Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure...

36
Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description 0058T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T CRYOPRESERVATION REPRODUCTIVE TISSUE OVARIAN 0075T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL 0076T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TCAT PLMT XTRC VRT CRTD STENT RS&IPRQ EA VSL 0184T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RECTAL TUMOR EXCISION TRANSANAL ENDOSCOPIC 0191T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT 0275T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PERC LAMINO-/LAMINECTOMY INDIR IMAG GUIDE LUMBAR 0295T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY RCRD SCAN ANLYS REP R&I 0296T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY RCRD W/CONECT INTL RCRD 0297T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY SCAN ANALYSIS W/REPORT 0298T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY REVIEW AND INTERPRETATN 0308T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ OC TLSCP PROSTH RMVL CRYSTALLINE/IO LENS 0342T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T THERAPEUTIC APHERESIS W/SELECTIVE HDL DELIP 0345T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSCATH MITRAL VALVE REPAIR VIA CORONARY SINUS 0347T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PLACE INTERSTITIAL DEVICE(S) IN BONE FOR RSA 0348T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS SPINE EXAM 0349T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS UPPER EXTREMITY EXAM 0350T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS LOWER EXTREMITY EXAM 0351T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTRAOP OCT BREAST OR AXILL NODE EACH SPECIMEN 0352T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT BREAST OR AXILL NODE SPECIMEN I&R 0353T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT OF BREAST SURG CAVITY REAL TIME INTRAOP 0354T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT BREAST SURG CAVITY REAL TIME/REFERRED I&R 0355T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T GI TRACT IMAGING INTRALUMINAL COLON WITH I&R 0356T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSERT DRUG IMPLANT INTO LACRIMAL CANAL FOR IOP 0358T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T BIA WHOLE BODY COMPOSITION ASSESSMENT W/I&R 0362T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME 0373T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME 0376T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ANT SEGMENT INSERT DRAIN W/O RESERVOIR EA ADDL 0378T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T VISUAL FIELD ASSESSMENT PHYS REVIEW AND REPORT 0379T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T VISUAL FIELD ASSESSMENT TECH SUPPORT W/INSTRUCT 0394T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T HDR ELECTRONIC BRACHYTHERAPY SKIN SURFACE 0395T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T HDR ELECTRONIC BRACHYTHERAPY NTRSTL/INTRCAV 0396T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTRAOP KINETIC BALANCE SENSR KNEE RPLCMT ARTHRP 0397T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ERCP WITH OPTICAL ENDOMICROSCOPY ADD ON 0398T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MRGFUS STEREOTACTIC ABLATION LESION INTRACRANIAL 0400T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 1-5 LES 0401T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 6+ LES 0402T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T COLLAGEN CROSS-LINKING OF CORNEA MED SEPARATE 0403T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DIABETES PREVENTION PROG STANDARDIZED CURRICULUM 0404T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSCERVICAL UTERINE FIBROID ABLTJ W/US GDN RF 0405T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OVERSIGHT CARE OF XTRCORP LIVER ASSIST SYS PAT 0408T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CAR MODULJ SYS PLS GEN TRANSVNS ELTRD 0409T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CARDIAC MODULJ SYS PLS GENERATOR ONLY 0410T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CARDIAC MODULJ SYS ATR ELECTRODE ONLY 0411T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CAR MODULJ SYS VENTR ELECTRODE ONLY 0412T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL CARDIAC MODULJ SYS PLS GENERATOR ONLY 0413T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE 0414T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RMVL & RPL CARDIAC MODULJ SYS PLS GENERATOR ONLY 0415T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REPOS CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE 0416T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RELOC SKIN POCKET CARDIAC MODULJ PULSE GENERATOR 0417T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PRGRMG DEVICE EVALUATION CARDIAC MODULJ SYSTEM 0418T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTERRO DEVICE EVALUATION CARDIAC MODULJ SYSTEM 0419T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DSTRJ NEUROFIBROMAS XTNSV FACE HEAD NECK >50 0420T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DSTRJ NEUROFIBROMAS XTNSV TRNK EXTREMITIES >100 0421T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSURETHRAL WATERJET ABLATION PROSTATE COMPL 0422T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TACTILE BREAST IMG COMPUTER-AIDED SENSORS UNI/BI 0423T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T SECRETORY TYPE II PHOSPHOLIPASE A2 (SPLA2-IIA) 0424T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA COMPLETE 0425T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA SENSING LEAD 0426T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA STIMJ LEAD

Transcript of Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure...

Page 1: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Prior Authorization : Procedure Specific Listing (Q1 2020)Code Category SubCategory Group Effective date Notes Description0058T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T CRYOPRESERVATION REPRODUCTIVE TISSUE OVARIAN0075T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL0076T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TCAT PLMT XTRC VRT CRTD STENT RS&IPRQ EA VSL0184T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RECTAL TUMOR EXCISION TRANSANAL ENDOSCOPIC0191T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT0275T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PERC LAMINO-/LAMINECTOMY INDIR IMAG GUIDE LUMBAR0295T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY RCRD SCAN ANLYS REP R&I0296T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY RCRD W/CONECT INTL RCRD0297T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY SCAN ANALYSIS W/REPORT0298T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T EXT ECG > 48HR TO 21 DAY REVIEW AND INTERPRETATN0308T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ OC TLSCP PROSTH RMVL CRYSTALLINE/IO LENS0342T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T THERAPEUTIC APHERESIS W/SELECTIVE HDL DELIP0345T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSCATH MITRAL VALVE REPAIR VIA CORONARY SINUS0347T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PLACE INTERSTITIAL DEVICE(S) IN BONE FOR RSA0348T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS SPINE EXAM0349T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS UPPER EXTREMITY EXAM0350T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RADIOSTEREOMETRIC ANALYSIS LOWER EXTREMITY EXAM0351T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTRAOP OCT BREAST OR AXILL NODE EACH SPECIMEN0352T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT BREAST OR AXILL NODE SPECIMEN I&R0353T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT OF BREAST SURG CAVITY REAL TIME INTRAOP0354T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OCT BREAST SURG CAVITY REAL TIME/REFERRED I&R0355T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T GI TRACT IMAGING INTRALUMINAL COLON WITH I&R0356T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSERT DRUG IMPLANT INTO LACRIMAL CANAL FOR IOP0358T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T BIA WHOLE BODY COMPOSITION ASSESSMENT W/I&R0362T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T BEHAVIOR ID SUPPORT ASSMT EA 15 MIN TECH TIME0373T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ADAPT BHV TX PRTCL MODIFICAJ EA 15 MIN TECH TIME0376T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ANT SEGMENT INSERT DRAIN W/O RESERVOIR EA ADDL0378T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T VISUAL FIELD ASSESSMENT PHYS REVIEW AND REPORT0379T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T VISUAL FIELD ASSESSMENT TECH SUPPORT W/INSTRUCT0394T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T HDR ELECTRONIC BRACHYTHERAPY SKIN SURFACE0395T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T HDR ELECTRONIC BRACHYTHERAPY NTRSTL/INTRCAV0396T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTRAOP KINETIC BALANCE SENSR KNEE RPLCMT ARTHRP0397T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T ERCP WITH OPTICAL ENDOMICROSCOPY ADD ON0398T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MRGFUS STEREOTACTIC ABLATION LESION INTRACRANIAL0400T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 1-5 LES0401T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T MULTI-SPECTRAL DIGITAL SKIN LES ANALYSIS 6+ LES0402T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T COLLAGEN CROSS-LINKING OF CORNEA MED SEPARATE0403T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DIABETES PREVENTION PROG STANDARDIZED CURRICULUM0404T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSCERVICAL UTERINE FIBROID ABLTJ W/US GDN RF0405T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T OVERSIGHT CARE OF XTRCORP LIVER ASSIST SYS PAT0408T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CAR MODULJ SYS PLS GEN TRANSVNS ELTRD0409T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CARDIAC MODULJ SYS PLS GENERATOR ONLY0410T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CARDIAC MODULJ SYS ATR ELECTRODE ONLY0411T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC CAR MODULJ SYS VENTR ELECTRODE ONLY0412T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL CARDIAC MODULJ SYS PLS GENERATOR ONLY0413T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE0414T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RMVL & RPL CARDIAC MODULJ SYS PLS GENERATOR ONLY0415T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REPOS CARDIAC MODULJ SYS TRANSVENOUS ELECTRODE0416T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RELOC SKIN POCKET CARDIAC MODULJ PULSE GENERATOR0417T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PRGRMG DEVICE EVALUATION CARDIAC MODULJ SYSTEM0418T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTERRO DEVICE EVALUATION CARDIAC MODULJ SYSTEM0419T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DSTRJ NEUROFIBROMAS XTNSV FACE HEAD NECK >500420T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T DSTRJ NEUROFIBROMAS XTNSV TRNK EXTREMITIES >1000421T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TRANSURETHRAL WATERJET ABLATION PROSTATE COMPL0422T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T TACTILE BREAST IMG COMPUTER-AIDED SENSORS UNI/BI0423T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T SECRETORY TYPE II PHOSPHOLIPASE A2 (SPLA2-IIA)0424T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA COMPLETE0425T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA SENSING LEAD0426T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA STIMJ LEAD

Page 2: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description0427T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INSJ/RPLC NSTIM SYSTEM SLEEP APNEA PLS GENERATOR0428T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL NSTIM SYSTEM SLEEP APNEA PLS GENERATOR0429T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL NSTIM SYSTEM SLEEP APNEA SENSING LEAD0430T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REMOVAL NSTIM SYSTEM SLEEP APNEA STIMJ LEAD0431T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T RMVL/RPLC NSTIM SYSTEM SLEEP APNEA PLS GENERATOR0432T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REPOS NSTIM SYSTEM SLEEP APNEA STIMJ LEAD0433T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T REPOS NSTIM SYSTEM SLEEP APNEA SENSING LEAD0434T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T INTERRO DEV EVAL NSTIM PLS GEN SYS SLEEP APNEA0435T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PRGRMG EVAL NSTIM PLS GEN SYS SLEEP APNEA 1 SESS0436T PROFESSIONAL CPT Category III Category III-Except 0359T-0361T, 0364T-0370T PRGRMG EVAL NSTIM PLS GEN SYS SLEEP APNEA STUDY0439T PROFESSIONAL CPT Category III Category III MYOCARDIAL PERFUSION ECHO ISCHM/VIABILITY ASSMT0440T PROFESSIONAL CPT Category III Category III ABLTJ PERC CRYOABLTJ IMG GDN UXTR/PERPH NERVE0441T PROFESSIONAL CPT Category III Category III ABLTJ PERC CRYOABLTJ IMG GDN LXTR/PERPH NERVE0442T PROFESSIONAL CPT Category III Category III ABLTJ PERC CRYOABLTJ IMG GDN NRV PLEX/TRNCL NRV0443T PROFESSIONAL CPT Category III Category III R-T SPCTRL ALYS PRST8 TISS FLUORESCENC SPCTRSCPY0444T PROFESSIONAL CPT Category III Category III INITIAL PLMT DRUG ELUTING OCULAR INSERT UNI/BI0445T PROFESSIONAL CPT Category III Category III SBSQ PLMT DRUG ELUTING OCULAR INSERT UNI/BI0449T PROFESSIONAL CPT Category III Category III INSJ AQUEOUS DRAIN DEV W/O EO RSVR INITIAL DEV0450T PROFESSIONAL CPT Category III Category III INSJ AQUEOUS DRAIN DEV W/O EO RSVR EACH ADDL DEV0451T PROFESSIONAL CPT Category III Category III INSJ/RPLCMT IMPLTBL AORTIC VENTR COMPLETE SYSTEM0452T PROFESSIONAL CPT Category III Category III INSJ/RPLCMT IMPLTBL AORTIC VENTR VASC HEMO SEAL0453T PROFESSIONAL CPT Category III Category III INSJ/RPLCMT IMPLTBL AORTIC VENTR MECHANO-ELEC0454T PROFESSIONAL CPT Category III Category III INSJ/RPLCMT IMPLTBL AORTIC VENTR SUBQ ELECTRODE0455T PROFESSIONAL CPT Category III Category III REMVL PERM IMPLT AORTIC VENTR COMPLETE SYSTEM0456T PROFESSIONAL CPT Category III Category III REMVL PERM IMPLT AORTIC VENTR VASC HEMO SEAL0457T PROFESSIONAL CPT Category III Category III REMVL PERM IMPLT AORTIC VENTR MECHANO-ELEC0458T PROFESSIONAL CPT Category III Category III REMVL PERM IMPLT AORTIC VENTR SUBQ ELECTRODE0459T PROFESSIONAL CPT Category III Category III RELOCAJ RPLCMT AORTIC VENTR MECHANO-ELECTRODE0460T PROFESSIONAL CPT Category III Category III REPOS AORTIC VENTR DEV SUBCUTANEOUS ELECTRODE0461T PROFESSIONAL CPT Category III Category III REPOS AORTIC VENTR DEV SUBQ ELECT CONTRPULSJ DEV0462T PROFESSIONAL CPT Category III Category III PRGRMG EVAL MECH-ELEC AORTIC VENTR SYS PER DAY0463T PROFESSIONAL CPT Category III Category III INTERROG EVAL IMPLT AORTIC VENTR SYS PER DAY0464T PROFESSIONAL CPT Category III Category III VISUAL EP TESTING FOR GLAUCOMA W/INTERPJ & REPRT0465T PROFESSIONAL CPT Category III Category III SUPCHRDL NJX OF RX AGT W/O SUPPLY OF MEDICATION0466T PROFESSIONAL CPT Category III Category III INSRT CH WALL RESPIR ELTRD & CONJ PULSE GEN0467T PROFESSIONAL CPT Category III Category III REVJ/RPLMNT CH WAL RESPIR ELTRD & CONJ PULSE GEN0468T PROFESSIONAL CPT Category III Category III REMOVAL CHEST WALL RESPIRATORY ELTRODE/ARRAY0487T PROFESSIONAL CPT Category III Category III TRANSVAGINAL BIOMECHANICAL MAPPING W/REPORT0489T PROFESSIONAL CPT Category III Category III AUTOL REGN CELL TX SCLERODERMA HANDS0490T PROFESSIONAL CPT Category III Category III AUTOL REGN CELL TX SCLDR MLT INJ 1/> HANDS0491T PROFESSIONAL CPT Category III Category III ABL LASER TX OPEN WND PR DAY 1ST 20 SQCM/<0492T PROFESSIONAL CPT Category III Category III ABL LASER TX OPEN WND PR DAY ADDL 20 SQCM0493T PROFESSIONAL CPT Category III Category III NEAR INFRARED SPECTROSCPY STUDIES LOW EXT WOUNDS0510T PROFESSIONAL CPT Category III Category III REMOVAL OF SINUS TARSI IMPLANT0511T PROFESSIONAL CPT Category III Category III REMOVAL AND REINSERTION OF SINUS TARSI IMPLANT0512T PROFESSIONAL CPT Category III Category III ESW INTEGUMENTARY WOUND HEALING INITIAL WOUND0513T PROFESSIONAL CPT Category III Category III ESW INTEGUMENTARY WOUND HEALING EA ADDL WOUND0514T PROFESSIONAL CPT Category III Category III INTRAOPERATIVE VISUAL AXIS ID USING PT FIXATION0515T PROFESSIONAL CPT Category III Category III INSERTION WRLS CAR STIMULATOR LV PACG COMPL SYS0516T PROFESSIONAL CPT Category III Category III INSERTION WRLS CAR STIMULATOR LV PACG ELTRD ONLY0517T PROFESSIONAL CPT Category III Category III INSERTION WRLS CAR STIMULATOR LV PACG PG COMPNT0518T PROFESSIONAL CPT Category III Category III REMOVAL PG COMPNT ONLY WRLS CAR STIMULATOR0519T PROFESSIONAL CPT Category III Category III REMOVAL&RPLCMT WRLS CAR STIMULATOR PG COMPNT0520T PROFESSIONAL CPT Category III Category III REMOVAL&RPLCMT WRLS CAR STIMULATOR W/NEW ELTRD0521T PROFESSIONAL CPT Category III Category III INTERROG DEV EVAL WRLS CAR STIMULATOR IN PERSON0522T PROFESSIONAL CPT Category III Category III PRGRMG DEVICE EVAL WRLS CAR STIMULATOR IN PERSON0523T PROFESSIONAL CPT Category III Category III INTRAPROCEDURAL CORONARY FFP W/3D FUNCJL MAPPING0524T PROFESSIONAL CPT Category III Category III EV CATHETER DIR CHEM ABLTJ INCMPTNT XTR VEIN0525T PROFESSIONAL CPT Category III Category III INSERTION/REPLACEMENT COMPLETE IIMS0526T PROFESSIONAL CPT Category III Category III INSERTION/REPLACEMENT IIMS ELECTRODE ONLY0527T PROFESSIONAL CPT Category III Category III INSERTION/REPLACEMENT IIMS IMPLANTABLE MNTR ONLY

Page 3: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description0528T PROFESSIONAL CPT Category III Category III PRGRMG DEVICE EVAL IIMS IN PERSON0529T PROFESSIONAL CPT Category III Category III INTERROGATION DEVICE EVAL IIMS IN PERSON0530T PROFESSIONAL CPT Category III Category III REMOVAL COMPLETE IIMS INCL IMG S&I0531T PROFESSIONAL CPT Category III Category III REMOVAL IIMS ELECTRODE ONLY INCL IMG S&I0532T PROFESSIONAL CPT Category III Category III REMOVAL IIMS IMPLANTABLE MNTR ONLY INCL IMG S&I0533T PROFESSIONAL CPT Category III Category III CONTINUOUS REC MVMT DO SX 6 D<10 D0534T PROFESSIONAL CPT Category III Category III CONT REC MVMT DO SX 6 D<10 D SETUP & PT TRAINJ0535T PROFESSIONAL CPT Category III Category III CONT REC MVMT DO SX 6 D<10 D 1ST REPRT CNFIG0536T PROFESSIONAL CPT Category III Category III CONT REC MVMT DO SX 6 D<10 D DL REVIEW I&R0537T PROFESSIONAL CPT Category III Category III CAR-T THERAPY HRVG BLD DRV T LMPHCYT PR DAY0538T PROFESSIONAL CPT Category III Category III CAR-T THERAPY PREPJ BLD DRV T LMPHCYT F/TRNS0539T PROFESSIONAL CPT Category III Category III CAR-T THERAPY RECEIPT & PREP CAR-T CELLS F/ADMN0540T PROFESSIONAL CPT Category III Category III CAR-T THERAPY AUTOLOGOUS CELL ADMINISTRATION0541T PROFESSIONAL CPT Category III Category III MYOCARDIAL IMG BY MCG DETCJ CARDIAC ISCHEMIA0542T PROFESSIONAL CPT Category III Category III MYOCARDIAL IMG BY MCG DETCJ CARDIAC ISCHEMIA I&R0563T PROFESSIONAL CPT Category III Category III 3/6/2020 EVACUATION MEIBOMIAN GLANDS USING HEAT BILATERAL0564T PROFESSIONAL CPT Category III Category III 3/6/2020 ONC CHEMO RX CYTOTOXICITY ASSAY CSC MIN 14 DRUGS0565T PROFESSIONAL CPT Category III Category III 3/6/2020 AUTOL CELL IMPLT ADPS TISS HRVG CELL IMPLT CRTJ0566T PROFESSIONAL CPT Category III Category III 3/6/2020 AUTOL CELL IMPLT ADPS TISS NJX IMPLT KNEE UNI0567T PROFESSIONAL CPT Category III Category III 3/6/2020 PERM FLP TUB OCCLS W/IMPLANT TRANSCRV APPROACH0568T PROFESSIONAL CPT Category III Category III 3/6/2020 INTRO MIX SALINE&AIR F/SSG CONF OCCLS FLP TUBE0569T PROFESSIONAL CPT Category III Category III 3/6/2020 TTVR PERCUTANEOUS APPROACH INITIAL PROSTHESIS0570T PROFESSIONAL CPT Category III Category III 3/6/2020 TTVR PERCUTANEOUS APPROACH EACH ADDL PROSTHESIS0571T PROFESSIONAL CPT Category III Category III 3/6/2020 INSJ/RPLCMT ICDS W/SUBSTERNAL ELECTRODE0572T PROFESSIONAL CPT Category III Category III 3/6/2020 INSJ SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELTRD0573T PROFESSIONAL CPT Category III Category III 3/6/2020 RMVL SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELTRD0574T PROFESSIONAL CPT Category III Category III 3/6/2020 REPOS PREV IMPL SS IMPLTBL DFB PACING ELTRD0575T PROFESSIONAL CPT Category III Category III 3/6/2020 PROGRAMMING DEV EVAL ICDS W/SS ELTRD IN PERSON0576T PROFESSIONAL CPT Category III Category III 3/6/2020 INTERROGATION DEV EVAL ICDS W/SS ELTRD IN PERSON0577T PROFESSIONAL CPT Category III Category III 3/6/2020 ELECTROPHYSIOLOGICAL EVAL ICDS W/SS ELECTRODE0578T PROFESSIONAL CPT Category III Category III 3/6/2020 REM INTERROG DEV EVAL SS LD ICDS <90D PHY/QHP0579T PROFESSIONAL CPT Category III Category III 3/6/2020 REM INTERROG DEV EVAL SS LD ICDS < 90D TECH0581T PROFESSIONAL CPT Category III Category III 3/6/2020 ABLATION MAL BRST TUMOR PERQ CRTX UNILATERAL0582T PROFESSIONAL CPT Category III Category III 3/6/2020 TRURL ABLTJ MAL PRST8 TISS HI ENERGY WATER VAPOR0583T PROFESSIONAL CPT Category III Category III 3/6/2020 TYMPANOSTOMY AUTOMATED TUBE DELIVERY SYSTEM0584T PROFESSIONAL CPT Category III Category III 3/6/2020 PERCUTANEOUS ISLET CELL TRANSPLANT0585T PROFESSIONAL CPT Category III Category III 3/6/2020 LAPAROSCOPIC ISLET CELL TRANSPLANT0586T PROFESSIONAL CPT Category III Category III 3/6/2020 OPEN ISLET CELL TRANSPLANT0587T PROFESSIONAL CPT Category III Category III 3/6/2020 PERCUTANEOUS IMPLANTATION/REPLACEMENT ISDNS PTN0588T PROFESSIONAL CPT Category III Category III 3/6/2020 REVISION OR REMOVAL ISDNS POSTERIOR TIBIAL NRV0589T PROFESSIONAL CPT Category III Category III 3/6/2020 ELEC ALYS SMPL PRGRMG IINS PTN 1-3 PARAMETERS0590T PROFESSIONAL CPT Category III Category III 3/6/2020 ELEC ALYS CPLX PRGRMG IINS PTN 4+ PARAMETERS0591T PROFESSIONAL CPT Category III Category III 3/6/2020 HEALTH & WELL-BEING COACHING F2F INDIV 1ST ASSMT0592T PROFESSIONAL CPT Category III Category III 3/6/2020 HEALTH & WELL-BEING COACHING F2F INDIV F-UP SESS0593T PROFESSIONAL CPT Category III Category III 3/6/2020 HEALTH & WELL-BEING COACHING FACE TO FACE GROUP99458 CPT CODES EVALUATION AND MANAGEMENT Other Evaluation and Management Services 3/6/2020 REMOTE PHYSIOLOGIC MONITORING EA ADDL 20 MIN MOA0430 HCPCS HCPCS - A CODES (AMBULANCE/TRANSPORTATION) Ambulance-Emergent AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAYA0431 HCPCS HCPCS - A CODES (AMBULANCE/TRANSPORTATION) Ambulance-Emergent AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAYA0435 HCPCS HCPCS - A CODES (AMBULANCE/TRANSPORTATION) Ambulance-Emergent FIXED WING AIR MILEAGE PER STATUTE MILEA0436 HCPCS HCPCS - A CODES (AMBULANCE/TRANSPORTATION) Ambulance-Emergent ROTARY WING AIR MILEAGE PER STATUTE MILEA4459 HCPCS HCPCS - A CODES (SUPPLIES) Med/Surg-Misc Supplies MANUAL PUMP-OPERATED ENEMA SYS REUSABLE ANY TYPEA5500 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY FIT CSTM PREP&SPL SHOE MX DNSITY INSRTA5501 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY FIT CSTM PREP&SPL SHOE MOLD PTS FTA5503 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY MOD SHOE/CSTM MOLD ROLLER/ROCKR BOTTOMA5504 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/WEDGE SHOEA5505 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/MT BAR SHOEA5506 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/OFF SET HEELA5507 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY NOS MOD SHOE/CSTM MOLD SHOE PER SHOEA5508 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY DELUXE FEATURE SHOE/CSTM MOLD SHOEA5510 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIAB ONLY DIR FORM COMPRS MOLD PTS FT W/O HEATA5512 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications FOR DIAB ONLY MX DNSITY INSRT DIR FORMD PRFAB EA

Page 4: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionA5513 HCPCS HCPCS - A CODES (SUPPLIES) Diabetic Shoes, Fitting and Modifications DIA ONLY MX DEN INSRT CSTM FRM MDL PT FT CF EAA6501 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BURN GARMENT BODYSUIT CUSTOM FABRICATEDA6502 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRS BURN GARMENT CHIN STRAP CUSTOM FABRICATEDA6503 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BURN GARMENT FACIAL HOOD CUSTOM FABA6504 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRS BURN GARMENT GLOVE WRIST CUSTOM FABA6505 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BURN GARMENT GLOVE ELB CUSTOM FABRICATEDA6506 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRS BURN GARMENT GLOVE AXILLA CUSTOM FABA6507 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BURN GARMENT FT KNEE LENGTH CUSTOM FABA6508 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRS BURN GARMENT FT THIGH LENGTH CUSTOM FABA6509 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BRN GARMNT UP TRNK WAIST ARM OPENING CSTMA6510 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRS BRN GARMNT TRNK ARMS TO LEG OPENING CSTMA6511 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BRN GARMNT LW TRNK W/LEG OPENING CSTM FABA6512 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS COMPRESSION BURN GARMENT NOCA6513 HCPCS HCPCS - A CODES (SUPPLIES) Dressings COMPRS BRN MASK FCE & OR NCK PLSTC/EQUL CSTM FABA6549 HCPCS HCPCS - A CODES (SUPPLIES) DRESSINGS GRADIENT COMPRESSION STOCKING/SLEEVE NOSB4102 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) Enteral Formula and Supplies ENTRAL FORMULA ADLT REPL FLS&LYTES 500 ML = 1 UB4103 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) ENTERAL FORMULAE AND ENTERAL SUPPLIES ENTRAL FORMULA PED REPL FLS&LYTES 500 ML = 1 UB4149 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) Enteral Formula and Supplies ENTRAL F MANF BLNDRIZD NAT FOODS W/NUTRIENTSB4150 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) ENTERAL FORMULAE AND ENTERAL SUPPLIES ENTRAL F NUTRITIONALLY CMPL W/INTACT NUTRIENTSB4152 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) Enteral Formula and Supplies ENTRAL F NUTRITION CMPL CAL DENSE INTACT NUTRNTSB4153 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) ENTERAL FORMULAE AND ENTERAL SUPPLIES ENTRAL FORMULA NUTIONALLY CMPL HYDROLYZED PROTSB4154 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) Enteral Formula and Supplies ENTRAL F NUTRITION CMPL NO INHERITED DZ METABB4155 HCPCS HCPCS - B CODES (ENTERAL AND PARENTERAL THERAPY) ENTERAL FORMULAE AND ENTERAL SUPPLIES ENTRAL F NUTRITIONALLY INCMPL/MODULAR NUTRIENTSC2624 HCPCS HCPCS - C CODES (OUTPATIENT PPS) Outpatient PPS IMPL WIRELESS PULM ARTERY PRESS SENSOR DEL CATHE0181 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT PWR PRESSURE REDUCING MATTRESS OVERLY/PAD PUMPE0182 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Decubitus Care Equipment PUMP ALTERNATING PRESSURE PAD REPLACEMENT ONLYE0184 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT DRY PRESSURE MATTRESSE0185 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Decubitus Care Equipment GEL/GEL-LIKE PRSS PAD MATTRSS STD LEN&WDTHE0186 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT AIR PRESSURE MATTRESSE0187 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Decubitus Care Equipment WATER PRESSURE MATTRESSE0193 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT POWERED AIR FLOTATION BEDE0194 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Decubitus Care Equipment AIR FLUIDIZED BEDE0196 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT GEL PRESSURE MATTRESSE0197 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Decubitus Care Equipment AIR PRESS PAD MATTRSS STD MATTRSS LENGTH&WIDTHE0198 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) DECUBITUS CARE EQUIPMENT WATER PRESS PAD MATTRSS STD MATTRSS LENGTH&WIDTHE0203 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HEAT/COLD APPLICATION THERAPEUTIC LGHTBOX MINI 10000 LUX TABL TOP MDLE0217 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HEAT/COLD APPLICATION WATER CIRCULATING HEAT PAD WITH PUMPE0250 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSP BED FIX HT W/ANY TYPE SIDE RAILS W/MATTRSSE0251 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSP BED FIX HT W/ANY TYPE SIDE RAIL W/O MATTRSSE0255 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED VARIBL HT W/ANY TYPE SIDE RAIL W/MATTRSSE0256 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED VARIBL HT ANY TYPE SIDE RAIL W/O MATTRSSE0260 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED SEMI-ELEC W/ANY TYPE SIDE RAIL W/MATTRSSE0261 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED SEMI-ELEC ANY TYPE SIDE RAIL W/O MATTRSSE0265 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSP BED TOT ELEC W/ANY TYPE SIDE RAIL W/MATTRSSE0266 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED TOT ELEC ANY TYPE SIDE RAIL W/O MATTRSSE0277 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories POWERED PRESSURE-REDUCING AIR MATTRESSE0290 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSPITAL BED FIX HT WITHOUT SIDE RAILS W/MATTRSSE0291 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSPITAL BED FIX HT W/O SIDE RAILS W/O MATTRSSE0293 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED VARIBL HT HI-LO W/O SIDE RAIL NO MATTRSSE0294 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSPITAL BED SEMI-ELEC W/O SIDE RAILS W/MATTRSSE0295 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSP BED SEMI-ELEC W/O SIDE RAILS W/O MATTRSSE0296 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSPITAL BED TOTAL ELEC W/O SIDE RAILS W/MATTRSSE0297 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOSP BED TOTAL ELEC W/O SIDE RAILS W/O MATTRSSE0301 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES HOS BED HEVY DUTY XTRA WIDE W/WT CAPACTY>350 PDSE0302 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED XTRA HEVY DUTY WT CAP>600 PDS W/O MTTRSSE0303 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES HOS BED HEVY DUTY W/WT CAP >350 PDS</=TO 600 PDSE0304 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories HOS BED EXTRA HEAVY DUTY WT CAP>600 PDS MATTRSSE0316 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES SFTY ENCLOS FRME/CANOPY USE W/HOSP BED ANY TYPEE0329 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES HOSPITAL BED PEDIATRIC ELECTRIC INCLUDE MATTRESSE0371 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES NONPWR ADV PRSS RDUC OVRLAY MATTRSS STD LEN&WDTHE0372 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Hospital Beds and Accessories PWR AIR OVRLAY MATTRSS STD MATTRSS LENGTH&WIDTH

Page 5: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionE0373 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) HOSPITAL BEDS AND ACCESSORIES NONPOWERED ADVANCED PRESSURE REDUCING MATTRESSE0465 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment HOME VENTILATOR ANY TYPE USED W/INVASIVE INTFE0466 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment HOME VENTILATOR ANY TYPE USED W/NON-INVASV INTFE0470 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/O BACKUE0471 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OXYGEN AND RELATED RESPIRATORY EQUIP RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACK-UPE0472 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACKUPE0481 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment INTRAPULM PERCUSSIVE VENT SYSTEM&REL ACSSORIESE0482 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OXYGEN AND RELATED RESPIRATORY EQUIP COUGH STIM DEVICE ALTRNAT POS&NEG ARWAY PRESSE0483 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM EAE0484 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OXYGEN AND RELATED RESPIRATORY EQUIP OSCILLATORY POS EXPIRATORY PRSS DEVC NON-ELEC EAE0485 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Oxygen, Respiratory Equipment ORL DEVC/APPL RDUC UP ARWAY COLLAPSIBILITY PRFABE0486 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OXYGEN AND RELATED RESPIRATORY EQUIP ORL DEVC/APPL RDUC UP AIRWAY COLLAPSIBILITY CSTME0601 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Suction Pump/Room vaporizers CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICEE0621 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Patient Lifts SLING OR SEAT PATIENT LIFT CANVAS OR NYLONE0625 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS PATIENT LIFT BATHROOM OR TOILET NOCE0627 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS SEAT LIFT MECHANISM ELECTRIC ANY TYPEE0629 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS SEAT LIFT MECHANISM NON-ELECTRIC ANY TYPEE0630 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Patient Lifts PATIENT LIFT HYDRAULIC/MECH INCL SEAT SLING/PADE0635 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS PATIENT LIFT ELECTRIC WITH SEAT OR SLINGE0636 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Patient Lifts MX PSTN PT SUPP SYS INTGR LIFT PT ACSSIBLE CNTRLE0637 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS COMB SIT STAND FRAME/TABLE SYS SEATLIFT FEATUREE0638 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Patient Lifts STANDING FRAME/TABLE SYS ONE POSITION ANY SZE0639 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS PT LIFT MOVEABLE ROOM-ROOM W/DISASSMBL&REASSMBLE0640 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Patient Lifts PATIENT LIFT FIX SYS INCLUDES ALL CMPNTS/ACCESSE0641 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS STANDING FRAME/TABLE SYS MULTI-POSITION ANY SZE0642 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PATIENT LIFTS STANDING FRAME/TABLE SYS MOBILE DYNAMIC ANY SZE0650 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES PNEUMATIC COMPRESSOR NONSEGMENTAL HOME MODELE0651 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances PNEUMAT COMPRS SEG HOM MDL NO CALBRTD GRDNT PRSSE0652 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES PNEUMAT COMPRS SEG HOM MDL W/CALBRTD GRADNT PRSSE0655 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF ARME0656 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS TRUNKE0657 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS CHESTE0660 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL LEGE0665 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL ARME0666 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEGE0667 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL LEGE0668 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL ARME0669 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEGE0670 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEG PNEU APPLINC PNEU COMPRS IN 2 FULL LEGS TRNKE0671 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL LEGE0673 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances SEGMENTAL GRADENT PRESS PNEUMAT APPLINC HALF LEGE0675 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) PNEUMATIC COMPRESSOR AND APPLIANCES PNEUMAT COMPRS DEVC HI PRSS RAPID INFLATION/DEFLE0676 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Pnoumatic Compressor and Appliances INTERMITTENT LIMB COMPRESSION DEVICE NOSE0720 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit TENS DEVICE TWO LEAD LOCALIZED STIMULATIONE0730 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS TENS DEVICE 4/MORE LEADS MULTI NERVE STIMULATIONE0731 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit FORM-FITTING CONDUCTIVE GARMENT DELIV TENS/NMESE0744 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit NEUROMUSCULAR STIMULATOR FOR SCOLIOSISE0745 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS NEUROMUSCULAR STIMULATOR ELECTRONIC SHOCK UNITE0746 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit ELECTROMYOGRAPHY BIOFEEDBACK DEVICEE0747 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS OSTOGNS STIM ELEC NONINVASV OTH THAN SP APPLICE0748 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit OSTOGNS STIMULATOR ELEC NONINVASV SPINAL APPLICE0749 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS OSTEOGENESIS STIMULATOR ELEC SURGICALLY IMPLE0760 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS OSTOGNS STIM LOW INTENS ULTRASOUND NON-INVASVE0764 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit FUNC NEUROMUSC STIM MUSC AMBUL CMPT CNTRL SC INJE0769 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS Unit ESTIM/ELECTROMAGNETIC WOUND TREATMENT DEVC NOCE0770 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TENS FES TRANSQ STIM NERV&/MUSC GRP CMPL SYS NOSE0935 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) TRAPEZE EQUIPMENT CONTINUOUS PASSIVE MOT EXERCISE DEVC KNEE ONLYE0950 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WHEELCHAIR ACCESSORY TRAY EACHE0955 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACSS HEADREST CUSHNED FIX MOUNT HARDWARE EAE0956 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACSS LAT TRNK/HIP SUPP FIX MOUNT HARDWARE EAE0957 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACSS MED THI SUPP FIX MOUNT HARDWARE EA

Page 6: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionE0958 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES MANUAL WHLCHAIR ACCESS 1-ARM DRIVE ATTACHMENT EAE0966 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES MANUAL WHEELCHAIR ACCESS HEADREST EXTENSION EAE0967 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WHLCHR AC HND RIM PROJ ANY TYP REPL ONLY EAE0968 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES COMMODE SEAT WHEELCHAIRE0969 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories NARROWING DEVICE WHEELCHAIRE0970 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories NO 2 FOOTPLATES EXCEPT FOR ELEVATING LEGRESTE0974 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MANUAL WHEELCHAIR ACCESS ANTI-ROLLBACK DEVICE EAE0980 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SAFETY VEST WHEELCHAIRE0983 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WCE0984 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WCE0985 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WHEELCHAIR ACCESSORY SEAT LIFT MECHANISME0986 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WHEELCHAIR ACSS PUSH-RIM ACT PWR ASSIST SYSE0988 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MANUAL WC ACCESSORY LEVR-ACTIVATD WHL DRIVE PAIRE0994 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories ARMREST EACHE1002 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLYE1003 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACSS PWR SEAT SYS RECLINE W/O SHEAR RDUCE1004 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACSS PWR SEAT SYS RECLINE W/MECH SHEAR RDUCE1005 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACSS PWR SEAT SYS RECLINE W/PWR SHEAR RDUCE1006 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACSS PWR SEAT SYS TILT&RECLINE NO SHEAR RDUCE1007 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACSS PWR SEAT TILT&RECLINE MECH SHEAR RDUCE1008 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACSS PWR SEAT TILT&RECLINE W/PWR SHEAR RDUCE1009 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCSS ADD PWR SEAT MECH LINKD LEG ELEV SYS EAE1010 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACCSS ADD PWR SEAT SYS PWR LEG ELEV SYS PAIRE1011 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MOD PEDIATRIC SIZE WC WIDTH ADJUSTMENT PACKAGEE1012 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCSS PWR SEAT SYS CNTR MNT PWR ELEV LEG EAE1014 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories RECLIN BACK ADDITION PEDIATRIC SIZE WHEELCHAIRE1015 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES SHOCK ABSORBER FOR MANUAL WHEELCHAIR EACHE1016 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SHOCK ABSORBER FOR POWER WHEELCHAIR EACHE1017 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY MNL WC EAE1018 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY PWR WC EAE1028 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WC ACCSS MANL SWINGAWAY OTH CNTRL INTRFCE/PSTNE1029 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WHEELCHAIR ACCESSORY VENTILATOR TRAY FIXEDE1030 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORIES WHEELCHAIR ACCESSORY VENTILATOR TRAY GIMBALEDE1031 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Rollabout Chair ROLLABOUT CHAIR ANY&ALL TYPES W/CASTERS 5 IN/GTE1035 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) ROLLABOUT CHAIR MULTI-PSTN PT TRNSF SYS W/SEAT PT WT </= 300 LBSE1036 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) ROLLABOUT CHAIR MULTI-PSTN PT TRNSF SYS EXTRA WIDE PT >300 LBSE1039 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Rollabout Chair TRNSPRT CHAIR ADLT SZ HEVY DUTY PT WT CAP>300 LBE1050 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING FULL RECLIN WHLCHAIR; FIX FULL-LEN ARMS LEGRESTSE1060 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Fully Reclining FULL RECLIN WHLCHAIR; DTACHBLE ARMS LEGRESTSE1070 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING FULLY RECLIN WHLCHAIR; DTACHBLE ARMS FOOTRESTSE1083 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Fully Reclining HEMI-W/C; FIXED FULL-LEN ARMS DETACHBLE LEGRESTE1084 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HEMI-WHLCHAIR; DTACHBLE ARMS DESK/FULL LEGRESTSE1085 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HEMI-WHLCHAIR; FIX FULL ARMS DTACHBLE FOOTRESTSE1086 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HEMI-WHLCHAIR; DTACHBLE ARMS DESK/FULL FOOTRESTSE1087 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HI-STRGTH LGHTWT WHLCHAIR; FIX ARMS DTACH LEGRSTE1088 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Fully Reclining HI-STRGTH LGHTWT WHLCHAIR; DTACHBL ARMS LEGRESTSE1089 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HI-STRGTH LGHTWT WHLCHAIR; FIX ARM DTACH FOOTRSTE1090 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING HI-STRGTH LGHTWT WHLCHAIR; DTACHBL ARMS FOOTRESTE1092 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIRS - FULLY RECLINING WIDE HEVY-DUTY WHLCHAIR; DTACHBLE ARMS LEGRESTSE1093 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Fully Reclining WIDE HEVY-DUTY WHLCHAIR; DTACHBLE ARMS FOOTRESTSE1100 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SEMI-RECLINNING SEMI-RECLIN WHLCHAIR; FIX ARMS DTACHBLE LEGRESTSE1130 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - STANDARD STD WHLCHAIR; FIX FULL-LEN ARMS DTACHBL FOOTRSTSE1140 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - STANDARD WHLCHAIR; DTACHBLE ARMS DTACHBLE FOOTRESTSE1150 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - STANDARD WHLCHAIR; DTACHBLE ARMS DTACHBLE ELEV LEGRESTSE1160 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Standard WHLCHAIR; FIX FULL-LEN ARMS DTACHBL ELEV LEGRSTSE1161 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - STANDARD MANUAL ADULT SIZE WHEELCHAIR INCLUDES TILT SPACEE1170 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Amputee AMPUTEE WHLCHAIR; FIX FULL ARMS DTACHBL LEGRESTSE1171 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - AMPUTEE AMPUTEE WHLCHAIR; FIX FULL ARMS W/O FOOT/LEGRESTE1172 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Amputee AMPUTEE WHLCHAIR; DTACHBL ARMS W/O FOOT/LEGRESTSE1180 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - AMPUTEE AMPUTEE WHLCHAIR; DTACHBL ARMS DTACHBL FOOTRESTSE1190 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Amputee AMPUTEE WHLCHAIR; DTACHBL ARMS DTACHBL LEGRESTS

Page 7: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionE1195 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - AMPUTEE HEVY DUTY WHLCHAIR; FIX FULL ARMS DTACHBL LEGRSTE1200 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Amputee AMPUTEE WHLCHAIR; FIX FULL ARMS DTACHBL FOOTRSTSE1220 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTEDE1221 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHEELCHAIR WITH FIXED ARM FOOTRESTSE1222 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHEELCHAIR WITH FIXED ARM ELEVATING LEGRESTSE1223 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHEELCHAIR WITH DETACHABLE ARMS FOOTRESTSE1224 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHEELCHAIR W/DETACHABLE ARMS ELEVATING LEGRESTSE1225 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHLCHAIR ACCESS MANUAL SEMIRECLINING BACK EACHE1226 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHLCHAIR ACCESS MANUAL FULL RECLINING BACK EACHE1227 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size SPECIAL HEIGHT ARMS FOR WHEELCHAIRE1228 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE SPECIAL BACK HEIGHT FOR WHEELCHAIRE1229 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHEELCHAIR PEDIATRIC SIZE NOSE1230 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE PWR OPERATED VEH SPEC BRAND NAME & MODEL NUMBERE1231 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/SEAT SYSE1232 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/SEAT SYSE1233 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/O SEATE1234 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/O SEATE1235 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHLCHAIR PED SIZE RIGD ADJUSTBL W/SEATING SYSTEME1236 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHLCHAIR PED SIZE FOLD ADJUSTBL W/SEATING SYSTEME1237 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size WHLCHAIR PED SZ RIGD ADJUSTBL W/O SEATING SYSTEME1238 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - SPECIAL SIZE WHLCHAIR PED SZ FOLD ADJUSTBL W/O SEATING SYSTEME1239 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Special Size POWER WHEELCHAIR PEDIATRIC SIZE NOSE1240 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - LIGHTWEIGHT LGHTWT WHLCHAIR; DTACHBLE ARMS DTACHBLE LEGRESTE1250 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - LIGHTWEIGHT LGHTWT WHLCHAIR; FIX FULL ARMS DTACHBL FOOTRESTSE1260 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - LIGHTWEIGHT LGHTWT WHLCHAIR; DTACHBL ARMS DTACHBL FOOTRESTSE1270 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - LIGHTWEIGHT LGHTWT WHLCHAIR; FIX ARMS DTACHBLE ELEV LEGRESTSE1280 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Heavy Duty HEVY-DUTY WHLCHAIR; DTACHBLE ARMS ELEV LEGRESTSE1285 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - HEAVY DUTY HEVY-DUTY WHLCHAIR; FIX ARMS DTACHBLE FOOTRESTSE1290 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - HEAVY DUTY HEVY-DUTY WC DTCHBL ARMS SWNG AWAY DTCHBL FTRSTE1295 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - HEAVY DUTY HEVY-DUTY WHLCHAIR; FIX FULL ARMS ELEV LEGRESTSE1296 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Heavy Duty SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOORE1297 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR - HEAVY DUTY SPECIAL WHEELCHAIR SEAT DEPTH BY UPHOLSTERYE1298 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Heavy Duty SPECIAL WHLCHAIR SEAT DEPTH &OR WIDTH CONSTRUCTE1700 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Jaw Motion Rehab and Accessories JAW MOTION REHABILITATION SYSTEME1701 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) JAW MOTION REHAB AND ACCESSORIES REPL CUSHNS JAW MOTION REHAB SYSTEM PKG SIXE1702 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Jaw Motion Rehab and Accessories REPL MSR SCLS JAW MOTION REHAB SYSTEM PKG 200E1800 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES DYN ADJUSTBL ELB EXT/FLX DEVC W/SFT INTRFCE MATLE1801 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices STATIC PROGRESSIVE STRETCH ELBOW DEVICEE1802 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES DYN ADJUSTBL FORARM PRON/SUPIN DEVC INTRFCE MATLE1805 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices DYN ADJUSTBL WRIST EXT/FLX DEVC W/INTERFCE MATLE1806 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES STATIC PROGRESSIVE STRETCH WRIST DEVICEE1810 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices DYN ADJUSTBL KNEE EXT/FLX DEVC W/INTERFCE MATLE1811 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES STATIC PROGRESSIVE STRETCH KNEE DEVICEE1812 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices DYN KNEE EXT/FLEX DEVC W/ACTV RESISTANCE CONTROLE1815 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES DYN ADJ ANKLE EXT/FLEX DEVC INCL SOFT INTF MATLE1816 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices STATIC PROGRESSIVE STRETCH ANKLE DEVICEE1818 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES STATIC PROGRESSIVE STRETCH FOREARM DEVICEE1820 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices REPL SFT INTERFCE MATL DYN ADJUSTBL EXT/FLX DEVCE1821 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES REPL SFT INTERFCE MATL/CUFF BI-DIR STAT DEVCE1825 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices DYN ADJUSTBL FNGR EXT/FLX DEVC W/SFT INTRFCE MATE1830 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES DYN ADJUSTBL TOE EXT/FLX DEVC W/SFT INTRFCE MATLE1831 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices STATIC PROGRESSIVE STRETCH TOE DEVICEE1840 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Orthopedic Devices DYN ADJUSTBL SHLDR FLX/ABDCT/ROT DEVC SFT MATLE1841 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES STATIC PROGRESSIVE STRETCH SHOULDER DEVICEE2000 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) OTHER ORTHOPEDIC DEVICES GASTR SUCTION PUMP HOM MODEL PRTBLE/STATION ELECE2201 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY MNL WC ACSS NONSTD SEAT WDTH >/= 20 IN & < 24 INE2202 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MANUAL WC ACSS NONSTD SEAT FRME WIDTH 24-27 INE2203 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY MANUAL WC ACSS NONSTD SEAT FRME DEPTH 20 < 22 INE2204 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MANUAL WC ACSS NONSTD SEAT FRME DEPTH 22-25 INE2205 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY MANUAL WC ACCESS HANDRIM W/O PROJ REPL ONLY EACHE2207 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY WHEELCHAIR ACCESSORY CRUTCH AND CANE HOLDER EACH

Page 8: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionE2208 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WHEELCHAIR ACCESSORY CYLINDER TANK CARRIER EACHE2209 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY ARM TROUGH WITH OR WITHOUT HAND SUPPORT EACHE2220 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WC ACSS SOLD PROPULSION TIRE SZ REPL ONLY EAE2227 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY MANUAL WC ACCESS GEAR REDUCTION DRIVE WHEEL EACHE2228 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WC ACCESS WHEEL BRAKING SYS&LOCK COMPLETE EAE2230 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY MANUAL WHEELCHAIR ACCESSORY MANUAL STANDING SYSE2291 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories BACK PLANAR PED SZ WC INCL FIX ATTCHING HARDWAREE2292 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY SEAT PLANAR PED SZ WC INCL FIX ATTCHING HARDWAREE2293 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories BACK CONTOURED PED WC INCL FIX ATTCH HARDWAREE2294 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY SEAT CONTOURED PED WC INCL FIX ATTCH HARDWAREE2295 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories MNL WC ACCESS PED SIZE WC DYNAMIC SEATING FRAMEE2300 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY WHEELCHAIR ACC PWR SEAT ELEVATION SYS ANY TYPEE2301 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WHEELCHAIR ACCESSORY POWER STANDING SYS ANY TYPEE2310 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&ONE PWRE2311 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&TWO/MOREE2312 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY POWER WC ACCESS HAND OR CHIN CONTROL INTERFACEE2313 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WC ACCESS HARNESS UPGRADE EXP CONTROLLR EAE2321 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS HND CNTRL REMOT JOYSTCK NO PRPRTNLE2322 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS HND CNTRL MX MECH SWTCH NO PRPRTNLE2323 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS SPCLTY JOYSTCK HNDLE HND CNTRL PRFABE2324 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WHLCHAIR ACSS CHIN CUP CHIN CNTRL INTERFCEE2325 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS SIP&PUFF INTERFCE NONPROPRTNALE2326 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS BREATH TUBE KIT SIP&PUFF INTERFCEE2327 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS HEAD CNTRL INTERFCE MECH PROPRTNALE2328 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS HEAD CNTRL/EXT CNTRL ELEC PRPRTNLE2329 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS HEAD CNTRL CNTC SWTCH MECH NOPRPRTNLE2330 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACCSS HEAD PROX SWITCH MECH NONPRPRTNLE2331 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS ATTENDANT CONTROL PROPROTIONALE2340 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WC ACCESS NONSTAND SEAT FRAME WD 20-23 INE2341 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS NONSTD SEAT FRME WIDTH 24-27 INE2342 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS NONSTD SEAT FRME DEPTH 20/21 INE2343 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS NONSTD SEAT FRME DEPTH 22-25 INE2351 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS ELEC INTERFCE OPERATE SPCH GEN DEVCE2366 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC ACSS BATTRY CHRGR 1 MODE W/ONLY 1 BATTRYE2367 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC ACSS BATT CHRGR DUL MODE W/EITHER BATT EAE2368 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WHEELCHAIR CMPNT MOTOR REPLACEMENT ONLYE2369 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY POWER WC CMPNNT DRIVE WHEEL GEAR BOX REPL ONLYE2370 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC COMP INT DR WHL MTR&GR BOX COMB REPL ONLYE2373 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC MINI-PROPORTIONAL COMPACT REMOTE JOYSTICKE2374 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC STANDARD REMOTE JOYSTICK REPLACEMENT ONLYE2375 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC NONEXPNDABLE CONTROLLER REPLACEMENT ONLYE2376 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PWR WC EXPANDABLE CONTROLLER REPLACEMENT ONLYE2377 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR ACCESSORY PWR WC EXPANDABLE CONTROLLER UPGRADE INIT ISSUEE2378 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WHEELCHAIR COMPONENT ACTUATOR REPLACE ONLYE2397 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories POWER WHLCHAIR ACCESSORY LITHIUM-BASED BATTRY EAE2402 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WOUND THERAPY NEG PRESS WOUND THERAPY ELEC PUMP STATION/PRTBLEE2500 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Speech Generating Device SPEECH GEN DEVC DIGITIZED </= 8 MINS REC TIMEE2502 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) SPEECH GENERATING DEVICE SPCH GEN DEVC DIGTIZD>8 MINS <= 20 MINS REC TIMEE2504 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Speech Generating Device SPCH GEN DEVC DIGTIZD>20 MINS</=40 MINS REC TIMEE2506 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) SPEECH GENERATING DEVICE SPEECH GEN DEVICE DIGITIZED >40 MINS REC TIMEE2508 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Speech Generating Device SPCH GEN DEVC SYNTHSIZD REQ MESS SPELL & CNTCTE2510 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) SPEECH GENERATING DEVICE SPCH GEN DEVC SYNTHESIZD MX METH MESS&DEVC ACCSSE2511 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Speech Generating Device SPEECH GEN SOFTWARE PROG PC/PERS DIGITAL ASSISTE2512 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) SPEECH GENERATING DEVICE ACCESS SPEECH GENERATING DEVICE MOUNTING SYSTEME2599 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Speech Generating Device ACCESSORY FOR SPEECH GENERATING DEVICE NOCE2607 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION SKN PROTECT&PSTN WC SEAT CUSHN WDTH <22 IN DEPTHE2608 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SKN PROTCT&PSTN WC SEAT CUSHN WDTH 22 IN/GT DPTHE2609 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION SIZEE2610 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WHEELCHAIR SEAT CUSHION POWEREDE2611 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION GEN WC BACK CUSHN WDTH < 22 IN HT MOUNT HARDWAREE2612 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories GEN WC BACK CUSHN WDTH 22 IN/GT HT MOUNT HARDWRE

Page 9: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionE2613 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION PSTN WC BACK CUSHN POST WIDTH < 22 IN ANY HEIGHTE2614 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PSTN WC BACK CUSHN POST WIDTH 22 IN/> ANY HEIGHTE2615 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION PSTN WC BACK CUSHN POSTLAT WIDTH < 22 IN ANY HTE2616 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PSTN WC BACK CUSHN POSTLAT WIDTH 22 IN/> ANY HTE2617 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION CSTM FAB WC BACK CUSHN ANY SZ ANY MOUNT HARDWAREE2620 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH <22 INE2621 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) WHEELCHAIR CUSHION PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH 22 IN/>E2622 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SKIN PROTECT WC SEAT CUSH WIDTH <22 IN ANY DEPTHE2623 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SKIN PROTCT WC SEAT CUSH WIDTH 22 IN/> ANY DEPTHE2624 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SKIN PROTECT & POSITIONING WC CUSH WIDTH < 22 INE2625 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories SKIN PROTECT & POSITIONING WC CUSH WIDTH 22 IN/>E2626 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS SHLDR ELB MOBIL ARM SUPP WC ADJUSTBLEE2627 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS SHLDR ELB M ARM SUPP ADJUSTBL RANCHOE2628 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS SHLDR ELB MOBIL ARM SUPP WC RECLININGE2629 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS SHLDR ELB M ARM SUPP FRICTION ARM SUPPE2630 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS SHLDR ELB MOBIL MONOSUSP ARM HAND SUPPE2631 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS ADD MOBILE ARM SUPPORT ELEV PROX ARME2632 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS ADD MOBIL ARM SUPP OFFSET/LAT RCKR ARME2633 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) Wheelchair - Accessories WC ACCESS ADD MOBILE ARM SUPPORT SUPINATORE8000 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) GAIT TRAINER GAIT TRAINER PED SZ POST SUPP W/ALL ACSS&CMPNTSE8001 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) GAIT TRAINER GAIT TRAINER PED SZ UPRT SUPP W/ALL ACSS&CMPNTSE8002 HCPCS HCPCS - E CODES (DURABLE MEDICAL EQUIPMENT) GAIT TRAINER GAIT TRAINER PED SZ ANT SUPP W/ALL ACSS&CMPNTSG0027 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Semen Analysis SEMEN ANALY; PRES/MOT EXCLD HUHNERG0128 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DIR SKLED SERV RN OP REHAB EA 10 MIN AFTR 1ST 5G0129 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services OCCUP TX REQ SKILLS QUAL OCCUP TRPST PER SESSIONG0151 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICE PHYS THERAP HOME HLTH/HOSPICE EA 15 MING0152 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICE OCCUP THERAP HOME HLTH/HOSPICE EA 15 MING0153 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SRVC SPCH&LANG PATH HOME HLTH/HOSPICE EA 15 MING0156 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SRVC HH/HOSPICE AIDE IN HH/HOSPICE SET EA 15 MING0157 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICES PT ASSIST HOME HEALTH/HOSPICE EA 15 MING0158 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICE OT ASSIST HOME HEALTH/HOSPICE EA 15 MING0159 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICES PT HOME HEALTH EST/DEL PT MP EA 15 MINSG0160 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICES OT HOME HEALTH EST/DEL OT MP EA 15 MINSG0161 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SERVICE SLP HH EST/DEL SPCH-LANG PATH MP EA 15 MG0162 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SKILLED SERVICE RN M&E PLAN OF CARE; EA 15 MINSG0237 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services MUSCLES FACE TO FACE ONE ON ONE EACH 15 MINUTESG0238 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services TX PROC IMPRV RESP FUNCT NOT G0237 FCE-FCE 15MING0239 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services TX PROC IMPRV RESP FUNCT/INCR RESP MUSC 2/> INDG0281 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services E-STIM 1/> AREAS CHRONIC STAGE III&IV ULCERSG0282 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services E-STIM 1/MORE AREAS WND CARE OTH THAN DESC G0281G0283 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services E-STIM 1/> AREAS OTH THAN WND CARE PART TX PLANG0299 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DIRECT SNS RN HOME HEALTH/HOSPICE SET EA 15 MING0300 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DIRECT SNS LPN HOME HLTH/HOSPICE SET EA 15 MING0422 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services INTENSIVE CARD REHAB; W/WO CONT ECG MON W/EXERG0423 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services INTENSIVE CARD REHAB; W/WO CONT ECG MON W/O EXERG0424 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services PULM REHAB INCL EXER 1 HR PER SESS TO 2 PER DAYG0425 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services TELEHEALTH CONSULT ED/IP 30 MIN W/PT TELEHLTHG0480 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DRUG TEST DEFINITV DR ID METH P DAY 1-7 DRUG CLG0481 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DRUG TEST DEFINITV DR ID METH P DAY 8-14 DRUG CLG0482 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DRUG TEST DEFINITV DR ID METH P DAY 15-21 DR CLG0483 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DRUG TST DEFINITV DR ID METH P DAY 22/MORE DR CLG0493 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SKILLED SERVICES RN OBV & ASMT PT COND EA 15 MING0495 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SKD SRVC RN TRAIN&/EDU PT/FAM HH/HOSPC EA 15 MING0496 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services SKD SRVC LPN TRAIN&/EDU PT/FAM HH/HOSPC E 15 MING0659 HCPCS HCPCS - G CODES (PROCEDURES/PROFESSIONAL SERVICES) Professional/Screening Services DRUG TEST DEFINITV DRUG ID METH ANY # DR CLASSESJ0725 HCPCS HCPCS - J CODES (DRUGS ADMINISTERED OTHER THAN ORAL) Drugs other than Oral INJECTION CHORIONIC GONADOTROPIN-1000 USP UNITSJ1380 HCPCS HCPCS - J CODES (DRUGS ADMINISTERED OTHER THAN ORAL) Drugs other than Oral INJECTION ESTRADIOL VALERATE UP TO 10 MGJ3355 HCPCS HCPCS - J CODES (DRUGS ADMINISTERED OTHER THAN ORAL) Drugs other than Oral INJECTION UROFOLLITROPIN 75 IUJ9218 HCPCS HCPCS - J CODES (DRUGS ADMINISTERED OTHER THAN ORAL) Chemotherapy Drugs LEUPROLIDE ACETATE PER 1 MGK0001 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes STANDARD WHEELCHAIRK0002 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes STANDARD HEMI WHEELCHAIR

Page 10: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionK0003 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes LIGHTWEIGHT WHEELCHAIRK0004 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes HIGH STRENGTH LIGHTWEIGHT WHEELCHAIRK0005 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes ULTRALIGHTWEIGHT WHEELCHAIRK0006 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes HEAVY-DUTY WHEELCHAIRK0007 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes EXTRA HEAVY-DUTY WHEELCHAIRK0009 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes OTHER MANUAL WHEELCHAIR/BASEK0010 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes STANDARD-WEIGHT FRAME MOTORIZED/POWER WHEELCHAIRK0011 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes STD-WT FRME MOTRIZD/PWR WHLCHAIR W/PROG CNTRLK0014 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes OTHER MOTORIZED/POWER WHEELCHAIR BASEK0017 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes DETACHABLE ADJUST HT ARMREST BASE REPL ONLY EAK0052 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes SWINGAWAY DETACHABLE FOOTRESTS REPL ONLY EACHK0053 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes ELEVATING FOOTRESTS ARTICULATING EACHK0056 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes SEAT HT<17/=TO/>21 IN LTWT/ULTRALTWT WHLCHAIRK0069 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REAR WHL ASM CMPL SLD TIRE SPKE/MLD REPL ONLY EAK0070 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REAR WHL ASM COMP PNEUM TIRE SPKS/MLD RPL ONLY EK0071 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes FRONT CASTER ASSEM COMPLETE PN TIRE REPL ONLY EAK0072 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes FRONT C ASSEMBLY COMPL SEMIPNEU TIRE REPL ONLY EK0098 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes DRIVE BELT FOR POWER WHEELCHAIR REPLACEMNT ONLYK0105 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes IV HANGER EACHK0108 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes OTHER ACCESSORIESK0455 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes INFUSION PUMP UNINTERRUPTED PARENTERAL ADMIN MEDK0462 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes TEMP REPL PT OWNED EQUIP BEING REPR ANY TYPEK0552 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes SPL EXT NON-INS RX INFUS PMP SYR T CART STERL EAK0606 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes AUTO EXT DEFIB W/INTGR ECG ANALY GARMENT TYPEK0607 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REPL BATTRY AUTO EXT DEFIB GARMNT TYPE ONLY EAK0608 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REPLACEMENT GARMENT USE W/AUTO EXTERNAL DEFIB EAK0609 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REPL ELEC W/AUTO EXT DEFIB GARMNT TYPE ONLY EAK0739 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes REPR/SRVC DME NOT O2 RQR TECH CMPNT PER 15 MINSK0800 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR OP VEH GRP 1 STD PT WT CAP TO & INCL 300 LBSK0801 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR OP VEH GRP 1 HEAVY DUTY PT 301 TO 450 LBSK0802 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR OP VEH GRP 1 VERY HEAVY DUTY PT 451-600 LBSK0806 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR OP VEH GRP 2 STD PT WT CAP TO & INCL 300 LBSK0807 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR OP VEH GRP 2 HEAVY DUTY PT 301 TO 450 LBSK0812 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIEDK0813 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 1 STD PORT SLING SEAT PT TO 300 LBSK0814 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 1 STD PORT CAPT CHAIR PT TO 300 LBSK0815 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 1 STD SLING SEAT PT UP TO &= 300 LBSK0816 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 1 STD CAPTAINS CHAIR PT TO &=300 LBSK0820 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD PORT SLING SEAT PT TO &=300 LBSK0821 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD PORT CAPT CHAIR PT TO &=300 LBSK0822 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD SLING SEAT PT TO &=300 LBSK0823 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD CAPTAINS CHAIR PT TO &=300 LBSK0824 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBSK0825 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBSK0826 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LBK0827 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBSK0828 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 XTRA HVY DUTY SLING SEAT PT 601LB/>K0829 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 XTRA HVY DUTY CHAIR PT 601 LBS/>K0830 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD SEAT ELEV SLING PT TO &=300 LBSK0831 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD SEAT ELEV CAP CHR PT TO 300 LBK0835 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD 1 PWR SLING SEAT PT TO 300 LBSK0836 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD 1 PWR CAPT CHAIR PT TO 300 LBSK0837 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 HVY 1 PWR SLING SEAT PT 301-450 LBSK0838 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 HVY 1 PWR CAPT CHAIR PT 301-450 LBSK0839 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 VRY HVY 1 PWR SLING PT 451-600 LBSK0840 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 XTRA HVY 1 PWR SLING PT 601 LBS/>K0841 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 MX PWR SLING SEAT PT TO &=300 LBSK0842 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 STD MX PWR CAPT CHR PT TO &=300 LBSK0843 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 2 HVY MX PWR SLNG SEAT PT 301-450 LBSK0848 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 STD SLING SEAT PT TO & = 300 LBSK0849 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 STD CAPTAIN CHAIR PT TO & = 300 LBS

Page 11: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionK0850 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBSK0851 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 301-450 LBSK0852 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 V HVY DUTY SLING SEAT PT 451-600 LBK0853 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 451-600 LBSK0854 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 XTRA HVY DTY SLNG SEAT PT 601 LBS/>K0855 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3X HVY DTY CHR PT WT CAP 601 LB/>K0856 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO &=300 LBK0857 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 STD 1 PWR CAPT CHAIR PT TO &=300 LBK0858 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HD 1 PWR SLING SEAT PT 301-450 LBSK0859 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HD 1 PWR CAPT CHAIR PT 301-450 LBSK0860 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LBK0861 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO &=300 LBK0862 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBSK0863 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 V HD MX PWR SLNG SEAT PT 451-600 LBK0864 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 3 XTR HD MX PWR SLNG SEAT PT 601 LB/>K0868 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD SLING SEAT PT TO & = 300 LBSK0869 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD CAPTAIN CHAIR PT TO & = 300 LBSK0870 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 HVY DUTY SLING SEAT PT 301-450 LBSK0871 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 V HVY DUTY SLING SEAT PT 451-600 LBK0877 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO &=300 LBK0878 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD 1 PWR CAPT CHAIR PT TO &=300 LBK0879 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 HD 1 PWR SLING SEAT PT 301-450 LBSK0880 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 V HD 1 PWR SLING SEAT PT 451-600 LBK0884 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD MX PWR SLNG SEAT PT TO &=300 LBK0885 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 STD MX PWR CAPT CHR PT TO &=300 LBSK0886 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 4 HD MX PWR SLING SEAT PT 301-450 LBSK0890 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 5 PED 1 PWR SLING SEAT PT TO &=125 LBK0891 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes PWR WC GRP 5 PED MX PWR SLNG SEAT PT TO &=125 LBK0898 HCPCS HCPCS - K CODES (DMERCS) HCPCS - K Codes POWER WHEELCHAIR NOT OTHERWISE CLASSIFIEDL0112 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CRANIL CERV ORTHOS CONGN TORTICOLLIS TYPE CUSTOML0113 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CRANIAL CERVL ORTHOSIS TORTICOLLIS TYPE PREFABL0170 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CERVICAL COLLAR MOLDED TO PATIENT MODELL0470 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR POST FRME&ANT APRON W/STRAP PRFABL0480 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR 1 PIECE W/O INTERFCE LINER CSTML0482 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR 1 PIECE W/INTERFCE LINER CSTML0484 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR 2 PIECE W/O INTERFCE LINER CSTML0486 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR 2 PIECE W/INTERFCE LINER CSTML0488 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO TRIPLANAR 1 PIECE W/INTERFCE LINER PRFABL0490 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO SAGIT-CORONAL W/OVRLAP REINFORCED ANT PRFABL0624 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal SACROILIAC ORTHOSIS RIGD/SEMI-RIGD PANELS CUSTOML0629 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LUMBAR-SACRAL ORTHOSIS FLEXIBLE CUSTOM FABL0631 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LUMB-SACRAL ORTHOS SAGIT CNTRL RIGID A&P PREFABL0632 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LUMB-SACRAL ORTHOS SAGIT CNTRL RIGID A&P CUSTOML0635 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONL CNTRL FLEX RIGID POST PREFABL0636 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONL CNTRL FLEX RIGID POST CUSTOML0637 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LUMB-SACRAL ORTHOS SAG-COR CNTRL RIGD A&P PREFABL0638 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LUMB-SACRAL ORTHOS SAG-COR CNTRL RIGD A&P CUSTOML0640 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONAL RIGID SHELL/PANEL CUSTM FABL0649 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONAL CONTROL RIGD POST PANELSL0650 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONAL CONTRL RIGD ANT POST PANELSL0651 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal LSO SAGITTAL-CORONAL CONTROL RIGD SHELLS/PANELSL0700 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CTLSO ANT-POSTERIOR-LAT CONTROL MOLDED PT MODELL0710 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CTLSO ANT-POST-LAT CNTRL MOLD PT-INTRFCE MATLL0859 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal ADD HALO PROC MRI COMPAT SYS RINGS&PINS ANY MATLL0999 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal ADD TO SPINAL ORTHOSIS NOT OTHERWISE SPECFIEDL1000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CTLSO INCLUSIVE FURNISHING INIT ORTHOS INCL MDLL1001 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal CERV THOR LUMB SACRAL IMMOBLIZR INFANT SZ PREFABL1200 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal TLSO INCLUSIVE FURNISHING INITIAL ORTHOSIS ONLYL1300 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal OTH SCOLIOSIS PROC BODY JACKET MOLDED PT MODELL1310 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal OTH SCOLIOSIS PROC POSTOPERATIVE BODY JACKETL1499 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Spinal SPINAL ORTHOSIS NOT OTHERWISE SPECIFIED

Page 12: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL1680 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb HIP ORTHOS DYN PELV CONTROL THIGH CUFF CSTM FABL1685 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb HIP ORTHOS ABDCT CNTRL POSTOP HIP ABDCT CSTML1686 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb HIP ORTHOS ABDUCT CNTRL POSTOP HIP PRFAB-FIT&ADJL1690 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb COMB BIL LUMBO-SAC HIP FEM ORTHOS PRFB W/FIT&ADJL1700 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb LEGG PERTHES ORTHOSIS TORONTO CUSTOM FABRICATEDL1710 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb LEGG PERTHES ORTHOSIS NEWINGTON CUSTOM FABL1720 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb LEGG PERTHES ORTHOSIS TRILAT TACHDIJAN CSTM FABL1730 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb LEGG PERTHES ORTHOSIS SCOTTISH RITE CUSTOM FABL1755 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb LEGG PERTHES ORTHOSIS PATTEN BOTTOM CSTM FABL1810 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS ELASTIC JOINTS PREFAB CUSTOM FITL1820 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KO ELAST W/CONDYLR PADS&JNT PRFAB INCL FIT&ADJL1832 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS IMMOBLIZER ADJUSTABLE JOINT PREFABL1834 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KO WITHOUT KNEE JOINT RIGID CUSTOM FABRICATEDL1840 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KO DEROTATION MEDIAL-LATERAL ACL CUSTOM FABL1843 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS SINGLE UPRIGHT THIGH & CALF PREFABL1844 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS SINGLE UPRIGHT THIGH & CALF CUSTOML1845 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS DOUBLE UPRIGHT THIGH & CALF PREFABL1846 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS DOUBLE UPRIGHT THIGH & CALF CUSTOML1847 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOSIS DOUBLE UPRIGHT AIR PREFAB CUSTOML1860 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KNEE ORTHOS MOD SUPRACONDYLR PROS SOCKT CSTM FABL1900 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO SPRNG WIRE DORSIFLX ASST CALF BAND CSTM FABL1904 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb ANKLE ORTH ANKLE GAUNTLET/SIMILAR CUSTOM FABL1907 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb ANKLE ORTHOSIS SUPRAMALLEOLAR WITH STRAPS CUSTOML1920 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO SINGLE UPRT W/STATIC/ADJUSTBL STOP CSTM FABL1932 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO RIGD ANT TIBL TOT CARB FIBER/EQUL MATL PRFABL1940 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb ANK FT ORTHOSIS PLASTIC/OTH MATERIAL CUSTOM FABL1945 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO MOLD PT MDL PLSTC RIGD ANT TIBL SECT CSTML1950 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb ANKLE FOOT ORTHOSIS SPIRAL PLASTIC CUSTOM-FABL1951 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb ANK FT ORTHOS SPIRAL PLSTC/OTH MATL PRFAB W/FITL1960 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO POSTERIOR SOLID ANK PLASTIC CUSTOM FABL1970 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO PLASTIC WITH ANKLE JOINT CUSTOM FABRICATEDL1980 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO 1 UPRT FREE PLANTR DORSIFLX SOLID STIRUP FABL1990 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO DBL UPRT PLANTR DORSIFLX SOLID STIRUP CSTML2000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO 1 UPRT FREE KNEE FREE ANK SOLID STIRUP CSTML2005 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO ANY MATL AUTO LOCK&SWNG RLSE W/ANK JNT CSTML2006 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb 3/6/2020 KAF DVC ANY MATERIAL ADJUSTABILITY CUSTOM FABL2010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO 1 UPRT SOLID STIRUP W/O KNEE JNT CSTM FABL2020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO DBL UPRT SOLID STIRUP THI&CALF CSTM FABL2030 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO DBL UPRT SOLID STIRUP W/O KNEE JNT CSTML2034 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO PLASTIC MED LAT ROTAT CNTRL CSTM FABL2036 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FULL PLASTIC DOUBLE UPRIGHT CSTM FABL2037 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FULL PLASTIC SINGLE UPRIGHT CUSTOM FABL2038 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FULL PLASTIC MX-AXIS ANKLE CUSTOM FABL2106 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO FX ORTHOSIS TIB FX CAST THERMOPLSTC CSTM FABL2108 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO FX ORTHOSIS TIB FX CAST ORTHOSIS CSTM FABL2112 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO FX ORTHO TIB FX ORTHO SFT PRFAB W/FIT & ADJL2114 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb AFO TIBL FX ORTHOS SEMI-RIGD PRFAB W/FIT & ADJL2126 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FEM FX CAST ORTHOSIS THERMOPLSTC CSTM FABL2128 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FX ORTHOSIS FEM FX CAST ORTHOSIS CSTM FABL2132 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FEM FX CAST ORTHOSIS SFT PRFAB W/FIT & ADJL2134 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FEM FX CAST ORTHOS SEMI-RIGD PRFAB FIT&ADJL2136 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Limb KAFO FEM FX CAST ORTHOSIS RIGD PRFAB W/FIT & ADJL2755 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Extremity Additions ADD LOW EXT ORTHOSIS HYBRID COMPOS PER SEG CSTML2861 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Extremity Additions ADD LOW EXT JOINT KNEE/ANK CSTM FAB ONLY EAL2999 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Lower Extremity Additions LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIEDL3000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FT INSRT MOLD PT MDL UCB TYPE BERKLY SHELL EAL3001 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSERT REMOVABLE MOLDED PT MODEL SPENCO EAL3002 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSRT REMV MOLDED PT MDL PLASTAZOTE/EQUL EAL3003 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSERT REMV MOLDED PT MODEL SILICONE GEL EAL3010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FT INSRT REMV MOLD PT MDL LNGTUDNL ARCH SUPP EAL3020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSRT REMV MOLD PT MDL LNGTUDNL/MT SUPP EA

Page 13: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL3030 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSERT REMOVABLE FORMED PATIENT FOOT EACHL3031 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Inserts FOOT INSRT/PLAT REMV ADD LW EXT ORTHOS HI STRGTHL3040 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPPORT REMV PREMOLDED LONGTUDNL EAL3050 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPPORT REMOVABLE PREMOLDED MT EAL3060 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPPORT REMV PREMOLDED LONGTUDNL/MT EAL3070 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPPORT NONREMV ATTCH SHOE LNGTUDNL EAL3080 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPPORT NONREMOVABLE ATTCH SHOE MT EAL3090 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support FOOT ARCH SUPP NONREMV ATTCH SHOE LNGTUDNL/MT EAL3100 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Arch Support HALLUS-VALGUS NIGHT DYNAMIC SPLINT PREFABRICATEDL3140 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Abduction and Rotation Bars FOOT ABDUCTION ROTATION BAR INCLUDING SHOESL3150 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Abduction and Rotation Bars FOOT ABDUCTION ROTATION BAR WITHOUT SHOESL3160 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Abduction and Rotation Bars FOOT ADJUSTABLE SHOE-STYLED POSITIONING DEVICEL3170 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Abduction and Rotation Bars FOOT PLASTIC SILCONE HEEL STABILIZER PREFAB EACHL3201 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR INFNTL3202 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR CHILDL3203 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC SHOE OXFORD W/SUPINATOR/PRONATOR JRL3204 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR INFNTL3206 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR CHILDL3207 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC SHOE HIGHTOP W/SUPINATOR/PRONATOR JRL3208 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear SURGICAL BOOT EACH INFANTL3209 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear SURGICAL BOOT EACH CHILDL3211 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear SURGICAL BOOT EACH JUNIORL3212 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear BENESCH BOOT PAIR INFANTL3213 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear BENESCH BOOT PAIR CHILDL3214 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear BENESCH BOOT PAIR JUNIORL3215 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR LADIES SHOE OXFORD EACHL3216 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR LADIES SHOE DEPTH INLAY EACHL3217 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED FTWEAR LADIES SHOE HITOP DEPTH INLAY EAL3219 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR MENS SHOE OXFORD EACHL3221 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR MENS SHOE DEPTH INLAY EACHL3222 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED FOOTWEAR MENS SHOE HITOP DEPTH INLAY EAL3224 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR WOMAN SHOE OXFRD PART BRACEL3225 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR MAN SHOE OXFORD PART BRACEL3230 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR CUSTOM SHOE DEPTH INLAY EACHL3250 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPED FTWEAR CSTM MOLD REMV INNR MOLD PROSTHL3251 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear FOOT SHOE MOLDED PATIENT MODEL SILICONE SHOE EAL3252 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear FOOT SHOE MOLDED PT MDL PLASTAZOTE CSTM FABR EAL3253 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear FOOT MOLDED SHOE PLASTAZOTE CUSTOM FITTED EACHL3254 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear NONSTANDARD SIZE OR WIDTHL3255 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear NONSTANDARD SIZE OR LENGTHL3257 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear ORTHOPEDIC FOOTWEAR ADDITIONAL CHARGE SPLIT SIZEL3265 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Orthopedic Footwear PLASTAZOTE SANDAL EACHL3300 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEVATION HEEL TAPERED METATARSALS PER INCHL3310 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEVATION HEEL AND SOLE NEOPRENE PER INCHL3320 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEVATION HEEL AND SOLE CORK PER INCHL3330 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEVATION METAL EXTENSIONL3332 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEV INSIDE SHOE TAPERED UP ONE-HALF INCHL3334 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Lifts LIFT ELEVATION HEEL PER INCHL3340 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges HEEL WEDGE SACHL3350 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges HEEL WEDGEL3360 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges SOLE WEDGE OUTSIDE SOLEL3370 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges SOLE WEDGE BETWEEN SOLEL3380 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges CLUBFOOT WEDGEL3390 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges OUTFLARE WEDGEL3400 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges METATARSAL BAR WEDGE ROCKERL3410 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges METATARSAL BAR WEDGE BETWEEN SOLEL3420 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Wedges FULL SOLE AND HEEL WEDGE BETWEEN SOLEL3430 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL COUNTER PLASTIC REINFORCEDL3440 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL COUNTER LEATHER REINFORCEDL3450 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL SACH CUSHION TYPEL3455 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL NEW LEATHER STANDARD

Page 14: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL3460 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL NEW RUBBER STANDARDL3465 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL THOMAS WITH WEDGEL3470 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL THOMAS EXTENDED TO BALLL3480 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL PAD AND DEPRESSION FOR SPURL3485 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoe Modification - Heels HEEL PAD REMOVABLE FOR SPURL3649 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Transfer or Replacement ORTHOPED SHOE MODIFICATION ADDITION/TRANSFER NOSL3764 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb EWHO INCL 1/MORE NONTORSION JOINTS CSTM FABL3766 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb EWHFO INCL 1/MORE NONTORSION JOINTS CSTM FABL3806 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHFO CUSTOM FABRICATED INCL FITTING & ADJUSTMENTL3808 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WRIST HAND FINGER ORTHOSIS RIGID W/O JNT; CUSTOML3891 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb ADD UP EXT JNT WRIST/ELB CSTM FAB ORTHOT ONLY EAL3900 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHFO DYN FLEXOR HINGE WRST/FNGR DRIVEN CSTM FABL3901 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHFO DYN FLEXOR HINGE CABLE DRIVEN CSTM FABL3904 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHFO EXTERNAL POWERED ELECTRIC CUSTOM FABRICATEDL3905 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHO INCL 1/MORE NONTORSION JOINTS CSTM FABL3906 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WHO W/O JNT MAY INCL SFT INTRFCE STRAPS CSTM FABL3915 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb WRIST HAND ORTHOSIS 1/>NONTORSION JNT PRFAB CSTML3921 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Upper Limb HFO INCL 1/MORE NONTORSION JOINTS CUSTOM FABL3960 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoulder-Elbow-Wrist-Hand SEWHO ABDUCT PSTN AIRPLANE DESN PREFAB W/FIT&ADJL3961 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoulder-Elbow-Wrist-Hand SEWHO SHOULDER CAP DESIGN W/O JOINTS CSTM FABL3962 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoulder-Elbow-Wrist-Hand SEWHO ABDUCT PSTN ERBS PALS DESN PRFAB W/FIT&ADJL3967 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Shoulder-Elbow-Wrist-Hand SEWHO ABDUCTION POSITIONING W/O JOINTS CSTM FABL3971 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHO SHOULDER CAP DESIGN CSTM FABL3973 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHO ABDUCT PSTN THOR CMPNT&SUPP BAR CSTM FABL3975 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHFO SHOULDER CAP DESIGN W/O JOINTS CSTM FABL3976 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHFO ABDUCT PSTN THOR CMPNT W/O JOINTS CUS FABL3977 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHFO SHOULD CAP DESIGN CUSTOM FAB ELASTIC BANDL3978 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Mobile Arm Supports SEWHFO ABDUCT PSTN THOR CMPNT&SUPP BAR CSTM FABL4000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE GIRDLE FOR SPINAL ORTHOSIS CTLSO OR SOL4002 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPL STRAP ANY ORTHOSIS ALL CMPNTS ANY LEN TYPEL4010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE TRILATERAL SOCKET BRIML4020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE QUADRILAT SOCKET BRIM MOLDED PT MODELL4030 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE QUADRILATERAL SOCKET BRIM CUSTOM FITTEDL4040 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE MOLDED THI LACER CSTM FAB ORTHOSIS ONLYL4045 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE NONMOLD THI LACER CSTM FAB ORTHOSIS ONLYL4050 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE MOLDED CALF LACER CSTM FAB ORTHOSIS ONLYL4055 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE NONMOLD CALF LACER CSTM FAB ORTHOS ONLYL4060 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE HIGH ROLL CUFFL4070 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFOL4080 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE METAL BANDS KAFO PROXIMAL THIGHL4090 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE METAL BANDS KAFO-AFO CALF/DISTAL THIGHL4100 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE LEATHER CUFF KAFO PROXIMAL THIGHL4110 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE LEATHER CUFF KAFO-AFO CALF/DISTAL THIGHL4130 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPLACE PRETIBIAL SHELLL4205 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPAIR ORTHOTIC DEVC LABOR COMPONENT PER 15 MINL4210 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Orthotic-Repairs REPAIR ORTHOTIC DEVC REPAIR/REPLACE MINOR PARTSL5000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PART FT SHOE INSERT W/LONGTUDNL ARCH TOE FILLERL5010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PARTIAL FT MOLDED SOCKET ANK HEIGHT W/TOE FILLERL5020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PART FT MOLDED SOCKET TIB TUBERCLE HT W/TOE FILL5050 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ANKLE SYMES MOLDED SOCKET SACH FOOTL5060 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ANK SYMES METL FRME MOLD LEATHR SOCKT ARTIC ANKL5100 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb BELOW KNEE MOLDED SOCKET SHIN SACH FOOTL5105 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb BELOW KNEE PLSTC SOCKT JNT&THIGH LACER SACH FOOTL5150 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb KNEE DISRTC MOLD SOCKT EXT KNEE JNT SHIN SACH FTL5160 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb KNEE DISARTIC MOLD SOCKT BENT KNEE EXT KNEE JNTL5200 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ABOVE KNEE MOLD SOCKT 1 AXIS CONSTANT FRICTIONL5210 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ABOVE KNEE SHRT PROSTH NO KNEE JNT NO ANK JNT EAL5220 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ABOVE KNEE SHORT PROSTH W/ARTIC ANK/FOOT DYNL5230 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ABOVE KNEE PROXIMAL FEM FOCAL DEFIC SACH FOOTL5250 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb HIP DISARTIC CANADIAN TYPE; MOLD SOCKT HIP JNTL5270 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb HIP DISRTC TILT TABLE; MOLD SCKT LOCK HIP JNT

Page 15: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL5280 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb HEMIPELVECT CANADIAN TYPE; MOLD SOCKT HIP JNTL5301 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb BELOW KNEE MOLD SOCKET SHIN SACH FT ENDOSKEL SYSL5312 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb KNEE DISARTIC MOLD SOCKET 1 AXIS KNEE SACH FOOTL5321 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb ABOVE KNEE OPEN END SACH FT ENDO SYS 1 AXIS KNEEL5331 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb JOINT SINGLE AXIS KNEE SACH FOOTL5341 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb SINGLE AXIS KNEE SACH FOOTL5400 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMED PSTSRG/ERLY FIT APPLY RIGD DRSS W/1 CHG BKL5410 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMD POSTSURG APPL RIGD DRS BK W/EA ADD CAST CHGL5420 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMED POSTSURG INIT RIGD DRESS 1 CHG AK/KNEEL5430 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMED POSTSURG INIT RIGD DRSG AK EA ADD CAST CHGL5450 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMED POSTSURG APPLIC NONWT BEAR RIGD BELW KNEEL5460 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb IMMED POSTSURG APPLIC NONWT BEAR RIGD ABOVE KNEEL5500 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb INIT BELOW KNEE PTB SOCKET NON-ALIGN DIR FORMEDL5505 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb INIT ABVE KNEE-DISARTC ISCH LEVL SOCKT NON-ALIGNL5510 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP BELOW KNEE PTB SOCKET NON-ALIGN MOLD MODELL5520 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=DIR FORML5530 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=MOLD MDLL5535 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP BELOW KNEE PTB NON-ALIGN PRFAB ADJ OPEN ENDL5540 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP BK PTB SCKT NON-ALIGN LAMNATD SCKT MOLD MDLL5560 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP AK-DISRTC ISCH LEVL PLASTER SOCKET MOLD MDLL5570 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP AK-DISRTC ISCH LEVL THERMOPLSTC/=DIR FORMEDL5580 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP AK DISARTIC NON-ALIGN THERMOPLSTC/=MOLD MDLL5585 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP AK-DISARTC NON-ALIGN PRFAB ADJ OPN END SCKTL5590 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP AK-DISARTIC NON-ALIGN LAMINATED SOCKET MOLDL5595 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP HIP DISARTIC-HEMIPELVECT THERMOPLSTC/=MOLDL5600 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Limb PREP HIP DISARTIC-HEMIPELVECT LAMINATD SCKT MOLDL5610 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXTRM ENDO SYS ABVE KNEE HYDRACADENCE SYSL5611 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXTRM ENDO AK-DISRTC 4-BAR LINK W/FRICTL5613 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTRM ENDO AK-DISARTIC 4-BAR W/HYDRAULICL5614 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT EXOSKEL SYS AK-DISARTC 4-BAR PNEUMATL5616 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTRM ENDO AK UNIVERSAL MXPLX SYS FRICTL5617 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREMITY QUICK CHG SLF-ALIGN U AK/BK EAL5618 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION TO LOWER EXTREMITY TEST SOCKET SYMESL5620 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY TEST SOCKET BELOW KNEEL5622 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM TEST SOCKET KNEE DISARTICL5624 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY TEST SOCKET ABOVE KNEEL5626 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM TEST SOCKET HIP DISARTICL5628 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM TEST SOCKET HEMIPELVECTOMYL5629 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM BELOW KNEE ACRYLIC SOCKETL5630 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM SYMES TYPE EXPANDABLE WALL SOCKTL5631 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT ABVE KNEE/KNEE DISARTIC ACRYLC SOCKTL5632 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM SYMES TYPE PTB BRIM DESIGN SOCKTL5634 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM SYMES TYPE POST OPENING SOCKTL5636 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOW EXTREM SYMES TYPE MED OPENING SOCKTL5637 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY BELOW KNEE TOTAL CONTCTL5638 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM BELOW KNEE LEATHER SOCKETL5639 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY BELOW KNEE WOOD SOCKETL5640 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM KNEE DISARTIC LEATHR SOCKTL5642 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM ABOVE KNEE LEATHER SOCKETL5643 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT HIP DISARTIC FLX INNR SOCKT EXT FRAMEL5644 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY ABOVE KNEE WOOD SOCKETL5645 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT BELW KNEE FLXIBLE INNR SOCKT EXT FRMEL5646 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT BELOW KNEE AIR FL GEL/= CUSHN SOCKTL5647 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM BELOW KNEE SUCTION SOCKETL5648 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT ABOVE KNEE AIR FL GEL/= CUSHN SOCKETL5649 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT ISCHIAL CONTAINMENT/NARROW M-L SOCKETL5650 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT TOTAL CONTACT ABVE KNEE/KNEE DISARTCL5651 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT ABVE KNEE FLXIBLE INNR SOCKT EXT FRMEL5652 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM SUCTN SUSP ABV KNEE/KNEE DISARTICL5653 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM KNEE DISARTIC XPNDABLE WALL SOCKTL5654 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION TO LOWER EXTREMITY SOCKET INSERT SYMES

Page 16: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL5655 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM SOCKET INSERT BELOW KNEEL5656 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM SOCKT INSERT KNEE DISARTICL5658 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM SOCKET INSERT ABOVE KNEEL5661 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM SOCKT INSERT MULTIDUROMETER SYMESL5665 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTRM SOCKT INSRT MXIDUROMETER BELW KNEEL5666 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREM BELOW KNEE CUFF SUSPENSIONL5668 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOW EXTREM BELOW KNEE MOLDED DIST CUSHNL5670 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM BELOW KNEE MOLD SUPRACONDYLR SUSPL5671 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOWER EXTRM BELOW/ABOVE KNEE SUSP LOCK MECHL5672 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOWER EXTREM BELOW KNEE REMV MED BRIM SUSPL5673 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT CSTM MOLD/PRFAB FOR USE W/LOCK MECHL5676 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOWER EXTREM BELW KNEE KNEE JNT 1 AXIS PAIRL5677 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM BELW KNEE KNEE JNT POLYCNTRC PAIRL5678 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOW EXTREM BELOW KNEE JOINT COVERS PAIRL5679 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT BK/AK CSTM MOLD/PRFAB NOT W/LOCK MECHL5680 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM BELOW KNEE THIGH LACER NONMOLDEDL5681 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXT BK/AK CST INS CNG/ATYP TRAUM AMP INITL5682 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXTRM BELW KNEE THI LACER GLUTL/ISCH MOLDL5683 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LW EXTR BK/AK CST FAB NO CNGN/TRAUM AMP INITL5684 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY BELOW KNEE FORK STRAPL5685 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXT PROS BELW KNEE SUSP/SEAL SLEEVE EAL5686 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADDITION LOWER EXTREMITY BELOW KNEE BK BACK CHCKL5688 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOWER EXTREMITY BELOW KNEE WAIST BELT WEBBNGL5692 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM ABVE KNEE PELV CONTROL BELT LIGHTL5694 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM ABVE KNEE PELV CNTRL BELT PADD&LNL5695 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTRM ABOVE KNEE PELV CNTRL SLV NEOPRENEL5696 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM ABOVE KNEE/KNEE DISARTIC PELV JNTL5697 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTREM ABVE KNEE/KNEE DISARTIC PELV BANDL5698 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ADD LOW EXTRMITY AK/KNEE DISRTC SILESIAN BANDGEL5699 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Lower Extremity Additions ALL LOWER EXTREMITY PROSTHESES SHOULDER HARNESSL5700 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements REPLACEMENT SOCKET BELOW KNEE BK MOLDED PT MODELL5701 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements REPL SOCKT ABOVE KNEE/KNEE DISARTIC W/ATTCH PLATL5702 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements REPLCMT SOCKT HIP DISARTIC W/HIP JNT MOLD PT MDLL5703 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements ANKLE SYMES MOLD PT MODEL SACH FOOT REPL ONLYL5704 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements CUSTOM SHAPED PROTECTIVE COVER BELOW KNEE BKL5705 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements CUSTOM SHAPED PROTECTIVE COVER ABOVE KNEE AKL5706 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements CUSTOM SHAPED PROTECTIVE COVER KNEE DISARTICL5707 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Replacements CUSTOM SHAPED PROTECTIVE COVER HIP DISARTICL5710 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN SYSTEM 1 AXIS MANUAL LOCKL5711 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN 1 AXIS MNL LOCK ULTRA-LGHTL5712 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN 1 AXIS FRICT SWING CNTRLL5714 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN VARIBL FRICT SWING CNTRLL5716 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN POLYCNTRC MECH STANCE LOCKL5718 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKL KNEE-SHIN POLYCNTRC FRICT SWING CNTRLL5722 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRLL5724 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN FLUID SWING PHASE CNTRLL5726 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN EXT JOINT FL SWING CNTRLL5728 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL KNEE-SHIN FLUID SWING&STANCE CNTRLL5780 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKL KNEE-SHIN PNEUMAT/HYDRA PNEUMAT CNTRLL5781 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD LW LIMB PROS RESIDUL LIMB VOL MGMT SYSL5782 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD LW LIMB PROS RESIDUL LIMB MGMT SYS HEVY DUTYL5785 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL SYSTEM BELW KNEE ULTRA-LGHT MATERIALL5790 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL SYSTEM ABVE KNEE ULTRA-LGHT MATERIALL5795 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Exoskeletal Additions ADD EXOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATLL5810 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN SYSTEM 1 AXIS MANUAL LOCKL5811 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN MNL LOCK ULTRA-LGHT MATLL5812 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRLL5814 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN HYDRAULIC SWING MECH LOCKL5816 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN MECH STANCE PHASE LOCKL5818 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRLL5822 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRL

Page 17: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL5824 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN FLUID SWING PHASE CNTRLL5826 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDO KNEE-SHIN HYDRAUL SWNG MIN HI ACTV FRMEL5828 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDO KNEE-SHIN FL SWING&STANCE PHASE CNTRLL5830 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN PNEUMAT/SWING PHASE CNTRLL5840 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDO KNEE-SHIN 4-BAR LINK/MX-AXIAL PNEUMATL5845 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN STANCE FLX FEATUR ADJL5848 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL KNEE-SHIN SYS FLUID STANCE EXTENSNL5850 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYS AK/HIP DISARTIC KNEE EXT ASSTL5855 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYS HIP DISARTIC MECH HIP EXT ASSTL5856 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSEL5857 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LOW EXT PROS KNEE-SHIN SYS SWING PHASE ONLYL5858 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LW EXT PROS KNEE SHIN SYS STANCE PHASE ONLYL5859 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LOW EXT PROS KN-SHIN PROG FLX/EXT ANY MOTORL5910 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYSTEM BELOW KNEE ALIGNABLE SYSTEML5920 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYS AK/HIP DISARTIC ALIGNABLE SYSTML5925 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL AK-DISARTIC/HIP DISARTIC MNL LOCKL5930 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYSTEM HIGH ACTV KNEE CONTROL FRAMEL5940 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYSTEM BELOW KNEE ULTRA-LGHT MATLL5950 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYSTEM ABVE KNEE AK ULTRA-LGHT MATLL5960 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATLL5961 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDO SYS POLYCNTRC HIP JOINT ROTATION CNTRLL5962 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL BK FLXIBLE PROTVE OUTR SURF COVRINGL5964 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDOSKEL AK FLEXIBLE PROTVE OUTR SURF COVERL5966 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD ENDO HIP DISRTC FLXIBL PROTVE OUTR SURF COVRL5968 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LW LIMB PROSTH MX-AXIAL ANK W/SWING PHASEL5969 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADDITION ENDOSKELETAL ANKLE-FOOT/ANK PWR ASSISTL5970 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOW EXTREM PROSTH FT EXTERNAL KEEL SACH FOOTL5971 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREM PROS SACH FOOT REPLACEMENT ONLYL5972 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREMITY PROSTHESES FOOT FLEX KEELL5973 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ENDOSKEL ANK FOOT SYS MICRPROCSS CONTROL PWR SRCL5974 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREM PROSTH FT SINGLE AXIS ANK/FOOTL5975 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LW EXTRM PRSTH COMB 1 AXIS ANK&FLXBL KEEL FTL5976 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREM PROSTHESES ENERGY STORING FOOTL5978 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREM PROSTH FT MULTI-AXIAL ANK/FOOTL5979 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LW EXTRM PRSTH MX-AXL ANK DYN RSPN FT 1 PECEL5980 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREMITY PROSTHESES FLEX-FOOT SYSTEML5981 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOWER EXTREM PROSTH FLEX-WALK SYSTEM/EQUALL5982 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL EXOSKEL LOW EXTREM PROSTH AXIAL ROTAT UNITL5984 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL ENDOSKEL LOW EXT PROSTH AXIAL ROTAT UNIT ADJL5985 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL ENDOSKEL LOW EXTREM PROSTH DYN PROSTH PYLNL5986 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LOW EXTREM PROSTH MULTI-AXIAL ROTATION UNITL5987 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ALL LW XTRM PRSTH SHNK FT SYS W/VRTCL LOAD PYLNL5988 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LW LIMB PROSTH VERTCL SHOCK RDUC PYLN FEATURL5990 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions ADD LOW EXTREM PROSTH USER ADJUSTBLE HEEL HTL5999 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Endoskeletal Additions LOWER EXTREMITY PROSTHESIS NOSL6000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PARTIAL HAND THUMB REMAININGL6010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PARTIAL HAND LITTLE & OR RING FINGER REMAININGL6020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PARTIAL HAND NO FINGER REMAININGL6026 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb TRANSCARPAL/MC/PART HAND DISARTICULATION PROSL6050 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb WRST DISARTIC MOLD SOCKET FLEX ELB HNG TRICP PADL6055 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb WRST DISARTIC MOLD SOCKT W/XPNDABLE INTERFCEL6100 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb BELW ELB MOLD SOCKT FLXIBLE ELB HINGE TRICP PADL6110 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb BELOW ELBOW MOLDED SOCKETL6120 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb BELW ELB MOLD DBL WALL SCKT STEP-UP HNG 1/2 CUFFL6130 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb BELW ELB STUMP ACTVATD LOCK HINGE HALF CUFFL6200 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb ELB DISARTC MOLD SOCKT OUTSIDE LOCK HINGE FORARML6205 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb ELB DISARTC MOLD SCKT W/XPND INTRFCE LOCK FORARML6250 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb ABVE ELB MOLD DBL WALL SCKT INTRL LCK ELB FORARML6300 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb SHLDR DISARTIC MOLD SOCKET INTRL LOCK ELB FORARML6310 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb SHOULDER DISARTIC PASSIVE REST COMPLETE PROSTHL6320 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb SHOULDER DISART PASSIVE REST SHOULDER CAP ONLY

Page 18: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL6350 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb INTERSCAP THOR HUM SECT INTRL LOCK ELB FORARML6360 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb INTERSCAPULAR THOR PASSIVE REST CMPL PROSTHL6370 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb INTERSCAPULAR THOR PASSIVE REST SHLDR CAP ONLYL6380 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb IMMED POSTSURG RIGD DRSG 1 CAST CHG WRST DISRTCL6382 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb IMMED POSTSURG RIGD DRSG 1 CAST CHG ELB DISARTICL6384 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb IMMED POSTSURG RIGD DRSG 1 CAST CHG SHLDR DISRTCL6386 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb IMMED POSTSURG/EARLY FIT EA ADD CAST CHG&REALIGNL6388 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb IMMED POSTSURG/EARLY FIT APPLIC RIGID DRESS ONLYL6400 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb BE MOLD SCKT ENDOSKEL SYS W/SFT PROSTH TISS SHAPL6450 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb ELB DISRTC MOLD SCKT ENDOSKEL W/SFT PROSTH TISSL6500 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb ABVE ELB MOLD SCKT ENDOSKEL W/SFT PROSTH TISSL6550 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb SHLDR DISRTC MOLD SCKT ENDOSKEL W/SFT PROS TISSL6570 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb INTRSCAP THOR MOLD SCKT ENDOSKEL W/SFT PROS TISSL6580 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP WRST DISRTC/BELW ELB 1 WALL PLSTC SCKT MOLDL6582 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP WRST DISRTC/BELW ELB 1 WALL SCKT DIR FORMEDL6584 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP ELB DISRTC/ABVE ELB 1 WALL PLSTC SOCKT MOLDL6586 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP ELB DISRTC/ABVE ELB 1 WALL SOCKT DIR FORMEDL6588 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP SHLDR DISRTC THOR 1 WALL PLSTC SCKT MOLDL6590 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb PREP SHLDR DISRTC THOR 1 WALL SOCKET DIR FORML6600 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITIONS POLYCENTRIC HINGE PAIRL6605 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD SINGLE PIVOT HINGE PAIRL6610 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD FLEXIBLE METAL HINGE PAIRL6611 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UPPER EXT PROS EXTERNAL PWR ADDITIONAL SWTCHL6615 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD DISCONNECT LOCKING WRST UNITL6616 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTREM ADD DISCNCT INSERT LOCK WRST U EAL6620 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXT ADD FLEX/EXT WRIST UNIT W/WO FRICTIONL6621 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTREM PROS ADD FLEXION/EXTENSION WRISTL6623 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXT ADD SPRNG ASST ROTATL WRST U W/LATCH RLSEL6624 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD FLX/EXT ROTATION WRIST UNITL6625 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD ROTATION WRST UNIT W/CABLE LOCKL6628 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTRM ADD QUICK DISCNCT HOOK OTTO BOCK/=L6629 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTRM ADD QUICK DISCNCT LAMINATION COLLRL6630 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION STAINLESS STEEL ANY WRISTL6632 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION LATEX SUSPENSION SLEEVE EAL6635 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITION LIFT ASSIST FOR ELBOWL6637 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITION NUDGE CONTROL ELB LOCKL6638 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXT ADD PROS ELEC LOCK ONLY W/MNL PWR ELBL6640 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD SHOULDER ABDUCT JOINT PAIRL6641 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD EXCURSIONUPPER EXTREM ADD EXCURL6642 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD EXCURSION AMPLIFIER LEVER TYPEL6645 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION SHLDR FLEX-ABDUCT JOINT EAL6646 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXT ADD SHLDR JNT MX PSTN W/BDY/EXT PWR SYSL6647 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTREM ADD SHLDR LOCK MECH BDY PWR ACTUATORL6648 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTREM ADD SHLDR LOCK MECH EXT PWR ACTUATORL6650 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION SHLDR UNIVERSAL JOINT EAL6655 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD STANDARD CONTROL CABLE EXTRAL6660 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION HEAVY DUTY CONTROL CABLEL6665 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION TEFLON/EQUAL CABLE LININGL6670 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITION HOOK HAND CABLE ADAPTERL6672 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD HARNESS CHST/SHLUPPER EXTREM ADL6675 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD HARNESS SINGLE CABLE DESIGNL6676 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADD HARNESS DUAL CABLE DESIGNL6677 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXT ADD HARNESS 3 CNTRL SIMULTAN OP DEVC&ELBL6680 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTREM ADD TST SOCKT WRST DISARTIC/BELW ELBL6682 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD TST SOCKT ELB DISARTIC/ABVE ELBL6684 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTRM ADD TST SCKT SHLDR DISRTC/INTRSCAP THORL6686 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITION SUCTION SOCKETL6687 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTRM ADD FRME TYPE SCKT BELW ELB/WRST DISRTCL6688 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UP EXTRM ADD FRME TYPE SOCKT ABVE ELB/ELB DISRTCL6689 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD FRAME TYPE SOCKT SHLDR DISARTICL6690 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD FRAME TYPE SOCKT INTERSCAP-THOR

Page 19: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL6691 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREMITY ADDITION REMOVABLE INSERT EACHL6692 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADDITION SILCON GEL INSERT/EQUAL EAL6693 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions UPPER EXTREM ADD LOCK ELB FORARM COUNTERBALANCEL6694 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UP EXT PROS BELW/ABVE ELB CSTM W/LOCK MECHL6695 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UP EXT PROS BELW/ABVE ELB CSTM W/O LOCK MECHL6696 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UP EXT PROS ELB CSTM CNGN/TRAUMAT AMP INITL6697 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UP EXT PROS ELB CSTM NOT CNGN/TRAUM AMP INITL6698 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Upper Limb Additions ADD UP EXT PROS ELB LOCK MECH EXCL SCKT INSRTL6703 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERMINAL DEVICE PASSIVE HND/MITT ANY MATERIAL SZL6704 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERMINAL DEVICE SPORT/RECREATIONAL/WORK ATTACHL6706 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERMINAL DEVICE HOOK MECH VOLUNTARY OPENINGL6707 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERMINAL DEVICE HOOK MECH VOLUNTARY CLOSINGL6709 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERMINAL DEVICE HAND MECH VOLUNTARY CLOSINGL6711 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DVC HOOK MECH VOL OPN ANY MATL ANY SZ PEDL6712 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DVC HOOK MECH VOL CLOS ANY MATL ANY SZ PEDL6713 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DVC HAND MECH VOL OPN ANY MATL ANY SIZE PEDL6714 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DEVC HAND MECH VOL CLOS ANY MATL ANY SZ PEDL6715 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DEV MX ARTIC DIGIT W/MOTORS INIT ISSUE/REPLL6721 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DEVC HOOK/HND HVY-DUTY MECH VOL OPN ANY SZL6722 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices TERM DEVC HOOK/HAND HVY-DUTY MECH VOL CLOSL6805 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices ADDITION TERMINAL DEVICE MODIFIER WRIST UNITL6810 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices ADDITION TERMINAL DEVICE PRECISION PINCH DEVICEL6880 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices ELEC HAND SWTCH/MYOELEC CNTRL INDEP ARTC DIG MTRL6881 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices AUTOMATIC GRASP ADD UPPER LIMB ELEC PROSTH DEVCL6882 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices MICRPRROCSS CNTRL FEATUR ADD UP LIMB PROSTH DEVCL6883 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices REPL SOCKET BE/WD MOLDED TO PATIENT MODELL6884 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices REPL SOCKET ABOVE ELBOW/ELBOW DISART MOLD TO PTL6885 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices REPL SOCKET SD/INTERSCAPULAR THOR MOLD PT MODELL6890 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices ADD UP EXT PROSTH GLOV TERM DEVC PRFAB W/FIT&ADJL6895 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices ADD UP EXT PROSTH GLOV TERM DEVC MATL CSTM FABL6900 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices HAND REST PART HAND W/GLOVE THUMB/1 FNGR REMAINL6905 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices HAND REST PART HAND W/GLOVE MX FNGR REMAINL6910 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices HAND REST PART HAND W/GLOVE NO FNGR REMAINL6915 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Terminal Devices HAND RESTORATION REPLACEMENT GLOVE FOR ABOVEL6920 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power WRST DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVICEL6925 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power WRST DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVCL6930 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power BELOW ELBOW OTTO BOCK/=SWITCH CNTRL TERM DEVICEL6935 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power BELOW ELBOW OTTO BOCK/=MYOELEC CNTRL TERM DEVICEL6940 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELBOW DISARTIC OTTO BOCK/=SWITCH CNTRL TERM DEVCL6945 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELB DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVCL6950 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ABOVE ELBOW OTTO BOCK/=SWITCH CNTRL TERM DEVCL6955 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ABOVE ELBOW OTTO BOCK/=MYOELEC CNTRL TERM DEVCL6960 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power SHLDR DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVCL6965 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power SHOULDR DISARTIC OTTO BOCK/=MYOELEC CNTRL TERML6970 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power INTERSCAP-THOR OTTO BOCK/=SWTCH CNTRL TERM DEVCL6975 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power INTERSCAP-THOR OTTO BOCK/=MYOELEC CNTRL TERM DVCL7007 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELECTRIC HAND SWITCH/MYOELECTRIC CONTROL ADULTL7008 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELECTRIC HAND SWITCH/MYOELECTRIC CNTRL PEDIATRICL7009 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELECTRIC HOOK SWITCH/MYOELECTRIC CONTROL ADULTL7040 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power PREHENSILE ACTUATOR SWITCH CONTROLLEDL7045 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC HOOK SWITCH/MYOELECTRIC CONTOL PEDIATRICL7170 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELECTRONIC ELBOW HOSMER/EQUAL SWITCH CONTROLLEDL7180 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB MICROPRC SEQENTIAL CNTRL ELB&TERM DEVCL7181 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB MICROPRC SIMULTAN CNTRL ELB&TERM DEVCL7185 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB ADOLES VRITY VILLAGE/EQUAL SWITCH CNTRLL7186 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB CHILD VRITY VILLAGE/EQUAL SWITCH CNTRLL7190 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB ADOLES VRITY VILLAGE/= MYOELEC CNTRLL7191 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELEC ELB CHLD VRITY VILL/= MYOELECTRNICALY CNTRLL7259 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ELECTRONIC WRIST ROTATOR ANY TYPEL7360 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power SIX VOLT BATTERY EACHL7362 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power BATTERY CHARGER SIX VOLT EACH

Page 20: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionL7364 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power TWELVE VOLT BATTERY EACHL7366 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power BATTERY CHARGER 12 VOLT EACHL7367 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power LITHIUM ION BATTERY RECHARGEABLE REPLACEMENTL7368 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power LITHIUM ION BATTERY CHARGER REPLACEMENT ONLYL7400 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXTREM PROS BELOW ELB/WD ULTRALIGHT MATLL7401 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXTREM PROS AE DISART ULTRALIGHT MATLL7402 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXT PROS SD/INTRSCAPULR THOR ULTRALT MATLL7403 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXTREM PROS BE/WRIST DISART ACRYLIC MATLL7404 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXTREM PROS ABOVE ELB DISART ACRYLIC MATLL7405 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power ADD UP EXTREM PROS SD/INTERSCAP THOR ACRYLC MATLL7499 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-External Power UPPER EXTREMITY PROSTHESIS NOSL7510 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Repairs REPR PROSTHETIC DEVICE REPR/REPLACE MINOR PARTSL7600 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic-Repairs PROSTHETIC DONNING SLEEVE ANY MATERIAL EACHL8000 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROS MASTECTOMY BRA W/O INTEG PROS FORML8001 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROS MASTECT BRA W/INTEG BREAST FORM UNIL8002 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROS MASTECT BRA W/INTEG BREAST FORM BILL8010 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROSTHESIS MASTECTOMY SLEEVEL8015 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis EXT BRST PROS GARMNT W/MASTECT FORM POST-MASTECTL8020 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROSTHESIS MASTECTOMY FORML8030 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROSTH SILICONE/EQUAL W/O INTEGRAL ADHESL8031 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROSTHESIS SILICONE/EQUAL W/NTEGRAL ADHESL8032 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis NIPPLE PROSTHESIS PREFAB REUSABLE ANY TYPE EACHL8033 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis 3/6/2020 NIPPLE PROSTH CSTM FAB REUSABL ANY MATL ANY T EAL8035 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis CSTM BREAST PROSTH POST MASTECT MOLDED PT MODELL8039 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis BREAST PROSTHESIS NOT OTHERWISE SPECIFIEDL8040 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis NASAL PROSTHESIS PROVIDED BY A NON-PHYSICIANL8041 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis MIDFACIAL PROSTHESIS PROVIDED BY A NON-PHYSICIANL8042 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis ORBITAL PROSTHESIS PROVIDED BY A NON-PHYSICIANL8043 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis UPPER FACIAL PROSTHESIS PROVIDED A NON-PHYSICIANL8044 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis HEMI-FACIAL PROSTHESIS PROVIDED A NON-PHYSICIANL8045 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis AURICULAR PROSTHESIS PROVIDED BY A NON-PHYSICIANL8046 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis PARTIAL FACIAL PROSTHESIS PROVIDED NON-PHYSICIANL8047 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis NASAL SEPTAL PROSTHESIS PROVIDED A NON-PHYSICIANL8048 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis UNS MAXILLOFCE PROSTH BR PROVIDED NON-PHYSICIANL8049 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthesis REP/MOD MAXLOFCE PROSTH LABR EA 15 MIN NON-MDL8680 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACHL8681 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants PT PROG W/IMPL PROG NEUROSTM PULSE GEN REPL ONLYL8682 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANTABLE NEUROSTIMULATOR RADIOFREQ RECEIVERL8683 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants RF TRNSMT USE W/IMPLANTABLE NEUROSTIM RF RECVL8684 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants RF TRNSMT IMPL SCRL NEURO BOWEL BLADDR MGMT REPLL8685 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANT NEUROSTIM 1 ARRAY RECHARGEABLEL8686 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANT NEUROSTIM 1 ARRAY NON-RECHARGEABLEL8687 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANT NEUROSTIM 2 ARRAY RECHARGEABLEL8688 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants IMPLANT NEUROSTIM 2 ARRAY NON-RECHARGEABLEL8689 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants EXT RECHARG SYS BATTRY IMPL NEUROSTIM REPL ONLYL8695 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants EXT RECHARGING SYS BATTERY W/IMPL NEUROSTIM REPLL8699 HCPCS HCPCS - L CODES (ORTHOTIC/PROSTHETIC PROCEDURES) Prosthetic Implants PROSTHETIC IMPLANT NOT OTHERWISE SPECIFIEDS0516 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare SAFETY EYEGLASS FRAMESS1040 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare CRANIAL REMOLDING ORTHOTIC PED RIGID CUSTOM FABS5160 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare EMERGENCY RESPONSE SYSTEM; INSTALLATION&TESTINGS5161 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare EMERGENCY RESPONSE SYSTEM; SERVICE FEE PER MONTHS8420 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE AID SLEEVE&GLOVE CUSTOM MADES8422 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE AID SLEEVE CUSTOM MED WEIGHTS8423 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE AID SLEEVE CUSTOM HEAVY WEIGHTS8425 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE AID GLOVE CUSTOM MEDIUM WEIGHTS8426 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE AID GLOVE CUSTOM HEAVY WEIGHTS8429 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare GRADIENT PRESSURE EXTERIOR WRAPS9123 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare NURSING CARE THE HOME; REGISTERED NURSE PER HOURS9124 HCPCS HCPCS - S CODES (PRIVATE PAYER CODES) Temporary - Non-Medicare NURSING CARE IN THE HOME; BY LPN PER HOURT1001 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid NURSING ASSESSMENT/EVALUATIONT1002 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid RN SERVICES UP TO 15 MINUTES

Page 21: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionT1003 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid LPN/LVN SERVICES UP TO 15 MINUTEST1019 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid PERSONAL CARE SERVICES PER 15 MINUTEST1021 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid HOME HEALTH AIDE/CERTIFIED NURSE ASST PER VISITT1502 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid ADMIN ORL IM&/SUBQ MED HLTH CARE AGCY/PROF-VISITT2042 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid HOSPICE ROUTINE HOME CARE; PER DIEMT2043 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid HOSPICE CONTINUOUS HOME CARE; PER HOURT2044 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid HOSPICE INPATIENT RESPITE CARE; PER DIEMT2046 HCPCS HCPCS - T CODES (STATE MEDICAID AGENCY CODES) National T Codes - Medicaid HOSPICE LONG TERM CARE RM AND BD ONLY PER DIEMV5030 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID MONAURAL BODY WORN AIR CONDUCTIONV5040 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID MONAURAL BODY WORN BONE CONDUCTIONV5050 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID MONAURAL IN THE EARV5060 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID MONAURAL BEHIND THE EARV5070 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services GLASSES AIR CONDUCTIONV5080 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services GLASSES BONE CONDUCTIONV5090 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE UNSPECIFIED HEARING AIDV5100 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID BILATERAL BODY WORNV5110 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE BILATERALV5120 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services BINAURAL BODYV5130 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services BINAURAL IN THE EARV5140 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services BINAURAL BEHIND THE EARV5150 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services BINAURAL GLASSESV5160 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE BINAURALV5171 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT DEVICE MONAURAL ITEV5172 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT DEVICE MONAURAL ICTV5181 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALATERAL ROUT DVC MONAURAL BTEV5190 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALATERAL RTE MONAURAL GLASSESV5200 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE CONTRALATERAL MONAURALV5211 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL ITE/ITEV5212 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL ITE/ITCV5213 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL ITE/BTEV5214 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL ITC/ITCV5215 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL ITC/BTEV5221 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT ROUT SYS BINAURAL BTE/BTEV5230 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID CONTRALAT RTE SYS BINAURAL GLASSESV5240 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE CONTRALATERAL RTE SYSTEM BINAURALV5241 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services DISPENSING FEE MONAURAL HEARING AID ANY TYPEV5242 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID ANALOG MONAURAL CICV5243 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID ANALOG MONAURAL ITCV5244 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG MONAURAL CICV5245 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG MONAURAL ITCV5246 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG MONAURAL ITEV5247 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG MONAURAL BTEV5248 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID ANALOG BINAURAL CICV5249 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID ANALOG BINAURAL ITCV5250 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG BINAURAL CICV5251 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGTLLY PROG ANALOG BINAURAL ITCV5252 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITALLY PROGRAMMABLE BINAURAL ITEV5253 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITALLY PROGRAMMABLE BINAURAL BTEV5254 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL MONAURAL CICV5255 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL MONAURAL ITCV5256 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL MONAURAL ITEV5257 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL MONAURAL BTEV5258 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL BINAURAL CICV5259 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL BINAURAL ITCV5260 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL BINAURAL ITEV5261 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID DIGITAL BINAURAL BTEV5264 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services EAR MOLD/INSERT NOT DISPOSABLE ANY TYPEV5267 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services HEARING AID/ALD/SUPP/ACCESS NOT OTHERWISE SPECV5273 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSTIVE LISTENING DEVICE USE W/COCHLEAR IMPLANTV5274 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSISTIVE LEARNING DEVICE NOSV5275 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services EAR IMPRESSION EACH

Page 22: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes DescriptionV5281 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LIST DEVC PERS FM/DM SYS MONAURL ANY TYPEV5282 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LIST DEVC PERS FM/DM SYS BINAURL ANY TYPEV5283 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LIST DEVC PERS FM/DM NCK LOOP INDUCT RECVV5284 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LIST DEVICE PERS FM/DM EAR LEVEL RECEIVERV5285 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LIST DEVC PERS FM/DM DIR AUDIO INPUT RECVV5286 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LISTEN DEVC PERS BLUE TOOTH FM/DM RECEIVRV5287 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSISTIVE LISTENING DEVC PERS FM/DM RECEIVER NOSV5288 HCPCS HCPCS - V CODES (HEARING SERVICES) Hearing Services ASSIST LISTEN DEVC PERS FM/DM TRANSMITTER ALDV2118 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware ANISEIKONIC LENS SINGLE VISIONV2199 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware NOT OTHERWISE CLASSIFIED SINGLE VISION LENSV2218 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware ANISEIKONIC PER LENS BIFOCALV2299 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware SPECIALTY BIFOCALV2318 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware ANISEIKONIC LENS TRIFOCALV2399 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware SPECIALTY TRIFOCALV2410 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNSV2430 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENSV2499 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware VARIABLE SPHERICITY LENS OTHER TYPEV2500 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS PMMA SPHERICAL PER LENSV2501 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENSV2502 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS PMMA BIFOCAL PER LENSV2503 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS PMMA COLOR VISION DEFIC PER LENSV2510 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS GAS PERMEABLE SPHERICAL PER LENSV2511 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CNTC LENS GAS PERMEABLE TORIC PRISM BALLST-LENSV2512 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS GAS PERMEABLE BIFOCAL PER LENSV2513 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CNTC LENS GAS PERMEABLE EXTENDED WEAR PER LENSV2520 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS HYDROPHILIC SPHERICAL PER LENSV2521 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CNTC LENS HYDROPHIL TORIC/PRISM BALLST PER LENSV2522 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS HYDROPHILIC BIFOCAL PER LENSV2523 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENSV2530 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS SCLERAL GAS IMPERMEABLE PER LENSV2531 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS SCLERAL GAS PERMEABLE PER LENSV2599 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware CONTACT LENS OTHER TYPEV2600 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware HAND HELD LOW VISION&OTH NON SPECTACL MOUNT AIDSV2610 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware SINGLE LENS SPECTACLE MOUNTED LOW VISION AIDSV2615 HCPCS HCPCS - V CODES (VISION SERVICES) Vision-Hardware TELESCOPIC & OTH COMPOUND LENS SYSTEMV2623 HCPCS HCPCS - V CODES (VISION SERVICES) Prosthetic Eye PROSTHETIC EYE PLASTIC CUSTOMV2624 HCPCS HCPCS - V CODES (VISION SERVICES) Prosthetic Eye POLISHING/RESURFACING OF OCULAR PROSTHESISV2625 HCPCS HCPCS - V CODES (VISION SERVICES) Prosthetic Eye ENLARGEMENT OF OCULAR PROSTHESISV2626 HCPCS HCPCS - V CODES (VISION SERVICES) Prosthetic Eye REDUCTION OF OCULAR PROSTHESISV2700 HCPCS HCPCS - V CODES (VISION SERVICES) Misc BALANCE LENS PER LENSV2710 HCPCS HCPCS - V CODES (VISION SERVICES) Misc SLAB OFF PRISM GLASS OR PLASTIC PER LENSV2718 HCPCS HCPCS - V CODES (VISION SERVICES) Misc PRESS-ON LENS FRESNELL PRISM PER LENSV2730 HCPCS HCPCS - V CODES (VISION SERVICES) Misc SPECIAL BASE CURVE GLASS OR PLASTIC PER LENSV2744 HCPCS HCPCS - V CODES (VISION SERVICES) Misc TINT PHOTOCHROMATIC PER LENSV2745 HCPCS HCPCS - V CODES (VISION SERVICES) Misc ADD LENS; TINT COLOR SOLID EXCLD PHOTOCHRMATCV2755 HCPCS HCPCS - V CODES (VISION SERVICES) Misc U-V LENS PER LENSV2760 HCPCS HCPCS - V CODES (VISION SERVICES) Misc SCRATCH RESISTANT COATING PER LENSV2761 HCPCS HCPCS - V CODES (VISION SERVICES) Misc MIRROR COAT TYPE SOLID GRADENT/= LENS MATL-LENSV2762 HCPCS HCPCS - V CODES (VISION SERVICES) Misc POLARIZATION ANY LENS MATERIAL PER LENSV2770 HCPCS HCPCS - V CODES (VISION SERVICES) Misc OCCLUDER LENS PER LENSV2780 HCPCS HCPCS - V CODES (VISION SERVICES) Misc OVERSIZE LENS PER LENSV2781 HCPCS HCPCS - V CODES (VISION SERVICES) Misc PROGRESSIVE LENS PER LENSV2782 HCPCS HCPCS - V CODES (VISION SERVICES) Misc LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENSV2783 HCPCS HCPCS - V CODES (VISION SERVICES) Misc LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENSV2784 HCPCS HCPCS - V CODES (VISION SERVICES) Misc LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENSV2786 HCPCS HCPCS - V CODES (VISION SERVICES) Misc SPECIALTY OCCUPATIONAL MULTIFOCAL LENS PER LENSV2797 HCPCS HCPCS - V CODES (VISION SERVICES) Misc VISN SPL ACSS &/ SRVC CMPNT ANOTHER HCPCS CODEV2799 HCPCS HCPCS - V CODES (VISION SERVICES) Misc VISION ITEM OR SERVICE MISCELLANEOUST2045 PROFESSIONAL Medicaid Family Care Partnership w LTC MCD FCP w LTC (HCPC) HOSPICE GENERAL INPATIENT CARE; PER DIEM90378 CPT CODES MEDICINE IMMUNE GLOBULINS RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E90901 CPT CODES MEDICINE BIOFEEDBACK BIOFEEDBACK TRAINING ANY MODALITY

Page 23: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description90912 CPT CODES MEDICINE Biofeedback 3/6/2020 BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT91110 CPT CODES MEDICINE Gastroenterology GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R91111 CPT CODES MEDICINE GASTROENTEROLOGY GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R92507 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC IND92508 CPT CODES MEDICINE Diagnostic/Treatment TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV92520 CPT CODES MEDICINE Diagnostic/Treatment LARYNGEAL FUNCTION STUDIES92521 CPT CODES MEDICINE Diagnostic/Treatment EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER)92522 CPT CODES MEDICINE Diagnostic/Treatment EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE92523 CPT CODES MEDICINE Diagnostic/Treatment EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION92524 CPT CODES MEDICINE Diagnostic/Treatment BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE92526 CPT CODES MEDICINE Diagnostic/Treatment TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING92597 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES EVAL&/FITG VOICE PROSTC DEV SUPLMNT ORAL SPEEC92601 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG92602 CPT CODES MEDICINE Diagnostic Assessment-Cochlear Implant ANALYSIS COCHLEAR IMPLT PT <7 YR SBSQ REPRGRMG92603 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG92604 CPT CODES MEDICINE Diagnostic Assessment-Cochlear Implant ANALYSIS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG92605 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV F2F 1ST HR92606 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ92607 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR92608 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN92609 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES THER SP-GENRATJ DEV PRGRMG&MODIFICAJ92610 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services EVAL ORAL&PHARYNGEAL SWLNG FUNCJ92611 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES MOTION FLUOR EVAL SWLNG FUNCJ C/V REC92612 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services FLEXIBLE ENDOSCOPIC EVAL SWALLOW C/V REC92613 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES FLEXIBLE ENDOSCOPIC EVAL SWALLOW C/V REC I&R92614 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services FLEXIBLE ENDOSCOPIC EVAL LARYN SENSORY C/V REC92615 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES FLEXIBLE ENDOSCOPIC EVAL LARYN SENS C/V REC I&R92618 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV ADD 30 MIN92620 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN92621 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN92626 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV 1ST HR92627 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV EA ADDL 1592630 CPT CODES MEDICINE SPECIAL OTORHINOLARYNGOLOGIC SERVICES AUDITORY REHABILITATION PRELINGUAL HEARING LOSS92633 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS92700 CPT CODES MEDICINE Audiology-Evaluation/Therapeutic Services UNLISTED OTORHINOLARYNGOLOGICAL SERVICE93797 CPT CODES MEDICINE CARDIOVASCULAR OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR93798 CPT CODES MEDICINE Cardiac Rehabilitation OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING93799 CPT CODES MEDICINE CARDIOVASCULAR UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE94667 CPT CODES MEDICINE PULMONARY MANJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL94669 CPT CODES MEDICINE Pulmonary-Procedures/Services MECHANICAL CHEST WALL OSCILLATION LUNG FUNCTION95700 CPT CODES MEDICINE EEG Studies 3/6/2020 EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS95873 CPT CODES MEDICINE NEUROLOGY AND NEUROMUSCULAR PROCEDURES ELECTRICAL STIMULATION GUID W/CHEMODENERVATION95874 CPT CODES MEDICINE Muscle and Motion Studies NEEDLE EMG GUID W/CHEMODENERVATION95992 CPT CODES MEDICINE Neurology-Other Services CANALITH REPOSITIONING PROCEDURE96020 CPT CODES MEDICINE Neurofunctional Brain Testing TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP96105 CPT CODES MEDICINE NULL ASSESSMENT APHASIA W/INTERP & REPORT PER HOUR96900 CPT CODES MEDICINE Dermatological Procedures ACTINOTHERAPY ULTRAVIOLET LIGHT96910 CPT CODES MEDICINE SPECIAL DERMATOLOGICAL PROCEDURES PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB96912 CPT CODES MEDICINE Dermatological Procedures PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA96913 CPT CODES MEDICINE SPECIAL DERMATOLOGICAL PROCEDURES PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION97010 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS97012 CPT CODES MEDICINE Modalities APPL MODALITY 1/> AREAS TRACTION MECHANICAL97014 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED97016 CPT CODES MEDICINE Modalities APPL MODALITY 1/> AREAS VASOPNEUMATIC DEVICES97018 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPL MODALITY 1/> AREAS PARAFFIN BATH97022 CPT CODES MEDICINE Modalities APPLICATION MODALITY 1/> AREAS WHIRLPOOL97024 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPLICATION MODALITY 1/> AREAS DIATHERMY97026 CPT CODES MEDICINE Modalities APPLICATION MODALITY 1/> AREAS INFRARED97028 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPL MODALITY 1/> AREAS ULTRAVIOLET97032 CPT CODES MEDICINE Modalities APPL MODALITY 1/> AREAS ELEC STIMJ EA 15 MIN97033 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPL MODALITY 1/> AREAS IONTOPHORESIS EA 15 MIN

Page 24: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description97034 CPT CODES MEDICINE Modalities APPL MODALITY 1/> AREAS CONTRAST BATHS EA 15 MIN97035 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION APPL MODALITY 1/> AREAS ULTRASOUND EA 15 MIN97036 CPT CODES MEDICINE Modalities APPL MODALITY 1/> AREAS HUBBARD TANK EA 15 MIN97039 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION UNLIST MODALITY SPEC TYPE&TIME CONSTANT ATTEND97110 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES97112 CPT CODES MEDICINE Modalities THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA97113 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION THER PX 1/> AREAS EACH 15 MIN AQUA THER W/XERSS97116 CPT CODES MEDICINE Modalities THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR97124 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION THER PX 1/> AREAS EACH 15 MINUTES MASSAGE97139 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION UNLISTED THERAPEUTIC PROCEDURE SPECIFY97140 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES97150 CPT CODES MEDICINE Modalities THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS97161 CPT CODES MEDICINE Physical Therapy PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS97162 CPT CODES MEDICINE Physical Therapy PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS97163 CPT CODES MEDICINE Physical Therapy PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS97164 CPT CODES MEDICINE Physical Therapy PHYSICAL THERAPY RE-EVAL EST PLAN CARE 20 MINS97165 CPT CODES MEDICINE Occupational Therapy OCCUPATIONAL THERAPY EVAL LOW COMPLEX 30 MINS97166 CPT CODES MEDICINE Occupational Therapy OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS97167 CPT CODES MEDICINE Occupational Therapy OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS97168 CPT CODES MEDICINE Occupational Therapy OCCUPATIONAL THER RE-EVAL EST PLAN CARE 30 MINS97169 CPT CODES MEDICINE Athletic Training ATHLETIC TRAINING EVAL LOW COMPLEX 15 MINS97170 CPT CODES MEDICINE Athletic Training ATHLETIC TRAINING EVAL MOD COMPLEX 30 MINS97171 CPT CODES MEDICINE Athletic Training ATHLETIC TRAINING EVAL HIGH COMPLEX 45 MINS97172 CPT CODES MEDICINE Athletic Training ATHLETIC TRAINING RE-EVAL EST PLAN CARE 20 MINS97530 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN97533 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION SENSORY INTEGRATIVE TECHNIQUES EACH 15 MINUTES97535 CPT CODES MEDICINE Modalities SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES97537 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION COMMUNITY/WORK REINTEGRATION TRAING EA 15 MIN97542 CPT CODES MEDICINE Modalities WHEELCHAIR MGMT EA 15 MIN97545 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION WORK HARDENING/CONDITIONING 1ST 2 HR97546 CPT CODES MEDICINE Modalities WORK HARDENING/CONDITIONING EACH HOUR97597 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION PA only required if completed during PT/OT DEBRIDEMENT OPEN WOUND 20 SQ CM/<97598 CPT CODES MEDICINE Wound Care PA only required if completed during PT/OT DEBRIDEMENT OPEN WOUND EACH ADDITIONAL 20 SQ CM97760 CPT CODES MEDICINE PHYSICAL MEDICINE AND REHABILITATION ORTHOTICS MGMT & TRAING INITIAL ENCTR EA 15 MINS97799 CPT CODES MEDICINE Physical Therapy UNLISTED PHYSICAL MEDICINE/REHAB SERVICE/PROC99504 CPT CODES MEDICINE Home Visits HOME VISIT MECHANICAL VENTILATION CARE99509 CPT CODES MEDICINE Home Visits HOME VISIT ASSISTANCE DAILY LIV&PRSONAL CARE99600 CPT CODES MEDICINE Home Visits UNLISTED HOME VISIT SERVICE/PROCEDURE99605 CPT CODES MEDICINE Medication Management By Pharmacist MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT99606 CPT CODES MEDICINE Medication Management By Pharmacist MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT0155U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 PIK3CA GENE ANALYSIS0156U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 COPY NUMBER SEQUENCE ANALYSIS0158U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 MLH1 GENE MRNA SEQUENCE ANALYSIS0159U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 MSH2 GENE MRNA SEQUENCE ANALYSIS0160U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 MSH6 GENE MRNA SEQUENCE ANALYSIS0161U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 PMS2 GENE MRNA SEQUENCE ANALYSIS0162U CPT CODES PATHOLOGY AND LABORATORY Proprietary Laboratory Analyses 3/6/2020 HERED COLON CA TARGETED MRNA SEQUENCE ALYS PANEL80305 CPT CODES PATHOLOGY AND LABORATORY Drug Testing DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE80306 CPT CODES PATHOLOGY AND LABORATORY Drug Testing DRUG TST PRSMV READ INSTRMNT ASSTD DIR OPT OBS80307 CPT CODES PATHOLOGY AND LABORATORY Drug Testing DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE81105 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-1 GENOTYPING GENE ANALYSIS COMMON VARIANT81106 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-2 GENOTYPING GENE ANALYSIS COMMON VARIANT81107 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-3 GENOTYPING GENE ANALYSIS COMMON VARIANT81108 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-4 GENOTYPING GENE ANALYSIS COMMON VARIANT81109 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-5 GENOTYPING GENE ANALYSIS COMMON VARIANT81110 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-6 GENOTYPING GENE ANALYSIS COMMON VARIANT81111 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-9 GENOTYPING GENE ANALYSIS COMMON VARIANT81112 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HPA-15 GENOTYPING GENE ANALYSIS COMMON VARIANT81120 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IDH1 COMMON VARIANTS81121 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IDH2 COMMON VARIANTS81161 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular DMD DUPLICATION/DELETION ANALYSIS

Page 25: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description81162 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRCA1 BRCA2 GENE ALYS FULL SEQ FULL DUP/DEL ALYS81170 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular ABL1 GENE ANALYSIS KINASE DOMAIN VARIANTS81175 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular ASXL1 GENE ANALYSIS FULL GENE SEQUENCE81176 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular ASXL1 GENE ANALYSIS TARGETED SEQ ANALYSIS81200 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular ASPA GENE ANALYSIS COMMON VARIANTS81201 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular APC GENE ANALYSIS FULL GENE SEQUENCE81202 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular APC GENE ANALYSIS KNOWN FAMILIAL VARIANTS81203 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular APC GENE ANALYSIS DUPLICATION/DELETION VARIANTS81205 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BCKDHB GENE ANALYSIS COMMON VARIANTS81206 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE81207 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE81208 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BCR/ABL1 OTHER BREAKPNT QUALITATIVE/QUANTITATIVE81209 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BLM GENE ANALYSIS 2281DEL6INS7 VARIANT81210 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRAF GENE ANALYSIS V600 VARIANT(S)81212 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRCA1 BRCA 2 GEN ALYS 185DELAG 5385INSC 6174DELT81215 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRCA1 GENE ANALYSIS KNOWN FAMILIAL VARIANT81216 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS81217 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular BRCA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT81218 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CEBPA GENE ANALYSIS FULL GENE SEQUENCE81219 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CALR GENE ANALYSIS COMMON VARIANTS IN EXON 981220 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CFTR GENE ANALYSIS COMMON VARIANTS81221 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS81222 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS81223 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CFTR GENE ANALYSIS FULL GENE SEQUENCE81224 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS81228 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CYTOGENOM CONST MICROARRAY COPY NUMBER VARIANTS81229 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CYTOGENOM CONST MICROARRAY COPY NUMBER&SNP VAR81230 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CYP3A4 GENE ANALYSIS COMMON VARIANTS81231 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CYP3A5 GENE ANALYSIS COMMON VARIANTS81232 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular DYPD GENE ANALYSIS COMMON VARIANTS81235 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular EGFR GENE ANALYSIS COMMON VARIANTS81238 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular F9 FULL GENE SEQUENCE81240 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular F2 GENE ANALYSIS 20210G >A VARIANT81241 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT81242 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular FANCC GENE ANALYSIS COMMON VARIANT81243 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular FMR1 ANALYSIS EVAL TO DETECT ABNORMAL ALLELES81244 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES81245 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular FLT3 GENE ANALYSIS INTERNAL TANDEM DUP VARIANTS81246 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular FLT3 GENE ANLYS TYROSINE KINASE DOMAIN VARIANTS81247 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular G6PD GENE ANALYSIS COMMON VARIANTS81248 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular G6PD GENE ANALYSIS KNOWN FAMILIAL VARIANTS81249 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular G6PD GENE ANALYSIS FULL GENE SEQUENCE81250 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular G6PC GENE ANALYSIS COMMON VARIANTS81251 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS81252 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular GJB2 GENE ANALYSIS FULL GENE SEQUENCE81256 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS81257 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIANT81258 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBA1/HBA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT81259 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE81260 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IKBKAP GENE ANALYSIS COMMON VARIANTS81261 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IGH@ REARRANGE ABNORMAL CLONAL POP AMPLIFIED81262 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IGH@ REARRANGE ABNORMAL CLONAL POP DIRECT PROBE81263 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IGH@ VARIABLE REGION SOMATIC MUTATION ANALYSIS81264 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IGK@ GENE REARRANGE DETECT ABNORMAL CLONAL POP81265 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC81266 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN81267 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION81268 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA81269 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS81270 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular JAK2 GENE ANALYSIS P.VAL617PHE VARIANT81272 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular KIT GENE ANALYSIS TARGETED SEQUENCE ANALYSIS

Page 26: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description81273 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular KIT GENE ANALYSIS D816 VARIANT(S)81275 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular KRAS GENE ANALYSIS VARIANTS IN EXON 281276 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular KRAS GENE ANALYSIS ADDITIONAL VARIANT(S)81277 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular 3/6/2020 CYTOGENOMIC NEOPLASIA MICROARRAY ANALYSIS81283 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular IFNL3 GENE ANALYSIS RS12979860 VARIANT81287 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MGMT GENE PROMOTER METHYLATION ANALYSIS81288 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MLH1 GENE ANALYSIS PROMOTER METHYLATION ANALYSIS81290 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS81292 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS81293 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MLH1 GENE ANALYSIS KNOWN FAMILIAL VARIANTS81294 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MLH1 GENE ANALYSIS DUPLICATION/DELETION VARIANTS81295 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS81296 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS81297 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS81298 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS81299 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH6 GENE ANALYSIS KNOWN FAMILIAL VARIANTS81300 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIA81301 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MICROSATELLITE INSTAB ANAL MISMATCH REPAIR DEF81302 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MECP2 GENE ANALYSIS FULL SEQUENCE81303 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MECP2 GENE ANALYSIS KNOWN FAMILIAL VARIANT81304 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular MECP2 GENE ANALYSIS DUPLICATION/DELETION VARIANT81307 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular 3/6/2020 PALB2 GENE ANALYSIS FULL GENE SEQUENCE81308 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular 3/6/2020 PALB2 GENE ANALYSIS KNOWN FAMILIAL VARIANT81309 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular 3/6/2020 PIK3CA GENE ANALYSIS TARGETED SEQUENCE ANALYSIS81310 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular NPM1 NUCLEOPHOSMIN GENE ANAL EXON 12 VARIANTS81311 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular NRAS GENE ANALYSIS VARIANTS IN EXON 2&381313 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PCA3/KLK3 PROSTATE SPECIFIC ANTIGEN RATIO81314 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PDGFRA GENE ANALYS TARGETED SEQUENCE ANALYS81315 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PML/RARALPHA COMMON BREAKPOINTS QUAL/QUANT81316 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PML/RARALPHA SINGLE BREAKPOINT QUAL/QUAN81317 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMS2 GENE ANALYSIS FULL SEQUENCE81318 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMS2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS81319 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS81321 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS81322 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT81323 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT81324 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS81325 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS81326 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT81327 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular SEPT9 GENE PROMOTER METHYLATION ANALYSIS81328 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular SLCO1B1 GENE ANALYSIS COMMON VARIANTS81330 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular SMPD1 GENE ANALYSIS COMMON VARIANTS81331 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular SNRPN/UBE3A METHYLATION ANALYSIS81334 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular RUNX1 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS81335 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular TPMT GENE ANALAYSIS COMMON VARIANTS81340 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD81341 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular TRB@ REARRANGEMENT ANAL DIRECT PROBE METHODOLOGY81342 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular TRG@ GENE REARRANGEMENT ANALYSIS81346 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular TYMS GENE ANALYSIS COMMON VARIANTS81355 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular VKORC1 GENE ANALYSIS COMMON VARIANT(S)81361 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBB COMMON VARIANTS81362 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBB KNOWN FAMILIAL VARIANTS81363 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBB DUPLICATION/DELETION VARIANTS81364 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HBB FULL GENE SEQUENCE81370 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS I&II LOW HLA-A -B -C -DRB1/3/4/5&DQB81371 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA I&LI LOW RESOLUTION HLA-A -B&-DRB181372 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS I TYPING LOW RESOLUTION COMPLETE81373 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS I TYPING LOW RESOLUTION ONE LOCUS EACH81374 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA I LOW RESOLUTION ONE ANTIGEN EQUIVALENT EACH81375 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA II LOW RESOLUTION HLA-DRB1/3/4/5 AND -DQB181376 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS II TYPING LOW RESOLUTION ONE LOCUS EA

Page 27: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description81377 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA II LOW RESOLUTION ONE ANTIGEN EQUIVALENT EA81378 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA I&II HIGH RESOLUTION HLA-A -B -C AND -DRB181379 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS I TYPING HIGH RESOLUTION COMPLETE81380 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS I TYPING HIGH RESOLUTION ONE LOCUS EA81381 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA I TYPING HIGH RESOLUTION 1 ALLELE/ALLELE GRP81382 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA CLASS II TYPING HIGH RESOLUTION ONE LOCUS EA81383 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HLA II HIGH RESOLUTION 1 ALLELE/ALLELE GROUP81400 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 181401 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 281402 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 381403 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 481404 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 581405 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 681406 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 781407 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 881408 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 MOLECULAR PATHOLOGY PROCEDURE LEVEL 981410 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 AORTIC DYSFUNCTION/DILATION GENOMIC SEQ ANALYSIS81411 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 AORTIC DYSFUNCTION/DILATION DUP/DEL ANALYSIS81412 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN81413 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 CAR ION CHNNLPATH GENOMIC SEQ ALYS INC 10 GNS81414 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 CAR ION CHNNLPATH DUP/DEL GN ALYS PANEL 2 GENES81415 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 EXOME SEQUENCE ANALYSIS81416 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 EXOME SEQUENCE ANALYSIS EACH COMPARATOR EXOME81417 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 EXOME RE-EVAL OF PREVIOUSLY OBTAINED EXOME SEQ81420 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS81422 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 FETAL CHROMOSOMAL MICRODELTJ GENOMIC SEQ ANALYS81425 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GENOME SEQUENCE ANALYSIS81426 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GENOME SEQUENCE ANALYSIS EACH COMPARATOR GENOME81427 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GENOME RE-EVALUATION OF PREC OBTAINED GENOME SEQ81430 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEARING LOSS GENOMIC SEQUENCE ANALYSIS 60 GENES81431 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEARING LOSS DUP/DEL ANALYSIS81432 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY BRST CA-RELATED GEN SEQ ANALYS 10 GEN81433 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY BRST CA-RELATED DUP/DEL ANALYSIS81434 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY RETINAL DSRDRS GEN SEQ ANALYS 15 GEN81435 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY COLON CA DSRDRS GEN SEQ ANALYS 10 GEN81436 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY COLON CA DSRDRS DUP/DEL ANALYS 5 GEN81437 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDTRY NURONDCRN TUM DSRDRS GEN SEQ ANAL 6 GEN81438 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDTRY NURONDCRN TUM DSRDRS DUP/DEL ANALYSIS81439 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 HEREDITARY CARDIOMYOPATHY GEN SEQ ANALYS 5 GEN81440 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 NUCLEAR MITOCHONDRIAL 100 GENE GENOMIC SEQ81442 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 NOONAN SPECTRUM DISORDERS GEN SEQ ANALYS 12 GEN81445 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE81448 CPT CODES PATHOLOGY AND LABORATORY Labs - Molecular HEREDITARY PERIPHERAL NEUROPATHY GEN SEQ PNL81450 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE81455 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51/> GEN81460 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 WHOLE MITOCHONDRIAL GENOME81470 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 X-LINKED INTELLECTUAL DBLT GENOMIC SEQ ANALYS81471 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 X-LINKED INTELLECTUAL DBLT DUP/DEL GENE ANALYS81479 CPT CODES PATHOLOGY AND LABORATORY Pathology - Molecular Level 1-9 UNLISTED MOLECULAR PATHOLOGY PROCEDURE81490 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) AUTOIMMUNE RHEUMATOID ARTHRTS ANALYS 12 BIOMRKRS81493 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) COR ART DISEASE MRNA GENE EXPRESSION 23 GENES81500 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS81503 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS81504 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY TISSUE OF ORIGIN SIMILAR SCOR ALGORITHM81506 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL81507 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) FETAL ANEUPLOIDY 21 18 13 SEQ ANALY TRISOM RISK81508 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS81509 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS81510 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) FETAL CONGENITAL ABNOR ASSAY THREE ANAL81512 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) FETAL CONGENITAL ABNOR ASSAY FIVE ANAL81519 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY BREAST MRNA GENE EXPRESSION 21 GENES

Page 28: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description81520 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONC BREAST MRNA GENE XPRSN PRFL HYBRD 58 GENES81521 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONC BREAST MRNA MICRORA GENE XPRSN PRFL 70 GENES81522 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) 3/6/2020 ONCOLOGY BREAST MRNA GENE XPRSN PRFL 12 GENES81525 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY COLON MRNA GENE EXPRESSION 12 GENES81535 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP 1ST81536 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY GYNE LIVE TUM CELL CLTR&CHEMO RESP ADD81538 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY LUNG MS 8-PROTEIN SIGNATURE81539 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY PROSTATE BIOCHEMICAL ASSAY 4 PROTEINS81540 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY TUM UNKNOWN ORIGIN MRNA 92 GENES81541 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONC PRST8 MRNA GENE XPRSN PRFL RT-PCR 46 GENES81542 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) 3/6/2020 ONC PRST8 MRNA MICRORA GENE XPRSN PRFL 22 GENES81545 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONCOLOGY THYROID GENE EXPRESSION 142 GENES81551 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) ONC PRST8 PRMTR METHYLATION PRFL R-T PCR 3 GENES81552 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) 3/6/2020 ONC UVEAL MLNMA MRNA GENE XPRSN PRFL 15 GENES81595 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) CARDIOLOGY HRT TRNSPL MRNA GENE EXPRESS 20 GENES81599 CPT CODES PATHOLOGY AND LABORATORY Multianalyte/Assay/Algorithmic/Analysis (MAAA) UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS82670 CPT CODES PATHOLOGY AND LABORATORY CHEMISTRY ASSAY OF ESTRADIOL83001 CPT CODES PATHOLOGY AND LABORATORY Labs-Chemistry GONADOTROPIN FOLLICLE STIMULATING HORMONE83002 CPT CODES PATHOLOGY AND LABORATORY CHEMISTRY GONADOTROPIN LUTEINIZING HORMONE87149 CPT CODES PATHOLOGY AND LABORATORY MICROBIOLOGY CULTURE TYPING NUCLEIC ACID PROBE DIR EA ORGANSM87150 CPT CODES PATHOLOGY AND LABORATORY Labs-Microbiology CULTYP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM87153 CPT CODES PATHOLOGY AND LABORATORY Labs-Microbiology CULTYP NUCLEIC ACID SEQUENCING METH EA ISOLATE87493 CPT CODES PATHOLOGY AND LABORATORY Labs-Microbiology INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE88230 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES TISS CUL NON-NEO DISORDERS LYMPHOCYTE88233 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX88235 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS88237 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic TISS CUL NEO DISORDERS BONE MARROW BLOOD CELLS88239 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES TISS CUL NEO DISORDERS SOLID TUMOR88240 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CRYOPRSRV FRZING&STORAGE CELLS EA CELL LINE88241 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES THAWING&EXPANSION FROZEN CELLS EACH ALIQUOT88245 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM BREAKAGE BASELINE SISTER 20-25 CLL88248 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES CHRMSM BREAKAGE BASELINE BREAKAGE 50-100 CLL88249 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM BREAKAGE SYNDS SCORE 100 CLL88261 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES CHRMSM COUNT 5 CELL 1KARYOTYPE BANDING88262 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM COUNT 15-20 CLL 2KARYOTYP BANDING88263 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES CHRMSM COUNT 45 CELL MOSAICISM 2KARYOTYPE88264 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM ANALYZE 20-25 CELLS88269 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP88271 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES MOLECULAR CYTOGENETICS DNA PROBE EACH88272 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic MOLECULAR CYTOGENETICS CHRMOML ISH 3-5 CELLS88273 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES MOLECULAR CYTOGENETICS CHRMOML ISH 10-30 CLL88274 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic MOLECULAR CYTOGENETICS INTERPHASE ISH 25-99 CLL88275 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL88280 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM ANALYSIS ADDL KARYOTYP EACH STUDY88283 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES CHRMSM ANALYSIS ADDL SPECIALIZED BANDING88285 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CHRMSM ANALYSIS ADDL CELLS COUNTED EACH STUDY88289 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES CHRMSM ANALYSIS ADDL HIGH RESOLUTION STUDY88291 CPT CODES PATHOLOGY AND LABORATORY Pathology-Cytogenetic CYTOGENETICS&MOLEC CYTOGENETICS INTERP&REP88299 CPT CODES PATHOLOGY AND LABORATORY CYTOGENETIC STUDIES UNLISTED CYTOGENETIC STUDY88387 CPT CODES PATHOLOGY AND LABORATORY Pathology-Surgical MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA88388 CPT CODES PATHOLOGY AND LABORATORY Pathology-Surgical MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE89250 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES CUL OOCYTE/EMBRYO <4 DAYS89251 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY89253 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES ASSTD EMBRYO HATCHING MICROTQS ANY METH89254 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive OOCYTE ID FROM FOLLICULAR FLU89255 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES PREPJ EMBRYO TR89257 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SPRM ID FROM ASPIR OTH/THN SEMINAL89258 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES CRYOPRSRV EMBRYO89259 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive CRYOPRSRV SPRM89260 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS89261 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS

Page 29: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description89264 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD89268 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive INSEMINATION OOCYTES89272 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES EXTND CUL OOCYTE/EMBRYO 4-7 DAYS89280 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive ASSTD FERTILIZATION MICROTQ </EQUAL 10 OOCYTES89281 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES ASSTD FERTILIZATION MICROTQ > 10 OOCYTES89290 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive BX OOCYTE MICROTQ </= 5 EMBRY89291 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES BX OOCYTE MICROTQ >5 EMBRY89300 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER89310 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES SEMEN ALYS MOTILITY&CNT X W/HUHNER TST89320 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT89321 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM89322 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA89325 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SPERM ANTIBODIES89329 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES SPERM EVALUATION HAMSTER PENETRATION TEST89330 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SPERM EVALUATION CERVICAL MUCOUS PENETRATION89331 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive SPERM EVALUATION RETROGRADE EJACULATION URINE89335 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive CRYOPRSRV REPRODUCTIVE TISSUE TESTICULAR89342 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive STORAGE PER YEAR EMBRYO89343 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES STORAGE PER YEAR SPERM/SEMEN89344 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive STORAGE PER YR REPRDTVE TISS TSTICULAR/OVARIAN89346 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES STORAGE PER YEAR OOCYTE89352 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive THAWING CRYOPRESERVED EMBRYO89353 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES THAWING CRYOPRESERVED SPERM/SEMEN EACH ALIQUOT89354 CPT CODES PATHOLOGY AND LABORATORY Labs-Reproductive THAWING CRYOPRESERVED TESTICULAR/OVARIAN89356 CPT CODES PATHOLOGY AND LABORATORY OTHER PROCEDURES THAWING CRYOPRESERVED OOCYTES EACH ALIQUOT89398 CPT CODES PATHOLOGY AND LABORATORY Pathology-Surgical UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE74440 CPT CODES RADIOLOGY Diagnostic-Imaging VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I74740 CPT CODES RADIOLOGY Diagnostic-Imaging HYSTEROSALPINGOGRAPHY RS&I74742 CPT CODES RADIOLOGY Diagnostic-Imaging TRANSCERVICAL CATHJ FALLOPIAN TUBE RS&I76801 CPT CODES RADIOLOGY Diagnostic-Ultrasound US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT76948 CPT CODES RADIOLOGY Diagnostic-Ultrasound US GUIDANCE ASPIRATION OVA IMG S&I11920 CPT CODES SURGERY Integumentary TATTOOING INCL MICROPIGMENTATION 6.0 CM/<11921 CPT CODES SURGERY Integumentary TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM11922 CPT CODES SURGERY Integumentary TATTOOING INCL MICROPIGMENTATION EA 20.0 CM11950 CPT CODES SURGERY Integumentary SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/<11951 CPT CODES SURGERY Integumentary SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC11952 CPT CODES SURGERY Integumentary SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC11954 CPT CODES SURGERY Integumentary SUBCUTANEOUS INJECTION FILLING MATRL >10.0 CC14021 CPT CODES SURGERY Integumentary ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM14060 CPT CODES SURGERY Integumentary ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/<15770 CPT CODES SURGERY Integumentary GRAFT DERMA-FAT-FASCIA15776 CPT CODES SURGERY Integumentary PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS15780 CPT CODES SURGERY Integumentary DERMABRASION TOTAL FACE15781 CPT CODES SURGERY Integumentary DERMABRASION SEGMENTAL FACE15782 CPT CODES SURGERY Integumentary DERMABRASION REGIONAL OTHER THAN FACE15786 CPT CODES SURGERY Integumentary ABRASION 1 LESION15787 CPT CODES SURGERY Integumentary ABRASION EACH ADDITIONAL 4 LESIONS OR LESS15788 CPT CODES SURGERY Integumentary CHEMICAL PEEL FACIAL EPIDERMAL15789 CPT CODES SURGERY Integumentary CHEMICAL PEEL FACIAL DERMAL15792 CPT CODES SURGERY Integumentary CHEMICAL PEEL NONFACIAL EPIDERMAL15793 CPT CODES SURGERY Integumentary CHEMICAL PEEL NONFACIAL DERMAL15820 CPT CODES SURGERY Integumentary BLEPHAROPLASTY LOWER EYELID15821 CPT CODES SURGERY Integumentary BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD15822 CPT CODES SURGERY Integumentary BLEPHAROPLASTY UPPER EYELID15823 CPT CODES SURGERY Integumentary BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN15824 CPT CODES SURGERY Integumentary RHYTIDECTOMY FOREHEAD15825 CPT CODES SURGERY Integumentary RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING15826 CPT CODES SURGERY Integumentary RHYTIDECTOMY GLABELLAR FROWN LINES15828 CPT CODES SURGERY Integumentary RHYTIDECTOMY CHEEK CHIN & NECK15829 CPT CODES SURGERY Integumentary RHYTIDECTOMY SMAS FLAP15830 CPT CODES SURGERY Integumentary EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY

Page 30: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description15832 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE THIGH15833 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE LEG15834 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE HIP15835 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE BUTTOCK15836 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE ARM15837 CPT CODES SURGERY Integumentary EXC EXCESSIVE SKIN &SUBQ TISSUE FOREARM/HAND15838 CPT CODES SURGERY Integumentary EXC EXCSV SKIN & SUBQ TISSUE SUBMENTAL FAT PAD15839 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE OTHER AREA15847 CPT CODES SURGERY Integumentary EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN15876 CPT CODES SURGERY Integumentary SUCTION ASSISTED LIPECTOMY HEAD & NECK15877 CPT CODES SURGERY Integumentary SUCTION ASSISTED LIPECTOMY TRUNK15878 CPT CODES SURGERY Integumentary SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY15879 CPT CODES SURGERY Integumentary SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY17360 CPT CODES SURGERY Integumentary CHEMICAL EXFOLIATION ACNE17380 CPT CODES SURGERY Integumentary ELECTROLYSIS EPILATION EACH 30 MINUTES17999 CPT CODES SURGERY Category III UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE19300 CPT CODES SURGERY Integumentary MASTECTOMY GYNECOMASTIA19303 CPT CODES SURGERY Integumentary MASTECTOMY SIMPLE COMPLETE19316 CPT CODES SURGERY Integumentary MASTOPEXY19318 CPT CODES SURGERY Integumentary REDUCTION MAMMAPLASTY19324 CPT CODES SURGERY Integumentary MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT19325 CPT CODES SURGERY Integumentary MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT19328 CPT CODES SURGERY Integumentary REMOVAL INTACT MAMMARY IMPLANT19330 CPT CODES SURGERY Integumentary REMOVAL MAMMARY IMPLANT MATERIAL19340 CPT CODES SURGERY Integumentary IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ19342 CPT CODES SURGERY Integumentary DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ19350 CPT CODES SURGERY Integumentary NIPPLE/AREOLA RECONSTRUCTION19355 CPT CODES SURGERY Integumentary CORRECTION INVERTED NIPPLES19357 CPT CODES SURGERY Integumentary BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ19361 CPT CODES SURGERY Integumentary BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL19364 CPT CODES SURGERY Integumentary BREAST RECONSTRUCTION FREE FLAP19366 CPT CODES SURGERY Integumentary BREAST RECONSTRUCTION OTHER TECHNIQUE19367 CPT CODES SURGERY Integumentary BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE19368 CPT CODES SURGERY Integumentary BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST19369 CPT CODES SURGERY Integumentary BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE19370 CPT CODES SURGERY Integumentary OPEN PERIPROSTHETIC CAPSULOTOMY BREAST19371 CPT CODES SURGERY Integumentary PERIPROSTHETIC CAPSULECTOMY BREAST19380 CPT CODES SURGERY Integumentary REVISION RECONSTRUCTED BREAST19396 CPT CODES SURGERY Integumentary PREPARATION MOULAGE CUSTOM BREAST IMPLANT19499 CPT CODES SURGERY Integumentary UNLISTED PROCEDURE BREAST20974 CPT CODES SURGERY Muskoskeletal ELECTRICAL STIMULATION BONE HEALING NONINVASIVE20975 CPT CODES SURGERY Muskoskeletal ELECTRICAL STIMULATION BONE HEALING INVASIVE20979 CPT CODES SURGERY Muskoskeletal LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE20999 CPT CODES SURGERY Muskoskeletal UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL21010 CPT CODES SURGERY Muskoskeletal ARTHROTOMY TEMPOROMANDIBULAR JOINT21050 CPT CODES SURGERY Muskoskeletal CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX21060 CPT CODES SURGERY Muskoskeletal MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX21070 CPT CODES SURGERY Muskoskeletal CORONOIDECTOMY SEPARATE PROCEDURE21073 CPT CODES SURGERY Muskoskeletal MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA21116 CPT CODES SURGERY Muskoskeletal INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY21120 CPT CODES SURGERY Muskoskeletal GENIOPLASTY AUGMENTATION21121 CPT CODES SURGERY Muskoskeletal GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE21122 CPT CODES SURGERY Muskoskeletal GENIOPLASTY 2/> SLIDING OSTEOTOMIES21123 CPT CODES SURGERY Muskoskeletal GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS21125 CPT CODES SURGERY Muskoskeletal AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL21127 CPT CODES SURGERY Muskoskeletal AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL21141 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT21142 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT21143 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT21145 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS21146 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS

Page 31: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description21147 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS21150 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION21151 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS21154 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT III W/O LEFORT I21155 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT III W/LEFORT I21159 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I21160 CPT CODES SURGERY Muskoskeletal RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I21198 CPT CODES SURGERY Muskoskeletal OSTEOTOMY MANDIBLE SEGMENTAL21199 CPT CODES SURGERY Muskoskeletal OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT21206 CPT CODES SURGERY Muskoskeletal OSTEOTOMY MAXILLA SEGMENTAL21208 CPT CODES SURGERY Muskoskeletal OSTEOPLASTY FACIAL BONES AUGMENTATION21209 CPT CODES SURGERY Muskoskeletal OSTEOPLASTY FACIAL BONES REDUCTION21210 CPT CODES SURGERY Muskoskeletal GRAFT BONE NASAL/MAXILLARY/MALAR AREAS21215 CPT CODES SURGERY Muskoskeletal GRAFT BONE MANDIBLE21230 CPT CODES SURGERY Muskoskeletal GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR21235 CPT CODES SURGERY Muskoskeletal GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR21240 CPT CODES SURGERY Muskoskeletal ARTHRP TEMPOROMANDIBULAR JOINT W/WO AUTOGRAFT21242 CPT CODES SURGERY Muskoskeletal ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT21243 CPT CODES SURGERY Muskoskeletal ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT21244 CPT CODES SURGERY Muskoskeletal RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE21245 CPT CODES SURGERY Muskoskeletal RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL21246 CPT CODES SURGERY Muskoskeletal RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE21247 CPT CODES SURGERY Muskoskeletal RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS21248 CPT CODES SURGERY Muskoskeletal RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL21249 CPT CODES SURGERY Muskoskeletal RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE21270 CPT CODES SURGERY Muskoskeletal MALAR AUGMENTATION PROSTHETIC MATERIAL21295 CPT CODES SURGERY Muskoskeletal REDUCTION MASSETER MUSCLE & BONE EXTRAORAL21296 CPT CODES SURGERY Muskoskeletal REDUCTION MASSETER MUSCLE & BONE INTRAORAL21299 CPT CODES SURGERY Muskoskeletal UNLISTED CRANIOFACIAL & MAXILLOFACIAL PROCEDURE21499 CPT CODES SURGERY Muskoskeletal UNLISTED MUSCULOSKELETAL PROCEDURE HEAD27096 CPT CODES SURGERY Muskoskeletal INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA28890 CPT CODES SURGERY Muskoskeletal ESWT HI NRG PHYS/QHP W/US GDN INVG PLNTAR FASCIA29800 CPT CODES SURGERY Muskoskeletal ARTHRS TEMPOROMANDIBULR JT DX W/WO SYNVAL BX SPX29804 CPT CODES SURGERY Muskoskeletal ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL30120 CPT CODES SURGERY Respiratory EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA30400 CPT CODES SURGERY Respiratory RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NASAL TI30410 CPT CODES SURGERY Respiratory RHINP PRIM COMPLETE XTRNL PARTS30420 CPT CODES SURGERY Respiratory RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR30430 CPT CODES SURGERY Respiratory RHINOPLASTY SECONDARY MINOR REVISION30435 CPT CODES SURGERY Respiratory RHINOPLASTY SECONDARY INTERMEDIATE REVISION30450 CPT CODES SURGERY Respiratory RHINOPLASTY SECONDARY MAJOR REVISION30460 CPT CODES SURGERY Respiratory RHINP DFRM W/COLUM LNGTH TIP ONLY30462 CPT CODES SURGERY Respiratory RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT30465 CPT CODES SURGERY Respiratory REPAIR NASAL VESTIBULAR STENOSIS30520 CPT CODES SURGERY Respiratory SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF32850 CPT CODES SURGERY Respiratory DONOR PNEUMONECTOMY FROM CADAVER DONOR32851 CPT CODES SURGERY Respiratory LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS32852 CPT CODES SURGERY Respiratory LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS32853 CPT CODES SURGERY Respiratory LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS32854 CPT CODES SURGERY Respiratory LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS32855 CPT CODES SURGERY Respiratory BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI32856 CPT CODES SURGERY Respiratory BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI33289 CPT CODES SURGERY Cardiovascular TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR33930 CPT CODES SURGERY Cardiovascular DONOR CARDIECTOMY-PNEUMONECTOMY33933 CPT CODES SURGERY Cardiovascular BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT33935 CPT CODES SURGERY Cardiovascular HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC33940 CPT CODES SURGERY Cardiovascular DONOR CARDIECTOMY33944 CPT CODES SURGERY Cardiovascular BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT33945 CPT CODES SURGERY Cardiovascular HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY33999 CPT CODES SURGERY Cardiovascular UNLISTED CARDIAC SURGERY36468 CPT CODES SURGERY Cardiovascular INJECTIONS SCLEROSANT FOR SPIDER VEINS LIM/TRNK

Page 32: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description36470 CPT CODES SURGERY Cardiovascular INJECTION SCLEROSANT SINGLE INCMPTNT VEIN36471 CPT CODES SURGERY Cardiovascular INJECTION SCLEROSANT MULTIPLE INCMPTNT VEINS36473 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN36474 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM SBSQ VEINS36475 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN36476 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS36478 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN36479 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS36482 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN36483 CPT CODES SURGERY Cardiovascular ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN37500 CPT CODES SURGERY Cardiovascular VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX37501 CPT CODES SURGERY Cardiovascular UNLISTED VASCULAR ENDOSCOPY PROCEDURE37700 CPT CODES SURGERY Cardiovascular LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ37718 CPT CODES SURGERY Cardiovascular LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN37722 CPT CODES SURGERY Cardiovascular LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW37735 CPT CODES SURGERY Cardiovascular LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS37760 CPT CODES SURGERY Cardiovascular LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG37761 CPT CODES SURGERY Cardiovascular LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG37765 CPT CODES SURGERY Cardiovascular STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS37766 CPT CODES SURGERY Cardiovascular STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS37780 CPT CODES SURGERY Cardiovascular LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX37785 CPT CODES SURGERY Cardiovascular LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG38204 CPT CODES SURGERY Hemic/Lymphatic MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ38205 CPT CODES SURGERY Hemic/Lymphatic BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC38206 CPT CODES SURGERY Hemic/Lymphatic BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL38220 CPT CODES SURGERY Hemic/Lymphatic DIAGNOSTIC BONE MARROW ASPIRATIONS38221 CPT CODES SURGERY Hemic/Lymphatic DIAGNOSTIC BONE MARROW BIOPSIES38230 CPT CODES SURGERY Hemic/Lymphatic BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC38232 CPT CODES SURGERY Hemic/Lymphatic BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS38240 CPT CODES SURGERY Hemic/Lymphatic TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR38241 CPT CODES SURGERY Hemic/Lymphatic TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR38242 CPT CODES SURGERY Hemic/Lymphatic ALLOGENEIC LYMPHOCYTE INFUSIONS43644 CPT CODES SURGERY Digestive LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM43645 CPT CODES SURGERY Digestive LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ43647 CPT CODES SURGERY Digestive LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM43648 CPT CODES SURGERY Digestive LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM43651 CPT CODES SURGERY Digestive LAPS SURG TRNSXJ VAGUS NRV TRUNCAL43652 CPT CODES SURGERY Digestive LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV43653 CPT CODES SURGERY Digestive LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX43659 CPT CODES SURGERY Digestive UNLISTED LAPAROSCOPIC PROCEDURE STOMACH43770 CPT CODES SURGERY Digestive LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE43771 CPT CODES SURGERY Digestive LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE43772 CPT CODES SURGERY Digestive LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE43773 CPT CODES SURGERY Digestive LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE43774 CPT CODES SURGERY Digestive LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT43775 CPT CODES SURGERY Digestive LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY43842 CPT CODES SURGERY Digestive GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY43843 CPT CODES SURGERY Digestive GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP43845 CPT CODES SURGERY Digestive GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM43846 CPT CODES SURGERY Digestive GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<43847 CPT CODES SURGERY Digestive GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ43848 CPT CODES SURGERY Digestive REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE43850 CPT CODES SURGERY Digestive REVJ GASTRODUOL ANAST W/RCNSTJ W/O VAGOTOMY43855 CPT CODES SURGERY Digestive REVJ GASTRODUOL ANAST W/RCNSTJ W/VGTMY43860 CPT CODES SURGERY Digestive REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY43865 CPT CODES SURGERY Digestive REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY43886 CPT CODES SURGERY Digestive GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY43887 CPT CODES SURGERY Digestive GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY43888 CPT CODES SURGERY Digestive GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT43999 CPT CODES SURGERY Digestive UNLISTED PROCEDURE STOMACH44132 CPT CODES SURGERY Digestive DONOR ENTERECTOMY OPEN CADAVER DONOR

Page 33: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description44133 CPT CODES SURGERY Digestive DONOR ENTERECTOMY OPEN LIVING DONOR44135 CPT CODES SURGERY Digestive INTESTINAL ALLOTRANSPLANTATION CADAVER DONOR44136 CPT CODES SURGERY Digestive INTESTINAL ALLOTRANSPLANTATION LIVING DONOR44137 CPT CODES SURGERY Digestive RMVL TRNSPLED INTESTINAL ALLOGRAFT COMPL47133 CPT CODES SURGERY Digestive DONOR HEPATECTOMY CADAVER DONOR47135 CPT CODES SURGERY Digestive LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE47140 CPT CODES SURGERY Digestive DONOR HEPATECTOMY LIVING DONOR SEG II & III47141 CPT CODES SURGERY Digestive DONOR HEPATECTOMY LIVING DONOR SEG II III & IV47142 CPT CODES SURGERY Digestive DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI47143 CPT CODES SURGERY Digestive BKBENCH PREP CADAVER DONOR47144 CPT CODES SURGERY Digestive BKBENCH PREPJ CADAVER WHOLE LIVER GRF I&IV VII47145 CPT CODES SURGERY Digestive BKBENCH PREPJ CADAVER DONOR WHL LVR GRF I&V VI47146 CPT CODES SURGERY Digestive BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA47147 CPT CODES SURGERY Digestive BKBENCH RCNSTJ LVR GRF ARTL ANAST EA48160 CPT CODES SURGERY Digestive PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS48550 CPT CODES SURGERY Digestive DONOR PANCREATECTOMY DUODENAL SGM TRANSPLANT48551 CPT CODES SURGERY Digestive BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT48552 CPT CODES SURGERY Digestive BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA48554 CPT CODES SURGERY Digestive TRANSPLANTATION PANCREATIC ALLOGRAFT50300 CPT CODES SURGERY Urinary DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL50320 CPT CODES SURGERY Urinary DONOR NEPHRECTOMY OPEN LIVING DONOR50323 CPT CODES SURGERY Urinary BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT50325 CPT CODES SURGERY Urinary BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT50327 CPT CODES SURGERY Urinary BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA50328 CPT CODES SURGERY Urinary BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA50329 CPT CODES SURGERY Urinary BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA50340 CPT CODES SURGERY Urinary RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE50360 CPT CODES SURGERY Urinary RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY50365 CPT CODES SURGERY Urinary RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY50370 CPT CODES SURGERY Urinary RMVL TRNSPLED RENAL ALLOGRAFT50380 CPT CODES SURGERY Urinary RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY50547 CPT CODES SURGERY Urinary LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR52402 CPT CODES SURGERY Urinary CSTO W/TRURL RESCJ/INC EJACULATORY DUXS53420 CPT CODES SURGERY Urinary URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE53425 CPT CODES SURGERY Urinary URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE53430 CPT CODES SURGERY Urinary URETHROPLASTY RCNSTJ FEMALE URETHRA54125 CPT CODES SURGERY Male Genital AMPUTATION PENIS COMPLETE54500 CPT CODES SURGERY Male Genital BIOPSY TESTIS NEEDLE SEPARATE PROCEDURE54505 CPT CODES SURGERY Male Genital BIOPSY TESTIS INCISIONAL SEPARATE PROCEDURE54520 CPT CODES SURGERY Male Genital ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH54660 CPT CODES SURGERY Male Genital INSJ TESTICULAR PROSTH SEPARATE PROCEDURE54690 CPT CODES SURGERY Male Genital LAPAROSCOPY SURGICAL ORCHIECTOMY55175 CPT CODES SURGERY Male Genital SCROTOPLASTY SIMPLE55180 CPT CODES SURGERY Male Genital SCROTOPLASTY COMPLICATED55200 CPT CODES SURGERY Male Genital VASOTOMY CANNULIZATION W/WO VAS INC UNI/BI SPX55300 CPT CODES SURGERY Male Genital VASOTOMY VASOGRAMS UNI/BI55400 CPT CODES SURGERY Male Genital VASOVASOSTOMY VASOVASORRHAPHY55550 CPT CODES SURGERY Male Genital LAPS LIGATION SPERMATIC VEINS VARICOCELE55866 CPT CODES SURGERY Male Genital LAPS PROSTECT RETROPUBIC RAD W/NRV SPARING ROBOT55870 CPT CODES SURGERY Male Genital ELECTROEJACULATION55899 CPT CODES SURGERY Male Genital UNLISTED PROCEDURE MALE GENITAL SYSTEM55970 CPT CODES SURGERY Male Genital INTERSEX SURG MALE FEMALE55980 CPT CODES SURGERY Male Genital INTERSEX SURG FEMALE MALE56625 CPT CODES SURGERY Female Genital VULVECTOMY SIMPLE COMPLETE56800 CPT CODES SURGERY Female Genital PLASTIC REPAIR INTROITUS56805 CPT CODES SURGERY Female Genital CLITOROPLASTY INTERSEX STATE57106 CPT CODES SURGERY Female Genital VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL57110 CPT CODES SURGERY Female Genital VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL57291 CPT CODES SURGERY Female Genital CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT57292 CPT CODES SURGERY Female Genital CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT57295 CPT CODES SURGERY Female Genital REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP

Page 34: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description57296 CPT CODES SURGERY Female Genital REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR57335 CPT CODES SURGERY Female Genital VAGINOPLASTY INTERSEX STATE57426 CPT CODES SURGERY Female Genital REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC58150 CPT CODES SURGERY Female Genital TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY58180 CPT CODES SURGERY Female Genital SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY58260 CPT CODES SURGERY Female Genital VAGINAL HYSTERECTOMY UTERUS 250 GM/<58262 CPT CODES SURGERY Female Genital VAG HYST 250 GM/< W/RMVL TUBE&/OVARY58275 CPT CODES SURGERY Female Genital VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY58290 CPT CODES SURGERY Female Genital VAGINAL HYSTERECTOMY UTERUS > 250 GM58291 CPT CODES SURGERY Female Genital VAG HYST > 250 GM RMVL TUBE&/OVARY58321 CPT CODES SURGERY Female Genital ARTIFICIAL INSEMINATION INTRA-CERVICAL58322 CPT CODES SURGERY Female Genital ARTIFICIAL INSEMINATION INTRA-UTERINE58323 CPT CODES SURGERY Female Genital SPERM WASHING ARTIFICIAL INSEMINATION58340 CPT CODES SURGERY Female Genital CATH & SALINE/CONTRAST SONOHYSTER/HYSTEROSALPI58345 CPT CODES SURGERY Female Genital TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING58350 CPT CODES SURGERY Female Genital CHROMOTUBATION OVIDUCT W/MATERIALS58541 CPT CODES SURGERY Female Genital LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/<58542 CPT CODES SURGERY Female Genital LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR58543 CPT CODES SURGERY Female Genital LAPS SUPRACERVICAL HYSTERECTOMY >25058544 CPT CODES SURGERY Female Genital LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY58700 CPT CODES SURGERY Female Genital SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX58720 CPT CODES SURGERY Female Genital SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX58740 CPT CODES SURGERY Female Genital LYSIS OF ADHESIONS SALPINX/OVARY58750 CPT CODES SURGERY Female Genital TUBOTUBAL ANASTATOMOSIS58752 CPT CODES SURGERY Female Genital TUBOUTERINE IMPLANTATION58760 CPT CODES SURGERY Female Genital FIMBRIOPLASTY58770 CPT CODES SURGERY Female Genital SALPINGOSTOMY58970 CPT CODES SURGERY Female Genital FOLLICLE PUNCTURE OOCYTE RETRIEVAL ANY METHOD58974 CPT CODES SURGERY Female Genital EMBRYO TRANSFER INTRAUTERINE58976 CPT CODES SURGERY Female Genital GAMETE ZYGOTE/EMBRYO FALLOPIAN TRANSFER ANY METH60512 CPT CODES SURGERY Endocrine PARATHYROID AUTOTRANSPLANTATION ADD-ON62320 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN62321 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN62322 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN62323 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN62324 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN62325 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN62327 CPT CODES SURGERY Nervous NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN62350 CPT CODES SURGERY Nervous IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM62351 CPT CODES SURGERY Nervous IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM62355 CPT CODES SURGERY Nervous RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH62360 CPT CODES SURGERY Nervous IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR62361 CPT CODES SURGERY Nervous IMPLTJ/RPLCMT FS NON-PRGRBL PUMP62362 CPT CODES SURGERY Nervous IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP62365 CPT CODES SURGERY Nervous RMVL SUBQ RSVR/PUMP INTRATHECAL/EPIDURAL INFUS62367 CPT CODES SURGERY Nervous ELECT ANLYS IMPLT ITHCL/EDRL PMP W/O REPRG/REFIL62368 CPT CODES SURGERY Nervous ELECT ANALYS IMPLT ITHCL/EDRL PUMP W/REPRGRMG62369 CPT CODES SURGERY Nervous ELECT ANLYS IMPLT ITHCL/EDRL PMP W/REPRG&REFIL63650 CPT CODES SURGERY Nervous PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL63655 CPT CODES SURGERY Nervous LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL64400 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH64405 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD GREATER OCCIPITAL NERVE64408 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD VAGUS NERVE64415 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD BRACHIAL PLEXUS64416 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD BRACHIAL PLEXUS CONT NFS CATH64417 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD AXILLARY NERVE64418 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD SUPRASCAPULAR NERVE64420 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL64421 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL64425 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD ILIOINGUINAL IH NERVES64430 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD PUDENDAL NERVE

Page 35: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description64435 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD PARACERVICAL NERVE64445 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD SCIATIC NERVE64446 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD SCIATIC NERVE CONT NFS CATH64447 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD FEMORAL NERVE64448 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD FEMORAL NERVE CONT NFS CATH64449 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD LUMBAR PLEXUS CONT NFS CATH64450 CPT CODES SURGERY Nervous if done same day as surgery, no PA required INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH64451 CPT CODES SURGERY Nervous 3/6/2020 INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG64454 CPT CODES SURGERY Nervous 3/6/2020 INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG64455 CPT CODES SURGERY Nervous if done same day as surgery, no PA required NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE64461 CPT CODES SURGERY Nervous if done same day as surgery, no PA required PVB THORACIC SINGLE INJECTION SITE W/IMG GID64462 CPT CODES SURGERY Nervous if done same day as surgery, no PA required PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID64463 CPT CODES SURGERY Nervous if done same day as surgery, no PA required PVB THORACIC CONT CATHETER INFUSION W/IMG GID64479 CPT CODES SURGERY Nervous NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL64480 CPT CODES SURGERY Nervous NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV64483 CPT CODES SURGERY Nervous NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL64484 CPT CODES SURGERY Nervous NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV64486 CPT CODES SURGERY Nervous if done same day as surgery, no PA required TAP BLOCK UNILATERAL BY INJECTION(S)64487 CPT CODES SURGERY Nervous if done same day as surgery, no PA required TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S)64488 CPT CODES SURGERY Nervous if done same day as surgery, no PA required TAP BLOCK BILATERAL BY INJECTION(S)64489 CPT CODES SURGERY Nervous if done same day as surgery, no PA required TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S)64490 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL64491 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL64492 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL64493 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL64494 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL64495 CPT CODES SURGERY Nervous NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL64505 CPT CODES SURGERY Nervous INJECTION ANES AGENT SPHENOPALATINE GANGLION64510 CPT CODES SURGERY Nervous NJX ANES STELLATE GANGLION CRV SYMPATHETIC64517 CPT CODES SURGERY Nervous INJECTION ANES SUPERIOR HYPOGASTRIC PLEXUS64520 CPT CODES SURGERY Nervous INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC64530 CPT CODES SURGERY Nervous INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG64600 CPT CODES SURGERY Nervous DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH64605 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC TRIGEMINAL NRV 2/3 DIV BRANCH64610 CPT CODES SURGERY Nervous DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR64611 CPT CODES SURGERY Nervous CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS64612 CPT CODES SURGERY Nervous CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL64615 CPT CODES SURGERY Nervous CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE64616 CPT CODES SURGERY Nervous CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA64617 CPT CODES SURGERY Nervous CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG64620 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE64624 CPT CODES SURGERY Nervous 3/6/2020 DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG64625 CPT CODES SURGERY Nervous 3/6/2020 RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN64630 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC AGENT PUDENDAL NERVE64632 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE64633 CPT CODES SURGERY Nervous DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA64634 CPT CODES SURGERY Nervous DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA64635 CPT CODES SURGERY Nervous DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL64636 CPT CODES SURGERY Nervous DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL64640 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE64642 CPT CODES SURGERY Nervous CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE64643 CPT CODES SURGERY Nervous CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE64644 CPT CODES SURGERY Nervous CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES64645 CPT CODES SURGERY Nervous CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES64646 CPT CODES SURGERY Nervous CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES64647 CPT CODES SURGERY Nervous CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES64650 CPT CODES SURGERY Nervous CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE64653 CPT CODES SURGERY Nervous CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY64680 CPT CODES SURGERY Nervous DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS64681 CPT CODES SURGERY Nervous DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS65710 CPT CODES SURGERY Eye KERATOPLASTY ANTERIOR LAMELLAR

Page 36: Prior Authorization : Procedure Specific Listing (Q1 2020) · Prior Authorization : Procedure Specific Listing (Q1 2020) Code Category SubCategory Group Effective date Notes Description:

Code Category SubCategory Group Effective date Notes Description65730 CPT CODES SURGERY Eye KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA65750 CPT CODES SURGERY Eye KERATOPLASTY PENETRAING APHAKIA65755 CPT CODES SURGERY Eye KERATOPLASTY PENETRATING PSEUDOPHAKIA65756 CPT CODES SURGERY Eye KERATOPLASTY ENDOTHELIAL65757 CPT CODES SURGERY Eye BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT65780 CPT CODES SURGERY Eye OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE65781 CPT CODES SURGERY Eye OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT65782 CPT CODES SURGERY Eye OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT66987 CPT CODES SURGERY Eye 3/6/2020 XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX W/ECP67345 CPT CODES SURGERY Eye CHEMODENERVATION EXTRAOCULAR MUSCLE67900 CPT CODES SURGERY Eye REPAIR BROW PTOSIS67901 CPT CODES SURGERY Eye RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL67902 CPT CODES SURGERY Eye RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING67903 CPT CODES SURGERY Eye RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL67904 CPT CODES SURGERY Eye RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL67906 CPT CODES SURGERY Eye RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING67908 CPT CODES SURGERY Eye RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ67909 CPT CODES SURGERY Eye REDUCTION OVERCORRECTION PTOSIS67911 CPT CODES SURGERY Eye CORRECTION LID RETRACTION67912 CPT CODES SURGERY Eye CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD67914 CPT CODES SURGERY Eye REPAIR ECTROPION SUTURE67915 CPT CODES SURGERY Eye REPAIR ECTROPION THERMOCAUTERIZATION67916 CPT CODES SURGERY Eye REPAIR ECTROPION EXCISION TARSAL WEDGE67917 CPT CODES SURGERY Eye REPAIR ECTROPION EXTENSIVE67921 CPT CODES SURGERY Eye REPAIR ENTROPION SUTURE67922 CPT CODES SURGERY Eye REPAIR ENTROPION THERMOCAUTERIZATION67923 CPT CODES SURGERY Eye REPAIR ENTROPION EXCISION TARSAL WEDGE67924 CPT CODES SURGERY Eye REPAIR ENTROPION EXTENSIVE67950 CPT CODES SURGERY Eye CANTHOPLASTY69710 CPT CODES SURGERY Auditory IMPLTJ/RPLCMT EMGNT BONE CNDJ DEV TEMPORAL BONE69711 CPT CODES SURGERY Auditory RMVL/RPR EMGNT BONE CNDJ DEV TEMPORAL BONE69714 CPT CODES SURGERY Auditory IMPLTJ OSSEOINTEGRATED TEMPORAL BONE W/MASTOID69715 CPT CODES SURGERY Auditory IMPLJ OSSEOINTEGRATED TEMPORAL BONE W/O MASTOID69717 CPT CODES SURGERY Auditory RPLMCT OSSEOINTEGRATE IMPLNT W/O MASTOIDECTOMY69718 CPT CODES SURGERY Auditory RPLMCT OSSEOINTEGRATE IMPLNT W/MASTOIDECTOMY69930 CPT CODES SURGERY Auditory COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY