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IAPEC-0895-18 April 2018

Experimental and investigational procedure codes

Following are updated experimental and investigational procedure codes and associated supporting policies effective January 1, 2018.

Procedure codes

Supporting policy

0001M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

0002M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

0003M LAB.00019 Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

0004M GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis

0008M GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment

0019T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions

0042T RAD.00045 Cerebral Perfusion Imaging Using Computed Tomography

0054T SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

0055T SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

0057T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue

0058T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue

0071T MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids

0072T MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids

0075T SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

0076T SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

0085T TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

0100T SURG.00113 Artificial Retinal Devices

0101T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions

0102T SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions

0106T MED.00082 Quantitative Sensory Testing

0107T MED.00082 Quantitative Sensory Testing

0108T MED.00082 Quantitative Sensory Testing

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0109T MED.00082 Quantitative Sensory Testing

0110T MED.00082 Quantitative Sensory Testing

0163T SURG.00055 Cervical Artificial Intervertebral Discs

0165T SURG.00055 Cervical Artificial Intervertebral Discs

0169T SURG.00099 Convection-Enhanced Delivery of Therapeutic Agents to the Brain

0171T SURG.00092 Implanted Devices for Spinal Stenosis

0172T SURG.00092 Implanted Devices for Spinal Stenosis

0182T RAD.00014 Brachytherapy for Oncologic Indications

0190T RAD.00056 Intraocular Epiretinal Brachytherapy

0195T SURG.00111 Axial Lumbar Interbody Fusion

0196T SURG.00111 Axial Lumbar Interbody Fusion

0200T SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

0201T SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

0202T SURG.00092 Implanted Devices for Spinal Stenosis

0205T RAD.00057 Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging

0206T MED.00074 Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data

0207T MED.00103 Automated Evacuation of Meibomian Gland

0219T SURG.00114 Facet Joint Allograft Implants for Facet Disease

0220T SURG.00114 Facet Joint Allograft Implants for Facet Disease

0221T SURG.00114 Facet Joint Allograft Implants for Facet Disease

0222T SURG.00114 Facet Joint Allograft Implants for Facet Disease

0232T MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

0233T MED.00104 Noninvasive Measurement of Advanced Glycation End products (AGEs) in the Skin

0249T SURG.00141 Doppler-Guided Transanal Hemorrhoidal Deaterialization

0253T SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

0263T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease

0264T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease

0265T TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease

0266T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0267T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0268T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0269T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0270T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0271T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0272T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

0273T SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

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0274T SURG.00071 Percutaneous and Endoscopic Spinal Surgery

0275T SURG.00071 Percutaneous and Endoscopic Spinal Surgery

0281T SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

0282T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

0283T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

0284T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

0285T SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

0288T SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence

0291T RAD.00062 Intravascular Optical Coherence Tomography (OCT)

0292T RAD.00062 Intravascular Optical Coherence Tomography (OCT)

0293T SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor

0294T SURG.00128 Implantable Left Atrial Hemodynamic (LAH) Monitor

0301T SURG.00137 Focused Microwave Therotherapy for Breast Cancer

0302T MED.00111 Intracardiac Ischemia Monitoring

0303T MED.00111 Intracardiac Ischemia Monitoring

0304T MED.00111 Intracardiac Ischemia Monitoring

0305T MED.00111 Intracardiac Ischemia Monitoring

0306T MED.00111 Intracardiac Ischemia Monitoring

0307T MED.00111 Intracardiac Ischemia Monitoring

0309T SURG.00111 Axial Lumbar Interbody Fusion

0312T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0313T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0314T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0315T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0316T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0317T SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0328T SURG.00033 Implantable Cardioverter-Defibrillator (ICD)

0329T MED.00118 Continuous Monitoring of Intraocular Pressure

0330T MED.00103 Automated Evacuation of Meibomian Gland

0331T RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)

0332T RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)

0335T SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

0336T SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

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0338T SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves

0339T SURG.00135 Radiofrequency Ablation of the Renal Sympathetic Nerves

0340T SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver

0342T MED.00113 Therapeutic Apheresis

0345T SURG.00121 Transcatheter Heart Valve Procedures

0347T RAD.00065 Radiostereometric Analysis (RSA)

0348T RAD.00065 Radiostereometric Analysis (RSA)

0349T RAD.00065 Radiostereometric Analysis (RSA)

0350T RAD.00065 Radiostereometric Analysis (RSA)

0351T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

0352T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

0353T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

0354T SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

0357T MED.00080 Cryopreservation of Oocytes or Ovarian Tissue

0375T SURG.00055 Cervical Artificial Intervertebral Discs

0380T CG-MED-47 Fundus Photography

0392T SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)

0393T SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)

0394T THER-RAD.00001 Brachytherapy for Oncologic Indications

0395T THER-RAD.00001 Brachytherapy for Oncologic Indications

0397T MED.00077 In-Vivo Analysis of Gastrointestinal Lesions

0402T MED.00109 Corneal Collagen Cross-Linking

0423T LAB.00031 Advanced Lipoprotein Testing

0424T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0425T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0426T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0427T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0428T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

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0429T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0430T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0431T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0432T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0433T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0434T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0435T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0436T MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

0438T SURG.00143 SpaceOAR® System

15775 ANC.00007 Cosmetic and Reconstructive Services: Skin Related

15776 ANC.00007 Cosmetic and Reconstructive Services: Skin Related

15783 ANC.00007 Cosmetic and Reconstructive Services: Skin Related

15819 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

15825 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

15826 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

15829 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

15837 ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin

15838 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

15839 ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin

15847 SURG.00048 Panniculectomy and Abdominoplasty

15876 MED.00032 Treatment of Hyperhidrosis

15878 MED.00032 Treatment of Hyperhidrosis

15879 MED.00032 Treatment of Hyperhidrosis

19105 SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver

20983 SURG.00025 Cryosurgical Ablation of Solid Tumors Outside the Liver

20985 SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System

21811 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation

21812 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation

21813 SURG.00120 Open Treatment of Rib Fracture(s) Requiring Internal Fixation

22526 SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy IDET, Percutaneous Intradiscal Radiofrequency Thermocoagulation PIRFT and Intradiscal Biacuplasty IDB)

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22527 SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy IDET, Percutaneous Intradiscal Radiofrequency Thermocoagulation PIRFT and Intradiscal Biacuplasty IDB)

22586 SURG.00111 Axial Lumbar Interbody Fusion

24300 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee

25259 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee

26340 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee

27275 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee

27279 SURG.00127 Sacroiliac Joint Fusion

27860 MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee

28446 SURG.00093 Treatment of Osteochondral Defects

28890 SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions

31295 SURG.00089 Balloon Sinus Ostial Dilation

31296 SURG.00089 Balloon Sinus Ostial Dilation

31297 SURG.00089 Balloon Sinus Ostial Dilation

31627 MED.00099 Electromagnetic Navigational Bronchoscopy

31647 SURG.00119 Endobronchial Valve Devices

31648 SURG.00119 Endobronchial Valve Devices

31649 SURG.00119 Endobronchial Valve Devices

31651 SURG.00119 Endobronchial Valve Devices

31660 SURG.00118 Bronchial Thermoplasty

31661 SURG.00118 Bronchial Thermoplasty

33418 SURG.00121 Transcatheter Heart Valve Procedures

33419 SURG.00121 Transcatheter Heart Valve Procedures

33548 SURG.00005 Partial Left Ventriculectomy

33990 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

33991 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

33992 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

33993 TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

34839 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34841 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

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34842 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34843 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34844 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34845 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34846 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34847 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

34848 SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

36468 SURG.00037 Treatment of Varicose Veins (Lower Extremities), ANC.00007 Cosmetic and Reconstructive Services: Skin Related

41512 SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea

43206 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions

43210 SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia

43252 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions

43257 SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease

46707 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

46762 SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence

52441 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

52442 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

53855 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

53860 SURG.00010 Treatments for Urinary Incontinence

55706 SURG.00107 Prostate Saturation Biopsy

61630 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement

61640 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement

61641 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement

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61642 SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement

61870 SURG.00026 Deep Brain Stimulation

62263 SURG.00072 Lysis of Epidural Adhesions

62264 SURG.00072 Lysis of Epidural Adhesions

62287 SURG.00071 Percutaneous and Endoscopic Spinal Surgery

62291 RAD.00053 Cervical and Thoracic Discography

64566 SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention

65760 SURG.00009 Refractive Surgery

65765 SURG.00009 Refractive Surgery

65771 SURG.00009 Refractive Surgery

66174 SURG.00095 Viscocanalostomy and Canaloplasty

66175 SURG.00095 Viscocanalostomy and Canaloplasty

69090 ANC.0008 Cosmetic and Reconstructive Services of the Head and Neck

72285 RAD.00053 Cervical and Thoracic Discography

75571 RAD.00001 Computed Tomography to Detect Coronary Artery Calcification

76977 RAD.00004 Peripheral Bone Mineral Density Measurement

77084 RAD.00054 MRI of the Bone Marrow

77422 THER-RAD.00008 Neutron Beam Radiotherapy

77423 THER-RAD.00008 Neutron Beam Radiotherapy

77605 MED.00026 Hyperthermia for Cancer Therapy

77620 MED.00026 Hyperthermia for Cancer Therapy

78350 RAD.00004 Peripheral Bone Mineral Density Measurement

78647 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications

81227 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

81240 GENE.00046 Prothrombin G20210A (Factor II) Mutation Testing

81291 GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing

81313 GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

81324 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies

81325 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies

81326 GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies

81350 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

81355 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

81410 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81411 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

Page 9 of 16

81415 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81416 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81417 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81425 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81426 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81427 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81430 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81431 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81435 GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility

81436 GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility

81437 GENE.00001 Genetic Testing for Cancer Susceptibility

81438 GENE.00001 Genetic Testing for Cancer Susceptibility

81440 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81445 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors, GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome, GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility, GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)

81450 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors

81455 GENE.00001 Genetic Testing for Cancer Susceptibility, GENE.00025 Molecular Profiling for the Evaluation of Malignant Tumors, GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome, GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility, GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)

81460 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81465 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81470 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81471 GENE.00043 Genetic Testing of an Individual's Genome for Inherited Diseases

81504 GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site

81506 GENE.00015 Predictive Genetic Testing for Non-Malignant Diseases

81525 GENE.00016 Gene Expression Profiling for Colorectal Cancer

81538 LAB.00011 Analysis of Proteomic Patterns

81540 GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site

82172 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

83695 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

83698 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

83700 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

Page 10 of 16

83701 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

83704 LAB.00031 Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management

84112 LAB.00029 Rupture of Membranes (ROM) Testing in Pregnancy

86001 LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests

86152 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

86153 LAB.00015 Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

86343 LAB.00027 Selected Blood, Serum and Cellular Allergy and Toxicity Tests

86352 LAB.00024 Immune Cell Function Assay

88375 MED.00077 In-Vivo Analysis of Gastrointestinal Lesions

90672 ADMIN.00007 Immunizations

91111 RAD.00030 Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule

91112 MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders

92132 MED.00095 Anterior Segment Optical Coherence Tomography

93025 MED.00041 Microvolt T-Wave Alternans

93702 MED.000105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema

95803 MED.00002 Selected Sleep Testing Services

95905 MED.00092 Automated Nerve Conduction Testing

95921 MED.00112 Autonomic Testing

95922 MED.00112 Autonomic Testing

95923 MED.00112 Autonomic Testing

95924 MED.00112 Autonomic Testing

95943 MED.00112 Autonomic Testing

96904 MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

97610 MED.00096 Low-Frequency Ultrasound Therapy for Wound Management

A4575 MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical)

A4638 DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease

A9272 DME.00009 Vacuum-Assisted Wound Therapy in the Outpatient Setting

A9507 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications

A9527 THER-RAD.00001 Brachytherapy for Oncologic Indications

A9584 RAD.00023 Single Photon Emission-Computed Tomography (SPECT) Scans for Noncardiovascular Indications

A9586 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

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A9599 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

C1821 SURG.00092 Implanted Devices for Spinal Stenosis

C1841 SURG.00113 Artificial Retinal Devices

C2624 MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management

C9349 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9352 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9353 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9354 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9355 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9356 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9358 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9360 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9361 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9364 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

C9458 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

C9459 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

C9461 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

C9472 MED.00083 Melanoma Vaccines

C9739 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

C9740 SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

C9741 MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management

E0218 DME.00037 Cooling Devices and Combined Cooling/Heating Devices

E0236 DME.00037 Cooling Devices and Combined Cooling/Heating Devices

E0481 DME.00012 Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV)

E0485 DME.00039 Prefabricated Oral Appliance for the Treatment of Obstructive Sleep Apnea

E0617 DME.00032 Automated External Defibrillators for Home Use

E0637 DME.00034 Standing Frames

E0638 DME.00034 Standing Frames

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E0641 DME.00034 Standing Frames

E0642 DME.00034 Standing Frames

E0762 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

E0764 DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

E0770 DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

E1801 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1806 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1811 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1816 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1818 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1821 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1831 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E1841 DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

E2120 DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease

E2230 DME.00034 Standing Frames

E2301 DME.00034 Standing Frames

G0130 RAD.00004 Peripheral Bone Mineral Density Measurement

G0219 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

G0252 RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion

G0255 MED.00082 Quantitative Sensory Testing

G0341 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation

G0342 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation

G0343 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation

G0428 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

G0460 MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

G9143 GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status

G9147 MED.00065 Hepatic Activation Therapy

L5973 OR PR.00003 Microprocessor Controlled Lower Limb Prosthesis

L6026 OR PR.0004 Myoelectric Upper Extremity Prosthetic Devices

Page 13 of 16

L6715 OR PR.00004 Partial-Hand Myoelectric Prosthesis

L8607 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

M0075 MED.00024 Adoptive Immunotherapy and Cellular Therapy

M0076 MED.00007 Prolotherapy for Joint and Ligamentous Conditions

Q4102 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4103 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4105 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4107 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4108 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4110 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4111 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4112 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4113 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4114 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4117 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4118 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4119 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4120 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4122 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4123 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4124 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4125

SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4126 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4127 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Page 14 of 16

Q4129 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4130 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4132 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4133 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4134 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4135 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4136 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4137 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4138 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4139 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4140 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4141 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4142 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4143 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4145 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4146 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4147 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4148 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4149 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4150 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4151 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4152 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4153 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Page 15 of 16

Q4154 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4155 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4156 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4157 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4158 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4159 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4160 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4161 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4162 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4163 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4164 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Q4165 SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

S0596 SURG.00009 Refractive Surgery

S1090 SURG.00132 Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery

S2102 TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation

S2103 TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)

S2107 MED.00024 Adoptive Immunotherapy and Cellular Therapy

S2117 SURG.00104 Subtalar Arthroereisis

S2230 SURG.00084 Implantable Middle Ear Hearing Aids

S2300 SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons

S2348 SURG.00071 Percutaneous and Endoscopic Spinal Surgery

S2400 SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations

S3721 GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

S3800 GENE.00013 Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child)

S3852 GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

S3861 GENE.00007 Cardiac Ion Channel Genetic Testing

S3865 GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)

Page 16 of 16

S3890 GENE.00008 Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance

S8040 MED.00002 Selected Sleep Testing Services

S8080 RAD.00023 Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications

S8085 RAD.00040 PET Scanning Using Gamma Cameras

S8130 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

S8131 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

S8930 DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

S8940 REHAB.00003 Hippotherapy

S9024 RAD.00012 Ultrasound for the Evaluation of Paranasal Sinuses

S9055 MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

S9056 MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State

S9090 SURG.00008 Mechanized Spinal Distraction Therapy for Low Back Pain (VAX-D® Therapy, DRS® System, Accu-Spina System™ IDD Therapy)

V2787 SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses

V2788 SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses

V5095 SURG.00084 Implantable Middle Ear Hearing Aids