Diem
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 16/41
Home Infusion Therapy (HIT) S5501
Home Infusion Therapy, Catheter
Care / Maintenance, Complex
(More Than One Lumen), Includes
Administrative Services,
Professional Pharmacy Services,
Care Coordination, And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5502
Home Infusion Therapy, Catheter
Care / Maintenance, Implanted
Access Device, Includes
Administrative Services,
Professional Pharmacy Services,
Care Coordination And All
Necessary Supplies And
Equipment, (Drugs And Nursing
Visits Coded Separately), Per Diem
(Use This Code For Interim
Maintenance Of Vascular Access
Not Currently In Use)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5517
Home Infusion Therapy, All
Supplies Necessary For Restoration
Of Catheter Patency Or Declotting
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5518
Home Infusion Therapy, All
Supplies Necessary For Catheter
Repair
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5520
Home Infusion Therapy, All
Supplies (Including Catheter)
Necessary For A Peripherally
Inserted Central Venous Catheter
(Picc) Line Insertion
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5521
Home Infusion Therapy, All
Supplies (Including Catheter)
Necessary For A Midline Catheter
Insertion
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5522
Home Infusion Therapy, Insertion
Of Peripherally Inserted Central
Venous Catheter (Picc), Nursing
Services Only (No Supplies Or
Catheter Included)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S5523
Midline Venous Catheter, Nursing
Services Only (No Supplies Or
Catheter Included)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) 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
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) 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 Home Infusion
Per Diem Code)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) 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 Home Infusion
Per Diem Code)
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 17/41
Home Infusion Therapy (HIT) 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 Infusion
Per Diem Code)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) 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
Home Infusion Per Diem Code)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9325
Home Infusion Therapy, Pain
Management Infusion;
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 S9326,
S9327 Or S9328)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9326
Home Infusion Therapy,
Continuous (Twenty-Four Hours Or
More) Pain Management Infusion;
Administrative Services,
Professional Pharmacy Services,
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9327
Home Infusion Therapy,
Intermittent (Less Than Twenty-
Four Hours) Pain Management
Infusion; Administrative Services,
Professional Pharmacy Services,
Care Coordination, And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9328
Home Infusion Therapy, Implanted
Pump Pain Management Infusion;
Administrative Services,
Professional Pharmacy Services,
Care Coordination, And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9329
Home Infusion Therapy,
Chemotherapy Infusion;
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 S9330 Or S9331)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9330
Home Infusion Therapy,
Continuous (Twenty-Four Hours Or
More) Chemotherapy Infusion;
Administrative Services,
Professional Pharmacy Services,
Care Coordination, And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 18/41
Home Infusion Therapy (HIT) S9331
Home Infusion Therapy,
Intermittent (Less Than Twenty-
Four Hours) Chemotherapy
Infusion; Administrative Services,
Professional Pharmacy Services,
Care Coordination, And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9336
Home Infusion Therapy,
Continuous Anticoagulant Infusion
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
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9338
Home Infusion Therapy,
Immunotherapy, Administrative
Services, Professional Pharmacy
Services, Care Coordination, And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately), Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9340
Home Therapy; Enteral Nutrition;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Enteral Formula And Nursing Visits
Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9341
Home Therapy; Enteral Nutrition
Via Gravity; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Enteral Formula And Nursing Visits
Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9342
Home Therapy; Enteral Nutrition
Via Pump; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Enteral Formula And Nursing Visits
Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9343
Home Therapy; Enteral Nutrition
Via Bolus; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Enteral Formula And Nursing Visits
Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9345
Home Infusion Therapy Anti-
Hemophilic Agent Infusion Therapy
(E. G. Factor Viii); Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9346
Home Infusion Therapy Alpha-1-
Proteinase Inhibitor (E. G.
Prolastin); Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 19/41
Home Infusion Therapy (HIT) S9347
Home Infusion Therapy
Uninterrupted Long-Term
Controlled Rate Intravenous Or
Subcutaneous Infusion Therapy (E.
G. Epoprostenol); Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9348
Home Infusion Therapy
Sympathomimetic/Inotropic Agent
Infusion Therapy (E. G.
Dobutamine); Administrative
Services Professional Pharmacy
Services Care Coordination All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9349
Home Infusion Therapy Tocolytic
Infusion Therapy; Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9351
Home Infusion Therapy
Continuous Or Intermittent Anti-
Emetic Infusion Therapy;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9353
Home Infusion Therapy
Continuous Insulin Infusion
Therapy; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9355
Home Infusion Therapy Chelation
Therapy; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG
PSY301.014
THE801.008
Clinical Guidelines
Autism Spectrum Disorders (ASD)
Chelation Therapy
_
Home Infusion Therapy (HIT) S9357
Home Infusion Therapy Enzyme
Replacement Intravenous Therapy;
(E. G. Imiglucerase); Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9359
Home Infusion Therapy Anti-
Tumor Necrosis Factor Intravenous
Therapy; (E. G. Infliximab);
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9361
Home Infusion Therapy Diuretic
Intravenous Therapy;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 20/41
Home Infusion Therapy (HIT) S9363
Home Infusion Therapy Anti-
Spasmotic Therapy; Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9364
Home Infusion Therapy Total
Parenteral Nutrition (Tpn);
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
Including Standard Tpn Formula
(Lipids Specialty Amino Acid
Formulas Drugs Other Than In
Standard Formula And Nursing
Visits Coded Separately) Per Diem
(Do Not Use With Home Infusion
Codes S9365-S9368 Using Daily
Volume Scales)
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9365
Home Infusion Therapy Total
Parenteral Nutrition (Tpn); One
Liter Per Day Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment Including Standard Tpn
Formula (Lipids Specialty Amino
Acid Formulas Drugs Other Than
In Standard Formula And Nursing
Visits Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9366
Home Infusion Therapy Total
Parenteral Nutrition (Tpn); More
Than One Liter But No More Than
Two Liters Per Day Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment Including Standard Tpn
Formula (Lipids Specialty Amino
Acid Formulas Drugs Other Than
In Standard Formula And Nursing
Visits Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9367
Home Infusion Therapy Total
Parenteral Nutrition (Tpn); More
Than Two Liters But No More Than
Three Liters Per Day
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
Including Standard Tpn Formula
(Lipids Specialty Amino Acid
Formulas Drugs Other Than In
Standard Formula And Nursing
Visits Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) S9368
Home Infusion Therapy Total
Parenteral Nutrition (Tpn); More
Than Three Liters Per Day
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
Including Standard Tpn Formula
(Lipids Specialty Amino Acid
Formulas Drugs Other Than In
Standard Formula And Nursing
Visits Coded Separately) Per Diem
MCG
MED201.011
Clinical Guidelines
Nutritional Support_
Home Infusion Therapy (HIT) 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
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 21/41
Home Infusion Therapy (HIT) 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 Use This Code For Flushing
Of Infusion Devices With Heparin
To Maintain Patency)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9373
Home Infusion Therapy Hydration
Therapy; Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem (Do Not Use
With Hydration Therapy Codes
S9374-S9377 Using Daily Volume
Scales)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9374
Home Infusion Therapy Hydration
Therapy; One Liter Per Day
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9375
Home Infusion Therapy Hydration
Therapy; More Than One Liter But
No More Than Two Liters Per Day
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9376
Home Infusion Therapy Hydration
Therapy; More Than Two Liters But
No More Than Three Liters Per Day
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9377
Home Infusion Therapy Hydration
Therapy; More Than Three Liters
Per Day Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies (Drugs And
Nursing Visits Coded Separately)
Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9379
Home Infusion Therapy Infusion
Therapy Not Otherwise Classified;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9490
Home Infusion Therapy
Corticosteroid Infusion;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 22/41
Home Infusion Therapy (HIT) S9494
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal Therapy;
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 Home Infusion
Codes For Hourly Dosing Schedules
S9497-S9504)
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9497
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal Therapy;
Once Every 3 Hours;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9500
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal Therapy;
Once Every 24 Hours;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9501
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal Therapy;
Once Every 12 Hours;
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9502
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal Therapy;
Once Every 8 Hours Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9503
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal; Once
Every 6 Hours; Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9504
Home Infusion Therapy Antibiotic
Antiviral Or Antifungal; Once
Every 4 Hours; Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9529
Routine Venipuncture For
Collection Of Specimen(S) Single
Home Bound Nursing Home Or
Skilled Nursing Facility Patient
MCG Clinical Guidelines _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 23/41
Home Infusion Therapy (HIT) 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) Per Diem
MCG
RX501.069
Clinical Guidelines
Erythropoiesis-Stimulating Agents (ESAs)_
Home Infusion Therapy (HIT) S9538
Home Transfusion Of Blood
Product(S); Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Blood Products Drugs And
Nursing Visits Coded Separately)
Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9542
Home Injectable Therapy Not
Otherwise Classified Including
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) S9558
Home Injectable Therapy; Growth
Hormone Including Administrative
Services Professional Pharmacy
Services Care Coordination And
All Necessary Supplies And
Equipment (Drugs And Nursing
Visits Coded Separately) Per Diem
MCG
RX501.040
Clinical Guidelines
Human Growth Hormone (GH)
Orthognathic Surgery
_
Home Infusion Therapy (HIT) S9559
Home Injectable Therapy
Interferon Including
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG Clinical Guidelines _
Home Infusion Therapy (HIT) 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
MCG
RX501.041
Clinical Guidelines
Gonadotropin-Releasing Hormone (GnRH) Agonists
and Antagonists
_
Home Infusion Therapy (HIT) S9562
Home Injectable Therapy
Palivizumab Including
Administrative Services
Professional Pharmacy Services
Care Coordination And All
Necessary Supplies And Equipment
(Drugs And Nursing Visits Coded
Separately) Per Diem
MCG
RX504.009
Clinical Guidelines
Respiratory Syncytial Virus (RSV)
Immunoprophylaxis
_
Home Infusion Therapy (HIT) 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
Separately) Per Diem
MCG Clinical Guidelines _
Molecular Genetic Lab Testing 81120 Idh1 Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81121 Idh2 Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81162 Brca1&2 Gen Full Seq Dup/Del AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81163 Brca1&2 Gene Full Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81164 Brca1&2 Gen Ful Dup/Del Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81165 Brca1 Gene Full Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 24/41
Molecular Genetic Lab Testing 81166 Brca1 Gene Full Dup/Del Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81167 Brca2 Gene Full Dup/Del Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81168 Ccnd1/Igh Translocation Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81170Abl1 Gene Analysis Kinase Domain
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81171Aff2 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81172Aff2 Gene Analysis
Characterization Of AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81173 Ar Gene Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81174 Ar Gene Known Famil Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81175Asxl1 Gene Analysis Full Gene
SequenceAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81176Asxl1 Gene Analysis Targeted Seq
AnalysisAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81177Atn1 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81178Atxn1 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81179Atxn2 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81180Atxn3 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81181Atxn7 Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81182Atxn8Os Gene Analysis Eval Detect
Abnor AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81183Atxn10 Gene Analysis Eval Detc
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81184Cacna1A Gene Analysis Eval Detect
Abnor AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81185 Cacna1A Gene Full Gene Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81186 Cacna1A Gen Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81187Cnbp Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81188Cstb Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81189 Cstb Gene Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81190 Cstb Gene Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81191 Ntrk1 Translocation Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81192 Ntrk2 Translocation Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81193 Ntrk3 Translocation Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81194 Ntrk Translocation Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81200Aspa Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81201 Apc Gene Full Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81202 Apc Gene Known Fam Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81203 Apc Gene Dup/Delet Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81204Ar Gene Analysis Characterization
Of AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81205Bckdhb Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81208Bcr/Abl1 Other Breakpnt
Qualitative/QuantitativeAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81209Blm Gene Analysis 2281Del6Ins7
VariantAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81210 Braf Gene Analysis V600 Variant(S) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81212 Brca1&2 185&5385&6174 Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81215 Brca1 Gene Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81216 Brca2 Gene Full Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81217 Brca2 Gene Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81218Cebpa Gene Analysis Full Gene
SequenceAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81219Calr Gene Analysis Common
Variants In Exon 8AIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81221 Cftr Gene Known Fam Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81222 Cftr Gene Dup/Delet Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 25/41
Molecular Genetic Lab Testing 81223 Cftr Gene Full Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81224Cftr Gene Analysis Intron 8 Poly-T
AnalysisAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81225 Cyp2C19 Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81226 Cyp2D6 Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81227 Cyp2C9 Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81228 Cytogen Micrarray Copy Nmbr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81229 Cytogen M Array Copy No&Snp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81230 Cyp3A4 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81231 Cyp3A5 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81232 Dpyd Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81233Btk Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81234Dmpk Gene Analysis Eval Detect
Abnormal AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81235Egfr Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81236Ezh2 Gene Analysis Full Gene
SequenceAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81237Ezh2 Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81238 F9 Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81239Dmpk Gene Analysis
Characterization Of AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81240F2 Gene Analysis 20210G >A
VariantAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81242Fancc Gene Analysis Common
VariantAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81244Fmr1 Gene Analysis
Characterization Of AllelesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81245Flt3 Gene Analysis Internal Tandem
Dup VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81246Flt3 Gene Anlys Tyrosine Kinase
Domain VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81247G6Pd Gene Analysis Common
VariantsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 81248 G6Pd Known Familial Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81249 G6Pd Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81252 Gjb2 Gene Full Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81253 Gjb2 Gene Known Fam Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81254Gjb6 Gene Analysis Common
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Molecular Genetic Lab Testing 81256Hfe Hemochromatosis Gene Anal
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Molecular Genetic Lab Testing 81257 Hba1/Hba2 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81258 Hba1/Hba2 Gene Fam Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81259 Hba1/Hba2 Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81261Igh@ Rearrange Abnormal Clonal
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Molecular Genetic Lab Testing 81262Igh@ Rearrange Abnormal Clonal
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Molecular Genetic Lab Testing 81263Igh@ Variable Region Somatic
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Molecular Genetic Lab Testing 81264Igh@ Variable Region Somatic
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Molecular Genetic Lab Testing 81265Comparative Anal Str Markers
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Molecular Genetic Lab Testing 81266Comparative Anal Str Markers Ea
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Molecular Genetic Lab Testing 81269 Hba1/Hba2 Gene Dup/Del Vrnts AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81270Jak2 Gene Analysis P.Val617Phe
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Molecular Genetic Lab Testing 81271Htt Gene Analysis Detect Abnormal
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 26/41
Molecular Genetic Lab Testing 81272Kit Gene Analysis Targeted
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Molecular Genetic Lab Testing 81273 Kit Gene Analysis D816 Variant(S) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81274Htt Gene Analysis Characterization
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Molecular Genetic Lab Testing 81275Kras Gene Analysis Variants In Exon
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Molecular Genetic Lab Testing 81276Kras Gene Analysis Additional
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Molecular Genetic Lab Testing 81277 Cytogenomic Neo Microra Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81278 Igh@/Bcl2 Translocation Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81279 Jak2 Gene Trgt Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81283 Ifnl3 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81284Fxn Gene Analysis Eval Detect
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Molecular Genetic Lab Testing 81285Fxn Gene Analysis Characterization
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Molecular Genetic Lab Testing 81286 Fxn Gene Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81288Mlh1 Gene Analysis Promoter
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Molecular Genetic Lab Testing 81289 Fxn Gene Known Famil Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81291 Mthfr Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81292 Mlh1 Gene Full Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81293 Mlh1 Gene Known Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81294 Mlh1 Gene Dup/Delete Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81295 Msh2 Gene Full Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81296 Msh2 Gene Known Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81297 Msh2 Gene Dup/Delete Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81298 Msh6 Gene Full Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81299 Msh6 Gene Known Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81300 Msh6 Gene Dup/Delete Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81301Microsatellite Instab Anal
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Molecular Genetic Lab Testing 81302 Mecp2 Gene Full Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81303 Mecp2 Gene Known Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81304 Mecp2 Gene Dup/Delet Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81305Myd88 Gene Analysis P.Leu265
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Molecular Genetic Lab Testing 81306 Nudt15 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81307 Palb2 Gene Full Gene Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81308 Palb2 Gene Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81309Pik3Ca Gene Analysis Targeted
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Molecular Genetic Lab Testing 81310Npm1 Nucleophosmin Gene Anal
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Molecular Genetic Lab Testing 81311Nras Gene Analysis Variants In
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Molecular Genetic Lab Testing 81312Pabpn1 Gene Analysis Eval Detc
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Molecular Genetic Lab Testing 81313 Pca3/Klk3 Antigen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81314Pdgfra Gene Analys Targeted
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Molecular Genetic Lab Testing 81315Pml/Raralpha Common
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Molecular Genetic Lab Testing 81316Pml/Raralpha Single Breakpoint
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Molecular Genetic Lab Testing 81317 Pms2 Gene Full Seq Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81318 Pms2 Known Familial Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81319 Pms2 Gene Dup/Delet Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 27/41
Molecular Genetic Lab Testing 81320Plcg2 Gene Analysis Common
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Molecular Genetic Lab Testing 81321 Pten Gene Full Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81322 Pten Gene Known Fam Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81323 Pten Gene Dup/Delet Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81324Pmp22 Gene Anal
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Molecular Genetic Lab Testing 81325 Pmp22 Gene Full Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81326 Pmp22 Gene Known Fam Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81327 Sept9 Gen Prmtr Mthyltn Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81328 Slco1B1 Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81330Smpd1 Gene Analysis Common
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Molecular Genetic Lab Testing 81331 Snrpn/Ube3A Methylation Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81332Serpina1 Gene Analysis Common
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Molecular Genetic Lab Testing 81333Tgfbi Gene Analysis Common
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Molecular Genetic Lab Testing 81334Runx1 Gene Analysis Targeted
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Molecular Genetic Lab Testing 81335 Tpmt Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81336 Smn1 Gene Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81337 Smn1 Gen Nown Famil Seq Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81338 Mpl Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81339 Mpl Gene Seq Alys Exon 10 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81340Trb@ Rearrangement Anal
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Molecular Genetic Lab Testing 81341Trb@ Rearrangement Anal Direct
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Molecular Genetic Lab Testing 81342 Trg@ Gene Rearrangement Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81343Ppp2R2B Gene Analysis Eval Detc
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Molecular Genetic Lab Testing 81344Tbp Gene Analysis Eval Detect
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Molecular Genetic Lab Testing 81345Tert Gene Analysis Targeted
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Call 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81346 Tyms Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81347 Sf3B1 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81348 Srsf2 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81350 Ugt1A1 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81351 Tp53 Gene Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81352 Tp53 Gene Trgt Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81353 Tp53 Gene Known Famil Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81355 Vkorc1 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81357 U2Af1 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81360 Zrsr2 Gene Common Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81361 Hbb Gene Com Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81362 Hbb Gene Known Fam Variant AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81363 Hbb Gene Dup/Del Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81364 Hbb Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81400 Mopath Procedure Level 1 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81401 Mopath Procedure Level 2 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81402 Mopath Procedure Level 3 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81403 Mopath Procedure Level 4 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81404 Mopath Procedure Level 5 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81405 Mopath Procedure Level 6 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 28/41
Molecular Genetic Lab Testing 81406 Mopath Procedure Level 7 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81407 Mopath Procedure Level 8 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81408 Mopath Procedure Level 9 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81410 Aortic Dysfunction/Dilation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81411 Aortic Dysfunction/Dilation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81412 Ashkenazi Jewish Assoc Dis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81413 Car Ion Chnnlpath Inc 10 Gns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81414 Car Ion Chnnlpath Inc 2 Gns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81415 Exome Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81416 Exome Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81417 Exome Re-Evaluation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81419 Epilepsy Gen Seq Alys Panel AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81422 Fetal Chrmoml Microdeltj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81425 Genome Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81426 Genome Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81427 Genome Re-Evaluation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81430 Hearing Loss Sequence Analys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81431 Hearing Loss Dup/Del Analys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81432 Hrdtry Brst Ca-Rlatd Dsordrs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81433 Hrdtry Brst Ca-Rlatd Dsordrs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81434 Hereditary Retinal Disorders AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81435 Hereditary Colon Ca Dsordrs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81436 Hereditary Colon Ca Dsordrs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81437 Heredtry Nurondcrn Tum Dsrdr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81438 Heredtry Nurondcrn Tum Dsrdr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81439 Hrdtry Cardmypy Gene Panel AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81440 Mitochondrial Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81442 Noonan Spectrum Disorders AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81443 Genetic Tstg Severe Inh Cond AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81445 Targeted Genomic Seq Analys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81448 Hrdtry Perph Neurphy Panel AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81450 Targeted Genomic Seq Analys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81460 Whole Mitochondrial Genome AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81465 Whole Mitochondrial Genome AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81470 X-Linked Intellectual Dblt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81471 X-Linked Intellectual Dblt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81479 Unlisted Molecular Pathology AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81490 Autoimmune Rheumatoid Arthr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81493 Cor Artery Disease Mrna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81500 Onco (Ovar) Two Proteins AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81503 Onco (Ovar) Five Proteins AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81504 Oncology Tissue Of Origin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81518 Onc Brst Mrna 11 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 29/41
Molecular Genetic Lab Testing 81520 Onc Breast Mrna 58 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81521 Onc Breast Mrna 70 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81522 Onc Breast Mrna 12 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81525 Oncology Colon Mrna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81529 Onc Cutan Mlnma Mrna 31 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81535 Oncology Gynecologic AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Molecular Genetic Lab Testing 81538 Oncology Lung AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Retire effective
03/31/2021
Molecular Genetic Lab Testing 81540 Oncology Tum Unknown Origin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81541 Onc Prostate Mrna 46 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81542 Onc Prostate Mrna 22 Cnt Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81545 Oncology Thyroid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retired effective
01/01/2021
Molecular Genetic Lab Testing 81546Onc Thyr Mrna 10,196 Genes Fine
Ndl Aspirate AlgAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81551 Onc Prostate 3 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81552 Onc Uveal Mlnma Mrna 15 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81554 Pulm Ds Ipf Mrna 190 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81595 Cardiology Hrt Trnspl Mrna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 81596 Nfct Ds Chrnc Hcv 6 Assays AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 81599 Unlisted Maaa AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 84999 Clinical Chemistry Test AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0001U Rbc Dna Hea 35 Ag 11 Bld Grp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0002M Liver Dis 10 Assays W/Ash AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0003M Liver Dis 10 Assays W/Nash AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0004M Scoliosis Dna Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0005U Onco Prst8 3 Gene Ur Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0006M Onc Hep Gene Risk Classifier AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0007M Onc Gastro 51 Gene Nomogram AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0011M Onc Prst8 Ca Mrna 12 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0012M Onc Mrna 5 Gen Rsk Urthl Ca AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0012U Germln Do Gene Reargmt Detcj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0013M Onc Mrna 5 Gen Recr Urthl Ca AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0013U Onc Sld Org Neo Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0014U Hem Hmtlmf Neo Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0016M Onc Bladder Mrna 209 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0016UOnc Hmtlmf Neo Rna Bcr/Abl1
Bld/Bne MarrowAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0017M Onc Dlbcl Mrna 20 Genes Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 07/01/2021
Molecular Genetic Lab Testing 0017UOnc Hmtlmf Neo Jak2 Mutation
Dna Bld/Bne MarrowAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0018U Onc Thyr 10 Microrna Seq Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0019U Onc Rna Tiss Predict Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0022U Trgt Gen Seq Dna&Rna 23 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0023UOnc Aml Dna Gntyp Int Tandem
Dup Detcj/NondetcjAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0026U Onc Thyr Dna&Mrna 112 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0027UJak2 Gene Analysis Trgt Seq Alys
Exons 12-14AIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0029U Rx Metab Advrs Trgt Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 30/41
Molecular Genetic Lab Testing 0030U Rx Metab Warf Trgt Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0031U Cyp1A2 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0032U Comt Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0033U Htr2A Htr2C Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0034U Tpmt Nudt15 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0036U Xome Tum & Nml Spec Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0037U Trgt Gen Seq Dna 324 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0040UBcr/Abl1 Gene Tlcj Alys Major Bp
QuantitativeAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0045U Onc Brst Dux Carc Is 12 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0046UFlt3 Gene Int Tandem Dupl
Variants QuantitativeAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0047U Onc Prst8 Mrna 17 Gene Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0048U Onc Sld Org Neo Dna 468 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0049U Npm1 Gene Analysis Quantitative AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0050U Trgt Gen Seq Dna 194 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0053U Onc Prst8 Ca Fish Alys 4 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0055U Card Hrt Trnspl 96 Dna Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0056U Hem Aml Dna Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0060U Twn Zyg Gen Seq Alys Chrms2 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0067U Onc Brst Imhchem Prfl 4 Bmrk AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0069U Onc Clrct Microrna Mir-31-3P AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0070U Cyp2D6 Gen Com&Slct Rar Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0071U Cyp2D6 Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0072U Cyp2D6 Gen Cyp2D6-2D7 Hybrid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0073U Cyp2D6 Gen Cyp2D7-2D6 Hybrid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0074U Cyp2D6 Nonduplicated Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0075U Cyp2D6 5' Gene Dup/Mlt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0076U Cyp2D6 3' Gene Dup/Mlt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0078U Pain Mgt Opi Use Gnotyp Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0079U Cmprtv Dna Alys Mlt Snps AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0084U Rbc Dna Gnotyp 10 Bld Groups AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
03/31/2021
Molecular Genetic Lab Testing 0087U Crd Hrt Trnspl Mrna 1283 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0088U Trnsplj Kdn Algrft Rej 1494 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0089U Onc Mlnma Prame & Linc00518 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0090U Onc Cutan Mlnma Mrna 23 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0094U Genome Rapid Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0101U Hered Colon Ca Do 15 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0102U Hered Brst Ca Rltd Do 17 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0103U Hered Ova Ca Pnl 24 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0104U Hered Pan Ca Pnl 32 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retired effective
01/01/2021
Molecular Genetic Lab Testing 0111U Onc Colon Ca Kras&Nras Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0113U Onc Prst8 Pca3&Tmprss2-Erg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0114U Gi Barretts Esoph Vim&Ccna1 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0118U Trnsplj Don-Drv Cll-Fr Dna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0120U Onc B Cll Lymphm Mrna 58 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0129U Hered Brst Ca Rltd Do Panel AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 31/41
Molecular Genetic Lab Testing 0130U Hered Colon Ca Do Mrna Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0131U Hered Brst Ca Rltd Do Pnl 13 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0132U Hered Ova Ca Rltd Do Pnl 17 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0133U Hered Prst8 Ca Rltd Do 11 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0134U Hered Pan Ca Mrna Pnl 18 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0135U Hered Gyn Ca Mrna Pnl 12 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0136U Atm Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0137U Palb2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0138U Brca1 Brca2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0153U Onc Breast Mrna 101 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0154UOnc Urothelial Cancer Rna Rt-Pcr
Fgfr3 Gene AlysAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0155UOnc Brst Ca Dna Pik3Ca Gene Alys
Brst Tum TissAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing 0156U Copy Number Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0157U Apc Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0158U Mlh1 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0159U Msh2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0160U Msh6 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0161U Pms2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0162U Hered Colon Ca Trgt Mrna Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0169U Nudt15&Tpmt Gene Com Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0170U Neuro Asd Rna Next Gen Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0171U Trgt Gen Seq Alys Pnl Dna 23 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0203U Ai Ibd Mrna Xprsn Prfl 17 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0204U Onc Thyr Mrna Xprsn Alys 593 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0205U Oph Amd Alys 3 Gene Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0208U Onc Mtc Mrna Xprsn Alys 108 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0209U Cytog Const Alys Interrog AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0211U Onc Pan-Tum Dna&Rna Gnrj Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0212U Rare Ds Gen Dna Alys Proband AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0213U Rare Ds Gen Dna Alys Ea Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0214U Rare Ds Xom Dna Alys Proband AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0215U Rare Ds Xom Dna Alys Ea Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0216U Neuro Inh Ataxia Dna 12 Com AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0217U Neuro Inh Ataxia Dna 51 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0218U Neuro Musc Dys Dmd Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0228U Onc Prst8 Ma Molec Prfl Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0229U Bcat1 Promoter Mthyltn Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0230U Ar Full Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0231U Cacna1A Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0232U Cstb Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0233U Fxn Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0234U Mecp2 Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0235U Pten Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0236U Smn1&Smn2 Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0237U Car Ion Chnlpthy Gen Seq Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 32/41
Molecular Genetic Lab Testing 0238U Onc Lnch Syn Gen Dna Seq Aly AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0239U Trgt Gen Seq Alys Pnl 311+ AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing 0242U Trgt Gen Seq Alys Pnl 55-74 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 10/01/2021
Molecular Genetic Lab Testing 0244U Onc Solid Orgn Dna 257 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 10/01/2021
Molecular Genetic Lab Testing 0245U Onc Thyr Mut Alys 10 Gen&37 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 10/01/2021
Molecular Genetic Lab Testing G9143
Warfarin Responsiveness Testing
By Genetic Technique Using Any
Method Any Number Of
Specimen(S)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing G9840
Ras (Kras And Nras) Gene Mutation
Testing Performed Before Initiation
Of Anti-Egfr Moab
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
07/01/2021
Molecular Genetic Lab Testing G9841
Ras (Kras And Nras) Gene Mutation
Testing Not Performed Before
Initiation Of Anti-Egfr Moab
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com
Retire effective
07/01/2021
Molecular Genetic Lab Testing S3800Genetic Testing For Amyotrophic
Lateral Sclerosis (Als)AIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3840
Dna Analysis For Germline
Mutations Of The Ret Proto-
Oncogene For Susceptibility To
Multiple Endocrine Neoplasia Type
2
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3841 Genetic Testing For Retinoblastoma AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3842Genetic Testing For Von Hippel-
Lindau DiseaseAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3844
Dna Analysis Of The Connexin 26
Gene (Gjb2) For Susceptibility To
Congenital Profound Deafness
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3845Genetic Testing For Alpha-
ThalassemiaAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3846Genetic Testing For Hemoglobin E
Beta-ThalassemiaAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3849Genetic Testing For Niemann-Pick
DiseaseAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing S3850Genetic Testing For Sickle Cell
AnemiaAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3852
Dna Analysis For Apoe Epsilon 4
Allele For Susceptibility To
Alzheimer'S Disease
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3853Genetic Testing For Myotonic
Muscular DystrophyAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Molecular Genetic Lab Testing S3854
Gene Expression Profiling Panel For
Use In The Management Of Breast
Cancer Treatment
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3861
Genetic Testing Sodium Channel
Voltage-Gated Type V Alpha
Subunit (Scn5A) And Variants For
Suspected Brugada Syndrome
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3865
Comprehensive Gene Sequence
Analysis For Hypertrophic
Cardiomyopathy
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3866
Genetic Analysis For A Specific
Gene Mutation For Hypertrophic
Cardiomyopathy (Hcm) In An
Individual With A Known Hcm
Mutation In The Family
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Molecular Genetic Lab Testing S3870
Comparative Genomic
Hybridization (Cgh) Microarray
Testing For Developmental Delay
Autism Spectrum Disorder And/Or
Intellectual Disability
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Non Emergent Air Ambulance: Fixed Wing and Rotary A0430
Ambulance Service Conventional
Air Services Transport One Way
(Fixed Wing)
ADM1001.005 Ambulance and Medical Transport Services _
Non Emergent Air Ambulance: Fixed Wing and Rotary A0431
Ambulance Service Conventional
Air Services Transport One Way
(Rotary Wing)
ADM1001.005 Ambulance and Medical Transport Services _
Non Emergent Air Ambulance: Fixed Wing and Rotary A0435Fixed Wing Air Mileage Per Statute
MileADM1001.005 Ambulance and Medical Transport Services _
Non Emergent Air Ambulance: Fixed Wing and Rotary A0436Rotary Wing Air Mileage Per
Statute MileADM1001.005 Ambulance and Medical Transport Services _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 33/41
Orthopedic Procedures-Artificial Intervertebral Disc 22856 Cerv Artific Diskectomy SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22857 Lumbar Artif Diskectomy SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22858 Second Level Cer Diskectomy SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22861 Revise Cerv Artific Disc SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22862 Revise Lumbar Artif Disc SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22864 Remove Cerv Artif Disc SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 22865 Remove Lumb Artif Disc SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 0095T Rmvl Artific Disc Addl Crvcl SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 0098T Rev Artific Disc Addl SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 0163T Lumb Artif Diskectomy Addl SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 0164T Remove Lumb Artif Disc Addl SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Artificial Intervertebral Disc 0165T Revise Lumb Artif Disc Addl SUR712.028 Artificial Intervertebral Disc _
Orthopedic Procedures-Lumbar Spinal Fusion 20930 Sp Bone Algrft Morsel Add-On SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 20931 Sp Bone Algrft Struct Add-On SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 20936 Sp Bone Agrft Local Add-On SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 20937 Sp Bone Agrft Morsel Add-On SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 20938 Sp Bone Agrft Struct Add-On SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22533 Lat Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22534 Lat Thor/Lumb Addl Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22558 Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22585 Additional Spinal Fusion SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22612 Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22614 Spine Fusion Extra Segment SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22630 Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22632 Spine Fusion Extra Segment SUR712.036 Lumbar Spinal Fusion _
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 34/41
Orthopedic Procedures-Lumbar Spinal Fusion 22633 Lumbar Spine Fusion Combined SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22634 Spine Fusion Extra Segment SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22800 Post Fusion </6 Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22802 Post Fusion 7-12 Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22804 Post Fusion 13/> Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22808 Ant Fusion 2-3 Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22810 Ant Fusion 4-7 Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22812 Ant Fusion 8/> Vert Seg SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22840 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22841 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22842 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22843 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22844 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22845 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22846 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22847 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22848 Insert Pelv Fixation Device SUR712.036 Lumbar Spinal Fusion _
Orthopedic Procedures-Lumbar Spinal Fusion 22853 Insj Biomechanical DeviceSUR712.040
SUR712.036
Interspinous Fixation (Fusion) Devices
Lumbar Spinal Fusion_
Orthopedic Procedures-Lumbar Spinal Fusion 22854 Insj Biomechanical DeviceSUR712.040
SUR712.036
Interspinous Fixation (Fusion) Devices
Lumbar Spinal Fusion_
Orthopedic Procedures-Lumbar Spinal Fusion 22859 Insj Biomechanical DeviceSUR712.040
SUR712.036
Interspinous Fixation (Fusion) Devices
Lumbar Spinal Fusion_
Orthopedic Prodecures - Functional Neuromuscular
Electrical Stimulation (FNMES)/Percutaneous and Implanted
Nerve Stimulation and Neuromodulation
A4595Electrical Stimulator Supplies 2
Lead Per Month (E. G. Tens Nmes)
MED201.033
MED205.032
Functional Neuromuscular Electrical Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
Retire effective 4/30/2021
Orthopedic Prodecures - Functional Neuromuscular
Electrical Stimulation (FNMES)/Percutaneous and Implanted
Nerve Stimulation and Neuromodulation
E0760Osteogenesis Stimulator Low
Intensity Ultrasound Non-InvasiveMED201.033 Functional Neuromuscular Electrical Stimulation
Retire effective
04/30/2021
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 35/41
Pain Management - Spinal Cord Stimulation 63650 Implant Neuroelectrodes SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63655 Implant Neuroelectrodes SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63661 Remove Spine Eltrd Perq Aray SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63662 Remove Spine Eltrd Plate SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63663 Revise Spine Eltrd Perq Aray SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63664 Revise Spine Eltrd Plate SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63685 Insrt/Redo Spine N Generator SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation 63688 Revise/Remove Neuroreceiver SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation C1822
Generator Neurostimulator
(Implantable) High Frequency
With Rechargeable Battery And
Charging System
SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8679
Implantable Neurostimulator
Pulse Generator Any Type
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8680
Implantable Neurostimulator
Electrode Each
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8685
Implantable Neurostimulator Pulse
Generator Single Array
Rechargeable Includes Extension
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8686
Implantable Neurostimulator Pulse
Generator Single Array Non-
Rechargeable Includes Extension
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8687
Implantable Neurostimulator Pulse
Generator Dual Array
Rechargeable Includes Extension
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Pain Management - Spinal Cord Stimulation/Percutaneuos
& Implanted Nerve Stimulation and NeuromodulationL8688
Implantable Neurostimulator Pulse
Generator Dual Array Non-
Rechargeable Includes Extension
SUR712.009
MED205.032
Spinal Cord Stimulation (SCS) and Dorsal Root
Ganglion (DRG) Stimulation
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation
_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64555 Implant Neuroelectrodes MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64575 Implant Neuroelectrodes MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64580 Implant Neuroelectrodes MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64585 Revise/Remove Neuroelectrode MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64590 Insrt/Redo Pn/Gastr Stimul MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64595 Revise/Rmv Pn/Gastr Stimul MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation64999 Nervous System Surgery MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation95970 Alys Npgt W/O Prgrmg MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation95971 Alys Smpl Sp/Pn Npgt W/Prgrm MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
Neuromodulation95972 Alys Cplx Sp/Pn Npgt W/Prgrm MED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
NeuromodulationL8681
Patient Programmer (External) For
Use With Implantable
Programmable Neurostimulator
Pulse Generator Replacement Only
MED205.032Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 36/41
Percutaneous and Implanted Nerve Stimulation and
NeuromodulationL8682
Implantable Neurostimulator
Radiofrequency ReceiverMED205.032
Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
NeuromodulationL8683
Radiofrequency Transmitter
(External) For Use With
Implantable Neurostimulator
Radiofrequency Receiver
MED205.032Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
NeuromodulationL8689
External Recharging System For
Battery (Internal) For Use With
Implantable Neurostimulator
Replacement Only
MED205.032Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Percutaneous and Implanted Nerve Stimulation and
NeuromodulationL8695
External Recharging System For
Battery (External) For Use With
Implantable Neurostimulator
Replacement Only
MED205.032Percutaneous and Implanted Nerve Stimulation
and Neuromodulation_
Radiation Therapy 19294Prep Tumor Cavity Iort W/Partial
MastectomyAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 19296Plmt Expandable Cath Brst
Following Prtl MastAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 19297Plmt Expandable Cath Brst
Concurrent Prtl MastAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 19298Plmt Radthx Brachytx Brst
Following Prtl MastAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 20555Placement Needles Muscle
Subsequent RadioelementAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 31643Brnchsc W/Plmt Cath Intrcv
Radioelmnt ApplAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 32701Thorax Stereotactic Radiation
Target W/Tx CourseAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 41019Placement Needle Head/Neck
Radioelement ApplicatAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 43499 Unlisted Procedure Esophagus AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 47999 Unlisted Procedure Biliary Tract AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 55860Expos Prostate Any Approach Insj
Radioact SubstAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55862Expos Prostate Insj Radioact Sbst
W/Lymph BxAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55865Expos Prostate Insj Radioac Sbst
W/Bi Pelv LymphAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55874Transperineal Plmt Biodegradable
Matrl 1/Mlt NjxAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55875Transperineal Plmt Ndl/Caths
Prostate Radj InsjAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55899Unlisted Procedure Male Genital
SystemAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 55920Placement Needle Pelvic Organ
Radioelement ApplAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 57155Insertion Uterine
Tandem&/Vaginal OvoidsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 57156 Insertion Vaginal Radiation Device AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 58346Insertion Heyman Capsules Clinical
BrachytherapyAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 61796Stereotactic Radiosurgery 1 Simple
Cranial LesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 61797Strtctc Radiosurgery Ea Addl
Cranial Les SimpleAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 61798Stereotactic Radiosurgery 1
Complex Cranial LesAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 61799Strtctc Radiosurgery Ea Addl
Cranial Les ComplexAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 61800Appl Strtctc Headframe
Stereotactic RadiosurgeryAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 63620Stereotactic Radiosurgery 1 Spinal
LesionAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 63621Stereotactic Radiosurgery Ea Addl
Spinal LesionAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 67218Dstrj Lesion Retina 1/> Sess Radj
ImpltjAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 76873Us Transrct Prstate Vol Brachytx
Plnning SpxAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 76965Us Guidance Interstitial
Radioelment ApplicationAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 77014 Ct Scan For Therapy Guide AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 772953-D Radiotherapy Plan Dose-
Volume HistogramsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 77301Ntsty Modul Radthx Pln Dose-Vol
HistosAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 77316Brachytx Isodose Pln Smpl
W/Dosimetry CalAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 77317Brachytx Isodose Pln Intermed
W/Dosimetry CalAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 77318Brachytx Isodose Pln Cplx
W/Dosimetry CalAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 77338 Design Mlc Device For Imrt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77370 Spec Medical Radj Physics Consltj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 37/41
Radiation Therapy 77371 Srs Multisource AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77372 Srs Linear Based AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77373 Sbrt Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77385 Ntsty Modul Rad Tx Dlvr Smpl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77386 Ntsty Modul Rad Tx Dlvr Cplx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77387 Guidance For Radj Tx Dlvr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77402 Radiation Treatment Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77407 Radiation Treatment Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77412 Radiation Treatment Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy 77424 Io Rad Tx Delivery By X-Ray AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77425 Io Rad Tx Deliver By Elctrns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77432Steretctc Radiation Tx
Management Cranial LesionAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 77435Stereotactic Body Radiation
ManagementAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 77469Intraoperative Radiation Treatment
ManagementAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy 77470 Special Treatment Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77520 Proton Trmt Simple W/O Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77522 Proton Trmt Simple W/Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77523 Proton Trmt Intermediate AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77525 Proton Treatment Complex AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77750 Infuse Radioactive Materials AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77761 Apply Intrcav Radiat Simple AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77762 Apply Intrcav Radiat Interm AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77763 Apply Intrcav Radiat Compl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77767 Hdr Rdncl Skn Surf Brachytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77768 Hdr Rdncl Skn Surf Brachytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77770 Hdr Rdncl Ntrstl/Icav Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77771 Hdr Rdncl Ntrstl/Icav Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77772 Hdr Rdncl Ntrstl/Icav Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77778 Apply Interstit Radiat Compl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 77790Supervision Handling Loading
Radiation SourceAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy 79005 Nuclear Rx Oral Admin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 79101 Nuclear Rx Iv Admin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 79403 Hematopoietic Nuclear Tx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 0394T Hdr Elctrnc Skn Surf Brchytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy 0395T Hdr Elctr Ntrst/Ntrcv Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy A9508Iodine I-131 Iobenguane Sulfate,
Diagnostic, Per 0.5 MillicurieAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy A9513Lutetium Lu 177 Dotatate
Therapeutic 1 MillicurieAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy A9528
Iodine I-131 Sodium Iodide
Capsule(S), Diagnostic, Per
Millicurie
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy A9531
Iodine I-131 Sodium Iodide,
Diagnostic, Per Microcurie (Up To
100 Microcuries)
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy A9543
Yttrium Y-90 Ibritumomab
Tiuxetan Therapeutic Per
Treatment Dose Up To 40
Millicuries
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
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Radiation Therapy A9590Iodine I-131, Iobenguane, 1
MillicurieAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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Radiation Therapy A9600Strontium Sr-89 Chloride,
Therapeutic, Per MillicurieAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
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November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 38/41
Radiation Therapy A9604
Samarium Sm-153 Lexidronam,
Therapeutic, Per Treatment Dose,
Up To 150 Millicuries
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy A9606Radium Ra-223 Dichloride,
Therapeutic, Per MicrocurieAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G0339
Image-Guided Robotic Linear
Accelerator-Based Stereotactic
Radiosurgery Complete Course Of
Therapy In One Session Or First
Session Of Fractionated Treatment
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G0340
Image-Guided Robotic Linear
Accelerator-Based Stereotactic
Radiosurgery Delivery Including
Collimator Changes And Custom
Plugging Fractionated Treatment
All Lesions Per Session Second
Through Fifth Sessions Maximum
Five Sessions Per Course Of
Treatment
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G0458
Low Dose Rate (Ldr) Prostate
Brachytherapy Services, Composite
Rate
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy G6001Ultrasonic Guidance For Placement
Of Radiation Therapy FieldsAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6002
Stereoscopic X-Ray Guidance For
Localization Of Target Volume For
The Delivery Of Radiation Therapy
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6003
Radiation Treatment Delivery
Single Treatment Area Single Port
Or Parallel Opposed Ports Simple
Blocks Or No Blocks: Up To 5Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6004
Radiation Treatment Delivery
Single Treatment Area Single Port
Or Parallel Opposed Ports Simple
Blocks Or No Blocks: 6-10Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6005
Radiation Treatment Delivery
Single Treatment Area Single Port
Or Parallel Opposed Ports Simple
Blocks Or No Blocks: 11-19Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6006
Radiation Treatment Delivery
Single Treatment Area Single Port
Or Parallel Opposed Ports Simple
Blocks Or No Blocks: 20Mev Or
Greater
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6007
Radiation Treatment Delivery 2
Separate Treatment Areas 3 Or
More Ports On A Single Treatment
Area Use Of Multiple Blocks: Up
To 5Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6008
Radiation Treatment Delivery 2
Separate Treatment Areas 3 Or
More Ports On A Single Treatment
Area Use Of Multiple Blocks: 6-
10Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6009
Radiation Treatment Delivery 2
Separate Treatment Areas 3 Or
More Ports On A Single Treatment
Area Use Of Multiple Blocks: 11-
19Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6010
Radiation Treatment Delivery 2
Separate Treatment Areas 3 Or
More Ports On A Single Treatment
Area Use Of Multiple Blocks: 20
Mev Or Greater
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6011
Radiation Treatment Delivery 3 Or
More Separate Treatment Areas
Custom Blocking Tangential Ports
Wedges Rotational Beam
Compensators Electron Beam; Up
To 5Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6012
Radiation Treatment Delivery 3 Or
More Separate Treatment Areas
Custom Blocking Tangential Ports
Wedges Rotational Beam
Compensators Electron Beam; 6-
10Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 39/41
Radiation Therapy G6013
Radiation Treatment Delivery 3 Or
More Separate Treatment Areas
Custom Blocking Tangential Ports
Wedges Rotational Beam
Compensators Electron Beam; 11-
19Mev
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6014
Radiation Treatment Delivery 3 Or
More Separate Treatment Areas
Custom Blocking Tangential Ports
Wedges Rotational Beam
Compensators Electron Beam;
20Mev Or Greater
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6015
Intensity Modulated Treatment
Delivery Single Or Multiple
Fields/Arcs Via Narrow Spatially
And Temporally Modulated Beams
Binary Dynamic Mlc Per
Treatment Session
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6016
Compensator-Based Beam
Modulation Treatment Delivery Of
Inverse Planned Treatment Using 3
Or More High Resolution (Milled
Or Cast) Compensator Convergent
Beam Modulated Fields Per
Treatment Session
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy G6017
Intra-Fraction Localization And
Tracking Of Target Or Patient
Motion During Delivery Of
Radiation Therapy (Eg 3D
Positional Tracking Gating 3D
Surface Tracking) Each Fraction Of
Treatment
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.com_
Radiation Therapy Q3001Radioelements For Brachytherapy,
Any Type, EachAIM Clinical Guidelines
Call 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Radiation Therapy S8030
Scleral Application Of Tantalum
Ring(S) For Localization Of Lesions
For Proton Beam Therapy
AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website
https://aimspecialtyhealth.comAdd effective 04/01/2021
Sleep Study: Facility based polysomnography/pap titration 95807 Sleep Study Attended MED204.005Diagnosis and Medical Management of Obstructive
Sleep Apnea Syndrome_
Sleep Study: Facility based polysomnography/pap titration 95808 Polysom Any Age 1-3> ParamMED204.005
MED201.049
Diagnosis and Medical Management of Obstructive
Sleep Apnea Syndrome
Polysomnography for Non-Respiratory Sleep
Disorders
_
Sleep Study: Facility based polysomnography/pap titration 95810 Polysom 6/> Yrs 4/> ParamMED204.005
MED201.049
Diagnosis and Medical Management of Obstructive
Sleep Apnea Syndrome
Polysomnography for Non-Respiratory Sleep
Disorders
_
Sleep Study: Facility based polysomnography/pap titration 95811 Polysom 6/>Yrs Cpap 4/> ParmMED204.005
MED201.049
Diagnosis and Medical Management of Obstructive
Sleep Apnea Syndrome
Polysomnography for Non-Respiratory Sleep
Disorders
_
Transplant Evaluations and Transplants 32851 Lung Transplant Single SUR703.010 Lung and Lobar Lung Transplant _
Transplant Evaluations and Transplants 32852 Lung Transplant With Bypass SUR703.010 Lung and Lobar Lung Transplant _
Transplant Evaluations and Transplants 32853 Lung Transplant Double SUR703.010 Lung and Lobar Lung Transplant _
Transplant Evaluations and Transplants 32854 Lung Transplant With Bypass SUR703.010 Lung and Lobar Lung Transplant _
Transplant Evaluations and Transplants 33935 Transplantation Heart/Lung SUR703.006 Heart/Lung Transplant _
Transplant Evaluations and Transplants 33945 Transplantation Of Heart SUR703.005 Heart Transplant _
Transplant Evaluations and Transplants 38204 Bl Donor Search Management _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38205 Harvest Allogeneic Stem Cell _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38206 Harvest Auto Stem Cells _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38207 Cryopreserve Stem Cells _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38208 Thaw Preserved Stem Cells _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38209 Wash Harvest Stem Cells _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38210 T-Cell Depletion Of Harvest _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38211 Tumor Cell Deplete Of Harvst _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38212 Rbc Depletion Of Harvest _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38213 Platelet Deplete Of Harvest _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38214 Volume Deplete Of Harvest _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38215 Harvest Stem Cell Concentrte _Refer to applicable Hematopoietic Cell
Transplantation policies_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 40/41
Transplant Evaluations and Transplants 38230 Bone Marrow Harvest Allogen _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38232 Bone Marrow Harvest Autolog _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38240 Transplt Allo Hct/Donor _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38241 Transplt Autol Hct/Donor _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38242 Transplt Allo Lymphocytes _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 38243 Transplj Hematopoietic Boost _Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants 44135 Intestine Transplnt CadaverSUR703.014
SUR703.009
Isolated Small Bowel Transplant
Small Bowel/Liver and Multivisceral Transplant _
Transplant Evaluations and Transplants 44136 Intestine Transplant LiveSUR703.014
SUR703.009
Isolated Small Bowel Transplant
Small Bowel/Liver and Multivisceral Transplant _
Transplant Evaluations and Transplants 47135 Transplantation Of LiverSUR703.014
SUR703.009
Isolated Small Bowel Transplant
Small Bowel/Liver and Multivisceral Transplant _
Transplant Evaluations and Transplants 48160 Pancreas Removal/Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants 48554 Transpl Allograft Pancreas SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants 50360 Transplantation Of Kidney #REF!
Kidney Transplant
Liver Transplant and Combined Liver-Kidney
Transplant
Pancreas and Related Organ Tissue Transplantation
_
Transplant Evaluations and Transplants 50365 Transplantation Of Kidney #REF!
Kidney Transplant
Liver Transplant and Combined Liver-Kidney
Transplant
Pancreas and Related Organ Tissue
Transplantation
_
Transplant Evaluations and Transplants 50380 Reimplantation Of KidneySUR703.008
SUR703.013
Liver Transplant and Combined Liver-Kidney
Transplant
Pancreas and Related Organ Tissue
Transplantation
_
Transplant Evaluations and Transplants 0584T Perq Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants 0585T Laps Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants 0586T Open Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants G0341
Percutaneous Islet Cell Transplant,
Includes Portal Vein
Catheterization And Infusion
SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants G0342
Laparoscopy For Islet Cell
Transplant, Includes Portal Vein
Catheterization And Infusion
SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants G0343
Laparotomy For Islet Cell
Transplant, Includes Portal Vein
Catheterization And Infusion
SUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants S2053Transplantation Of Small Intestine
And Liver AllograftsSUR703.009 Small Bowel/Liver and Multivisceral Transplant _
Transplant Evaluations and Transplants S2054Transplantation Of Multivisceral
Organs
SUR703.013
SUR703.009
Pancreas and Related Organ Tissue Transplantation
Small Bowel/Liver and Multivisceral Transplant_
Transplant Evaluations and Transplants S2060 Lobar Lung Transplantation SUR703.010 Lung and Lobar Lung Transplant _
Transplant Evaluations and Transplants S2065Simultaneous Pancreas Kidney
TransplantationSUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants S2102Islet Cell Tissue Transplant From
Pancreas; AllogeneicSUR703.013 Pancreas and Related Organ Tissue Transplantation _
Transplant Evaluations and Transplants S2140Cord Blood Harvesting For
Transplantation, Allogeneic_
Refer to applicable Hematopoietic Cell
Transplantation policies_
Transplant Evaluations and Transplants S2142Cord Blood-Derived Stem-Cell
Transplantation, Allogeneic_
Refer to applicable Hematopoietic Cell
Transplantation policies_
November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 41/41