List of Medical Protocols, Codes, Key Words and Preauthorization … · 2018-10-17 · Key Words...
Transcript of List of Medical Protocols, Codes, Key Words and Preauthorization … · 2018-10-17 · Key Words...
CPT only copyright American Medical Association. All rights reserved. 1 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
Actigraphy 04/01/17 Recommended 95803 Actiwatch, Fitbit, Motionlogger, Sleepwatch
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
06/01/09 04/01/12 04/01/13
Yes, through Case Management
38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232, 38240, 38242, 86812, 86813, 86816, 86817, 86821, 86822, S2140,
S2142, S2150
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
06/01/09 01/01/12 04/01/1307/01/14
Yes, through Case Management
38204, 38205, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 86812, 86813, 86816, 86817, 86821, 86822, S2150
Myelofibrosis
Allogeneic Pancreas Transplant
01/01/10 01/01/12 10/01/12 04/01/1307/01/14
Yes, through Case Management
S2065, 48550, 48551, 48552, 48554 Pancreas Retransplantation
Ambulance (Emergency)11/01/07 04/01/14
No
A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998,
A0999, S9960, S9961
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
01/01/10 04/01/12 04/01/13 04/01/1401/01/1507/01/1507/01/1607/01/17
No
93268, 93270, 93271, 93272, 93228, 93229, 33282, 33284, 0295T, 0296T, 0297T, 0298T,
0497T, 0498T
MCOT, ZioPatch
List of Medical Protocols, Codes, Key Words and Preauthorization Information
CPT only copyright American Medical Association. All rights reserved. 2 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Amniotic Membrane and Amniotic Fluid07/01/1707/01/18
Yes
65778, 65779, Q4100, Q4131, Q4132, Q4133, Q4137, Q4138, Q4139, Q4140, Q4145, Q4148, Q4150, Q4151, Q4153, Q4154, Q4155, Q4156, Q4157, Q4159, Q4160, Q4162, Q4163, Q4168, Q4169, Q4170, Q4171,
Q4173, Q4174Antigen Leukocyte Antibody Test 07/01/14 Recommended 83516 ALCAT
Aqueous Shunts and Stents for Glaucoma
07/01/11 04/01/12 01/01/1304/01/1404/01/1510/01/18
No 0191T, 0253T, 0376T, C1783,
66179, 66183, 66184Express shunt, trabeculectomy
Artificial Intervertebral Disc: Cervical Spine01/01/0810/01/1501/01/17
Yes22856, 22858, 22861, 22864,
0095T, 0098T, 0375TPrestige disc, ProDisc-C, Bryan cervical disc
Artificial Intervertebral Disc: Lumbar Spine 01/01/08 Recommended22857, 22862, 22865, 0163T,
0164T, 0165T Charité Artificial Disc, Intervertebral Disc Arthroplasty,
ProDisc Device; Maverick, FlexiCore
Artificial Pancreas Device Systems07/01/1504/01/1807/01/18
Yes S1034, S1035, S1036, S1037 LGS, hybrid closed loop system
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
07/01/09 01/01/12 01/01/1410/01/1410/01/1510/01/1710/01/18
No29866, 29867, 27415, 27416,
28446 DeNovo NT, DeNovo® ET Live Chondral Engineered Tissue
Graft (Neocartilage), OATS, CAIS, Chondrofix
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
04/01/10 04/01/11 01/01/12 01/01/1404/01/1604/01/18
Yes 27412, S2112, J7330 ACT
Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
01/01/11 10/01/12 07/01/1310/01/15
No0232T, P9020, S0157, S9055,
G0460, 0481T
Becaplermin, Autologel, Autologous platelet tissue graft, GPS II, Magellan, Autologous Platelet Separator, Safeblood,
Platelet Rich Plasma, Regranex
CPT only copyright American Medical Association. All rights reserved. 3 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure
03/01/05 10/01/1207/01/14
No93784, 93786, 93788, 93790,
A4670Sphygmomanometry
24 hour ambulatory blood pressure monitoring
Automated Percutaneous and Percutaneous Endoscopic Discectomy
07/15/07 04/01/12 01/01/1410/01/1610/01/18
Recommended62287, 62380, 0274T, 0275T,
C2614DeKompressor or Nucleotome, Percutaneous Discectomy
Autonomic Nervous System Testing04/01/1504/01/16
No95921, 95922, 95923, 95924,
95943
Axial Lumbosacral Interbody Fusion 04/01/12 Recommended 0195T, 0196T, 0309T, 22586 Paracoccygeal, Pre-sacral , or Trans-sacral interbody fusion,
AxiaLIF
Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis
01/01/0705/01/12 04/01/1404/01/15
No 31295, 31296, 31297, C1726 Acclarent, Relieva, Entellus, FinESS
Bariatric Surgery
07/01/10 10/01/11 01/01/1304/01/1404/01/1501/01/1601/01/1704/01/18
No
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, S2083, 95980, 95981, 95982, 97802,
97803, 97804, 43289
StomaphyX™ devices, EndoCinch, LapBand, REALIZE, Roux-en-Y
CPT only copyright American Medical Association. All rights reserved. 4 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Bioengineered Skin and Soft Tissue Substitutes
07/01/1207/01/1307/01/1407/01/1510/01/1510/01/1601/01/1707/01/1707/01/18
Yes
C1878, C9354, C9356, C9358, C9360, C9363, C9364, C9366, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4119, Q4120, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4129, Q4130, Q4131, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4176, Q4177, Q4178,
Q4179, Q4180, Q4181, Q418215040-15261, 15271-15278, 15777
AmnioFix, AlloDerm, Acellular tissue matrix, Allograft, artificial skin, bioengineered skin, skin substitutes
AlloPatch, AlloMax, Avaulta Plus, Biobrane, CellerateRx, Conexa, CRXa, ENDURAgen, E-Z Derm, MediHoney, Mediskin, Repriza, StrataGraft, OrCel, Epifix, Epicel,
TransCyte, Apligraf, Dermagraft, PriMatrix, Oasis wound matrix, Integra Dermal regeneration, Neopatch,
Floweramnioflo, Floweramniopatch, Flowerderm, Revita, Amnio wound, Transcyte, CellerateRX
Biofeedback as a Treatment of Chronic Pain 07/15/07 Recommended 90901, E0746, 90875, 90876
Biofeedback as a Treatment of Fecal Incontinence or Constipation
01/01/10 01/01/12 10/01/1207/01/13
Recommended90875, 90876,
90901, 90911, E0746
Biofeedback as a Treatment of Headache 01/01/10 01/01/11
Recommended 90875, 90876, 90901, E0746
Biofeedback as a Treatment of Urinary Incontinence in Adults
01/01/10 Recommended 90875, 90876, 90901, 90911, E0746
Biofeedback for Miscellaneous Indications
01/01/10 01/01/11 01/01/1207/01/1304/01/16
Recommended 90875, 90876, 90901, E0746
Bioimpedance Devices for Detection and Management of Lymphedema
07/01/18 Recommended 93702
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
04/01/10 01/01/11 10/01/12 01/01/1307/01/1307/01/15
No 33211, 33213, 33224, 33225Dual Chamber Pacing, Intrathoracic Fluid Monitoring with
biventricular pacing, Resyncronization, cardiac
CPT only copyright American Medical Association. All rights reserved. 5 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Blepharoplasty 01/01/13 No15820, 15821, 15822, 15823, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
Bronchial Thermoplasty 10/01/14 Recommended 31660, 31661 Alair, Asthmatx
Cardiac Rehabilitation in the Outpatient Setting
10/01/10 10/01/1107/01/1307/01/1401/01/1707/01/18
No93797, 93798, G0422, G0423,
S9472
Cardiovascular Risk Panels 04/01/15 No81291, 82465, 82652, 83090, 83698, 83718, 83721, 83880,
84478, 86141, 81599
Carrier Screening for Genetic Diseases04/01/1404/01/18
Yes 81255, 81412
Catheter Ablation as Treatment for Atrial Fibrillation
07/01/11 07/01/1207/01/1510/01/15
No 93656, 93657 Pulmonary vein ablation, Isolation pulmonary vein
Catheter Ablation for Cardiac Arrhythmias 07/01/12 No 93650, 93653, 93654, 93655
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
07/01/1103/01/1407/01/17
Yes77520, 77522, 77523, 77525,
77299, 77499
Chelation Therapy for Off-Label Uses
01/01/1010/01/1301/01/1501/01/16
NoM0300, J3520, J0470, J0600, S9355,
J0895, 96365, 96366, 96374
EndRate®, Chemical Endarterectomy
Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
01/01/1507/01/1504/01/16
No 88271 and units >99Anora™ miscarriage test, CombiSNP™ Array for Pregnancy
Loss, CombiBAC™ Array, Natera POC, Progenity lab
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
10/01/16 Recommended 86152, 86153, 0011M Veridex, NeoLABTM, NeoGenomics
Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
04/01/18 Recommended 86152, 86153
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
10/01/0910/01/18
No 93580Aplatzer, Angel wings, ASCOS, GORE HELEX Septal Occluder,
Sideris buttoned device, CardioSeal device, ASD
CPT only copyright American Medical Association. All rights reserved. 6 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Cochlear Implant
07/01/11 07/01/1210/01/1307/01/1410/01/1401/01/1701/01/1808/01/18
No
69930, 92601, 92602, 92603, 92604, L8614, L8615, L8616, L8617,
L8618, L8619, V5273, L8627, L8628, L8629
Nucleus Hybrid 24
Cognitive Rehabilitation
01/01/01 01/01/1107/01/1407/01/16
Recommended 97532, 97127
Computed Tomography Perfusion Imaging of the Brain04/01/1501/01/16
Yes 0042T Cerebral perfusion
Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
10/01/09 Recommended 0159T
Computer-Assisted Navigation for Orthopedic Procedure
07/01/10 07/01/12
Recommended 0054T, 0055T, 20985
Confocal Laser Endomicroscopy 07/01/13 No 43206, 43252, 88375, 0397T
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
04/01/09 04/01/11 04/01/1307/01/1301/01/1407/01/1501/01/18
No for 72 hour testing; Else yes
95250, 95251, S1030, S1031, A9276, A9277,
A9278
GlucoWatch, MiniMed® 530G System-Enlite™ Sensor, Enlite™ Serter, MiniLink Real-Time System, CareLink® Pro
Software for Diabetes, Revel
Continuous Passive Motion in the Home Setting07/01/10 01/01/11 01/01/12
Yes E0935, E0936 CPM, Joint rehabilitation
Cooling Devices Used in the Outpatient Setting 07/01/13 No E0218, E0236 AutoChill, CryoCuff, Game Ready, Hot/Ice Thermal Blanket,
Polar Care Cub
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
10/01/10 04/01/12 01/01/13
Recommended 92025 Keratometry
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatological Tumors
07/01/10 01/01/13 01/01/1404/01/18
No19105, 20983, 32994, 50250,
50542, 50593, 0340TCryoablation, Cryocare, CryoGen, CryoHit, SeedNet, Visica
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
07/01/10 Recommended47371, 47381, 47383, 77013,
77022
CPT only copyright American Medical Association. All rights reserved. 7 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Cytochrome P450 Genotyping
01/01/10 01/01/1107/01/1307/01/1407/01/1507/01/1607/01/17
No81225, 81226, 81227, 81401, 81402, 81404, 81405, 0028U,
0031U
Amplichip, CYP 450, Pharmacogenomic Testing, Clopidogrel, Plavix, CYP2D6, CYP1A2
Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
04/01/11 04/01/1207/01/15
Yes49999, 58999, 77605, 96446,
96549
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
11/01/07 Recommended S2348, 62287 Coblation, Disc Decompression, Laser discectomy, Disc
Nucleoplasty
Deep Brain Stimulation
01/01/10 10/01/1207/01/1407/01/1507/01/18
No
61850, 61863, 61864, 61867, 61868, 61885, 61886, 95970, 95978, 95979, L8679, L8680, L8685, L8686, L8687, L8688
Activa Tremor Control System, Dystonia, Essential Tremor, Parkinson’s Disease
Dermatologic Applications of Photodynamic Therapy
07/01/11 07/01/1207/01/1407/01/15
Recommended 96567, J7308, J7309, 96573, 96574BLU-U Blue Light, CureLight Broadband, Levulan KeraStick,
Metvix
Diagnosis and Management of Idiopathic Environmental Intolerance and Intracellular Micronutrient Analysis
12/05/06 01/01/13 01/01/14
RecommendedNo specific code - 86353 or 88348
might be used
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
07/01/1107/01/1207/01/1310/01/1407/01/1510/01/1510/01/1610/01/18
No
95782, 95783, 95800, 95801, 95806, 95807, 95808, 95810, 95811, A9279, A7047, E0601, E0470, E0471, E0472, E0485, E0486, G0398, G0399, G0400
STOP-BANG
Diagnosis and Treatment of Sacroiliac Joint Pain
09/01/0904/01/12 07/01/1304/01/1401/01/1601/01/1701/01/1807/01/18
Yes27096, 27279, 27280, 27299,
G0259, G0260iFuse
CPT only copyright American Medical Association. All rights reserved. 8 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
DNA-Based Testing for Adolescent Idiopathic Scoliosis04/01/1201/01/18
Yes 81479, 0004M, 81599ScoliScore, Axial Biotech, Genetic and Prognostic Testing,
scoliosis; Genetic Testing, scoliosis
Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography
01/01/15 Recommended 78607, A9584
Dementia with Lewy Bodies, Parkinsonian Syndromes, Parkinson’s Disease
123I-b-CIT, 123I-FP-CIT, 99mTc-TRODAT-1DaTscan, DAT-SPECT
Dynamic Posturography
07/01/10 04/01/11 04/01/1204/01/13
Recommended 92548 Equitest™, Metitur™, Moving Platform Posturography
Dynamic Spinal Visualization 01/01/09 No 76120, 76125
Cineradiography Digital Motion X ray
VideofloroscopyVideoflourography Videoradiography
Electrical Bone Growth Stimulation of the Appendicular Skeleton
01/01/09 10/01/10 04/01/1204/01/1304/01/14
Yes20974, 20975, E0747,
E0749
Electrical Stimulation for the Treatment of Arthritis 05/01/06 Recommended E0762 BioniCare Bio 1000
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
01/01/09 10/01/10 07/01/12
Yes E0748, E0749, 20974, 20975
Electromagnetic Navigation Bronchoscopy01/01/1104/01/12 04/01/13
No 31627, A4648 InReach™ or SpiN Drive™ system
Electrostimulation and Electromagnetic Therapy for Treating Wounds
10/01/09 04/01/14
NoE0761, E0769, G0281, G0282,
G0295, G0329 Alternating Current (AC) Electrical Stimulation, High Voltage Pulsed Current (HVPC), Low Intensity Direct Current (LIDC)
Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
04/01/15 No 31620, 31652, 31653, 31654
Endometrial Ablation 01/01/14 No 58353, 58356, 58563Her Option, Rollerball ablation, Hydro ThermAblator, The
NovaSure
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
07/01/10 10/01/1201/01/16
Recommended43257, 43211, 43229, 43254,
43270HALO
Endothelial Keratoplasty 04/01/14 No 65756, 65757 DLEK, DMEK, DSEK, DSAEK, EK, PK
CPT only copyright American Medical Association. All rights reserved. 9 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
01/01/12 10/01/12 07/01/1401/01/1501/01/1610/01/18
No
35475, 36100, 36215, 36216, 36217, 36218, 37184, 37185, 37218, 61624, 61630, 61635,
61645, 61650, 61651
Neurolink System, Percutaneous Transluminal Angioplasty, Vertebrobasilar Stenosis, Angioplasty, Wingspan Stent
System, penumbra, Merci clot retriever, mechanical embolectomy
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
07/01/10 07/01/12 07/01/1304/01/1401/01/15
Recommended
34812, 34820, 34800, 34802, 34803, 34804, 34805, 34825, 34826, 34839, 75952, 75953, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712,
34713
Stents, AAA, Powerlink Excluder, Zenith, EBT, AneuRx
Endovascular Therapies for Extracranial Vertebral Artery Disease
07/01/15 Recommended 0075T, 0076T V1-V3
Enhanced External Counterpulsation
07/01/09 04/01/1104/01/12 01/01/14
Yes G0166 ECP, EECP
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
10/01/1510/01/18
Recommended 81479, 0037U, 0047U, 0057UOnkoMatch by GenPath, FoundationOne CDx (F1CDx),
Guardant 360
Extracorporeal Photopheresis
07/01/1107/01/1301/01/1508/01/18
No 36522
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
07/01/09 01/01/13
No 28890, 0019T, 0101T, 0102TESWT, Epos Ultra, Orbasone, Orbaspec, OssaTron Device®,
SONOCUR®
Extracranial Carotid Artery Stenting
10/15/05 01/01/12 10/01/1208/01/18
No 37215, 37216, 0075T, 0076TACCULINK™ and RX ACCULINK™; Xact® RX; Precise® nitinol;
NexStent®; ProtégéRx® and SpideRx®
Facet Arthroplasty 01/01/12 Recommended 0202T TFAS
Facet Joint Denervation
01/01/10 10/01/1207/01/1307/01/1401/01/16
Yes64633, 64634, 64635, 64636,
64999, 77003 Radiofrequency neurotomy; pulsed radiofrequency, Slnergy,
medial branch block
CPT only copyright American Medical Association. All rights reserved. 10 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 01/01/13 Recommended
82239, 82492, 82656, 82710, 82715, 82725, 83520, 83630, 83631, 83986, 83993, 84311, 87102, 87328, 87329, 87336,
89160
Digestive Stool Analysis
Fecal Microbiota Transplantation 10/01/14 Yes 44705, G0455Donor feces infusion, Intestinal microbiota transplantation,
Fecal bacteriotherapy
Functional Neuromuscular Electrical Stimulation04/01/1007/01/1307/01/16
Recommended E0764, E0770, 64565, 64580 NMES
Gastric Electrical Stimulation10/01/03 04/01/13
No
64590, 64595, 43647, 43648, 43659, 43881, 43882, 43999, 95980, 95981, 95982, E0765,
L8679, L8680, L8685, L8686, L8687, L8688
Enterra Therapy System; Pacemaker, Gastric
Gender Reassignment Surgery05/01/1507/01/18
Yes
55970, 55980, 56805, 57335or
Various hysterectomy, mastectomy codes, etc: eg. Surgical codes with dx 302.50, 302.51, 302.52, 302.53,
302.85
Gender Dysphoria
Gene Expression Profiling for Cutaneous Melanoma 10/01/18 No 81401 LINC00518, PRAME
Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease
01/01/12 01/01/1410/01/1410/01/1601/01/18
No 81493, 81599Gene expression profiling, cardiovascular disease risk; Gene
expression assay, coronary artery disease risk
Gene Expression-Based Assays for Cancers of Unknown Primary
10/01/09 04/01/11 04/01/12 04/01/1304/01/1404/01/1504/01/18
Recommended 81504, 81540, 0019U Pathwork Tissue of unknown origin
General Approach to Evaluating the Utility of Genetic Panels
01/01/1401/01/1501/01/1601/01/17
Yes
81200-81355, 81400-81408, 81479, 81599, 81120, 81121, 81258, 81259, 81269, 81283, 81413,
81414, 0030U, 0046U
Chromosomal Microarray Genetic Testing, Gene Test Panels, Next-Generation Sequencing, Next Gen
CPT only copyright American Medical Association. All rights reserved. 11 of 29 Last Update 10/17/18
Name of Corporate Medical ProtocolProtocol
Effective DatePreauthorization
Required? CPT and/or HCPCS Codes Key Words
List of Medical Protocols, Codes, Key Words and Preauthorization Information
General Approach to Genetic Testing
04/01/1104/01/12 01/01/13 01/01/1401/01/1501/01/1601/01/17
Yes
81161, 81200, 81220, 81221, 81222, 81223, 81224, 81242, 81251, 81255, 81287, 81291, 81321, 81322, 81323, 81330, 81331, 81405, 81406, 81407, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, S3800,
S3841, S3842, S3843, S3844, S3845, S3846, S3849, S3850, S3853, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81175, 81176, 81230, 81231, 81247, 81248, 81249, 81328, 81334, 81346, 81361, 81362,
81363, 81364
Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing
01/01/14 No81435, 81436, 81445, 81450, 81455, 81471, 81479, 0048U
Genetic Testing for Alpha1-Antitrypsin Deficiency 01/01/1301/01/18
Yes 81332
Genetic Testing for Alzheimer Disease
07/01/03 07/01/1207/01/1407/01/1610/01/17
No S3852, 81401, 81405, 81406Apolipoprotein E (APOE) or Presenilin, TREM2, PSEN,
epsilon 4allele
Genetic Testing for Breast Cancer Gene Expression Prognosis Assay
04/01/10 04/01/11 04/01/12 04/01/1304/01/1401/01/1501/01/1707/01/1701/01/18
YesS3854, 0008M, 81519, 84999,
81520, 81521, 0045U Oncotype testing, Microchip array, MammaPrint, Her,
Her2
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Genetic Testing for Cardiac Ion Channelopathies
10/01/0907/01/1401/01/1604/01/18
Yes 81413, 81414, S3861Familion, Long QT Syndrome, Short QT Syndrome, Brugada
Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia
Genetic Testing for Cystic Fibrosis01/01/1701/01/18
No81220, 81221, 81222, 81223,
81224
Genetic Testing for Developmental Delay and Autism Spectrum Disorder
01/01/1104/01/1207/01/1404/01/1501/01/1601/01/1707/01/1701/01/18
Yes
81228, 81229, 81243, 81244, 81302, 81303, 81304, 81404, 81406, 81470, 81471, S3870,
81415, 81416, 81417
Chromosomal Microarray Analysis, Array Comparative Genomic Hybridization (ACGH), Genomic hybridization, MA,
NGS, MECP2
Genetic Testing for Duchenne and Becker Muscular Dystrophy
07/01/13 07/01/1407/01/1510/01/17
Yes 81161, 81408 DMD, BMD
Genetic Testing for Epilepsy 04/01/16 Yes 81479Genetic Testing for Familal Cutaneous Malignant Melanoma
01/01/11 01/01/12
Recommended 81404 Melaris
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
04/01/10 04/01/12 04/01/13 04/01/1401/01/17
Yes
81201, 81202, 81203, 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318,
81319, 81403
Adenomatous Polyposis Coli. APC, Familial Adenomatous Polyposis, FAP, BRAF V600E, Colaris test
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome
10/01/10 04/01/12 04/01/13 04/01/1407/01/1407/01/1501/01/1707/01/1701/01/1808/01/18
Yes81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217,
81406, 81408, 81479 BRCA1 and BRCA2 mutations, CHEK2, ATM, PALB2
Genetic Testing for Hereditary Hearing Loss04/01/1401/01/1501/01/18
Yes81252, 81253, 81254, 81430,
81431GJB2, GJB6
Genetic Testing for Hereditary Hemochromatosis01/01/1301/01/15
Yes 81256
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Genetic Testing for Human Leukocyte Genes (HLA) 01/01/17Yes for some
diagnosis
81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381,
81382, 81383
simple sequence, polymerase chain, reverse dot blot hybridization, PCR
Genetic Testing for Lactase Insufficiency 10/01/13 Recommended 81400 Lactotype
Genetic Testing for Leukemia and Lymphoma01/01/1701/01/18
Yes
81162, 81170, 81206, 81207, 81208, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81218, 81219, 81225, 81226, 81217, 81235, 81240, 81241, 81245, 81246, 81256, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81272, 81273, 81275, 81276, 81287, 81301, 81310, 81311, 81313, 81314, 81370-81383,
0023U, 0027U, 0040U, 0049U, 0050U, 0056U
Genetic Testing for Li-Fraumeni Syndrome10/01/1410/01/18
Yes 81405 TP53
Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment
10/01/11 Recommended 81479
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
07/01/1507/01/18
Yes 81405, 81408, 81410, 81411
Genetic Testing for Mental Health Conditions10/01/1404/01/1504/01/16
Yes81225, 81226, 81291, 81401,
81479, 0032U, 0033U
Genomind, LLC, Genecept Assay, STA2R, GeneSight Psychotropic panel, Proove narcotic risk, COMT, HRT2A,
HTR2C
Genetic Testing for Mitochondrial Disorders10/01/1410/01/1510/01/17
Yes81401, 81403, 81440, 81460,
81465Mitochondrial DNA
Genetic Testing for Noninvasive Prenatal Testing 01/01/1701/01/18
Yes0009M, 81420, 81507, 81508, 81509, 81510, 81511, 81512
Down Syndrome, Maternal Plasma DNA testing, Prenatal Detection, MaterniT21™ (Sequenom); verifi® (Verinata Health); Harmony™ (Ariosa Diagnostics); Panorama™
(Natera), Illumina, aneuploigy, massively parallel-sequencing
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
07/01/1207/01/16
Yes S3865, S3866, 81405, 81406, 81407 HCM
Genetic Testing for PTEN Hamartoma Tumor Syndrome07/01/1307/01/14
Yes 81321, 81322, 81323 ARUP lab, PHTS
Genetic Testing for Statin-Induced Myopathy 01/01/14 No 81400SLCO1B1
Boston Heart Diagnostics, Berkeley Heart Lab
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Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
01/01/1401/01/18
Recommended81324, 81325, 81326, 81403, 81404, 81415, 81406, 81479,
81448PMP22
Genetic Testing for Warfarin Dose04/01/201104/01/2018
Recommended G9143, 81227, 81355, 0030UCoumadin®, CYP450. Cytochrome p450, VKORC1, Vitamin K
epoxide reductase subunit C1, Genotyping, Pharmacogenomic Testing
Genetic Testing of CADASIL Syndrome
04/01/12 04/01/1404/01/1504/01/18
Yes 81406 Notch3
Genotype-Guided Tamoxifen Treatment 10/01/12 Recommended 81226
Heart Transplant
04/01/10 04/01/11 04/01/1204/01/14
Yes, through Case Management
33940, 33944, 33945
Heart/Lung Transplant
04/01/10 04/01/11 04/01/1204/01/14
Yes, through Case Management
33930, 33933, 33935, 33960, 33961
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
06/01/10 07/01/1210/01/1307/01/14
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
10/01/10 10/01/11 07/01/1204/01/13 07/01/1307/01/1407/01/16
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Autoimmune Diseases
06/01/09 04/01/11 04/01/12 04/01/14
Yes, through Case Management
38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221,
38240, 38241, 38243, S2150
Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
06/01/09 04/01/12 04/01/13
Yes, through Case Management
38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232,
38240, 38241, 38243, S2150
Ependymoblastoma, High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET), Central
Medulloblastoma, Neuroblastoma, Pinealblastoma
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Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
10/01/11 07/01/12
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
06/01/09 07/01/1204/01/13
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
06/01/09 04/01/12 04/01/13
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Hodgkin Lymphoma
06/01/09 04/01/12 04/01/1304/01/18
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
06/01/09 04/01/12 04/01/13
Yes, through Case Management
38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232,
38240, 38241, 38243, S2150
Lung Cancer
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
06/01/09 10/01/11 07/01/12 04/01/13
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
06/01/09 10/01/11 01/01/14
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation for Primary Amyloidosis
06/01/09 01/01/12 10/01/12
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
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Hematopoietic Cell Transplantation for Solid Tumors of Childhood
06/01/09 04/01/11 01/01/12 06/01/1204/01/1310/01/18
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Ewing’s Sarcoma, Wilms’ Tumor
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
01/01/1204/01/13
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
10/01/10 10/01/11
Yes, through Case Management
38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38240, 38241, 38243,
S2140, S2142, S2150
Seminoma or testicular cancer high dose chemotherapy
Hip Resurfacing10/01/1210/01/14
No S2118Birmingham Device, Conserve Plus, Cormet System, Surface
Hip ArthroplastyHippotherapy 01/01/05 Recommended S8940 Equine Movement TherapyHomocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
01/01/10 10/01/1210/01/17
No 83090
Hyperbaric Oxygen Therapy
10/01/10 10/01/11 07/01/1207/01/1307/01/1407/01/1501/01/1607/01/18
Yes 99183, A4575, G0277 HBO
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
01/01/1110/01/1410/01/1710/01/18
Recommended 64999, 0275T, G0276MILD® procedure, Posterior lumbar decompression, Lumbar
spinal stenosis, X-Sten MILD Tool Kit
Immune Cell Function Assay 01/01/11 04/01/12
Recommended 86352 Cylex, ImmuKnow
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
07/01/11 07/01/12 04/01/1301/01/1708/01/18
NoL8690, L8691, L8692, L8693, L8694,
69710, 69711, 69714, 69715, 69717, 69718
BAHA, Otomag Alpha 1 [M], Cordele II, Softband, Divino, Intenso, BP100, AC CROS
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Implantable Cardioverter Defibrillators
01/01/06 01/01/12 04/01/1307/01/1401/01/1604/01/18
No
33216, 33217, 33218, 33220, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 93260, 93261, 93644, C1721, C1722, C1882, G0448, 0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, 0328T
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
04/01/13 04/01/1404/01/17
Recommended S1090, 0406T, 0407TPropel, Relieva Stratus MicroFlow, SinuFoam, Sinuva
implant, mometasone furoate
Implantation of Intrastromal Corneal Ring Segments07/01/1008/01/18
No 0099T, 65785 Intacs, Keratoconus
In Vitro Chemoresistance and Chemosensitivity Assays
03/01/06 10/01/1201/01/1601/01/18
RecommendedSeries of lab codes used.
81535, 81536
AntiCancer, Inc, Chemo FX® Assay, Cytoprint, EDR, Extreme Drug Resistance, Histoculture, Oncotech, ChemoFit,
AccuTheranostics, ChemoFX
Ingestible pH and Pressure Capsule01/01/11 10/01/12
Recommended 91112 Smart Pill
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
01/01/10 01/01/11 01/01/1207/01/1307/01/15
Recommended51715, L8603, L8604, L8605, L8606,
Q3031, 0377T, 55874
Durasphere, Teflon®, Uryx, Tegress, Ethylene Vinyl Alcohol Copolymer, Coaptite®, Calcium H, Macroplastique,
Polydimethylsiloxane, Dextranomer/Hyaluronic Copolymer, Zuidex™ Implace™, Contigen
Intensity-Modulated Radiotherapy: Abdomen and Pelvis07/01/1107/01/1307/01/14
Recommended 77301, 77385, 77386, 77338,
G6015, G6016
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
07/01/11 01/01/13 01/01/1407/01/15
Recommended 77301, 77385, 77386, 77338,
G6015, G6016
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
10/01/1210/01/1303/01/1407/01/17
No 77301, 77385, 77386, 77338,
G6015, G6016
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
01/01/0710/01/1310/01/17
Recommended22867, 22868, 22869, 22870,
C1821 X-Stop (X Stop)
Spinous Process Distraction Device
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Interspinous Fixation (Fusion) Devices 04/01/13 Recommended 22840, 22851
Affix (Nuvasive), Aileron (Life Spine), Aspen (Lanx), Axle (X-Spine), BacFuse (Pioneer Surgical), BridgePoint (Alphatec),
coflex-F (Paradigm Spine), Inspan (Spine Frontier), PrimaLOK (OsteoMed), Octave, Spire (Medtronic), SP-Fix
(Globus)
Intra-Articular Hyaluronan Injections for Osteoarthritis
04/01/1307/01/1404/01/1504/01/17
NoJ7321, J7323, J7324, J7325, J7326,
J7327, J7328, Q9980, 20610, C9465Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc,
Viscosupplementation
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas
10/01/0903/01/14
Recommended 64999, A9527 GliaSite, IsoRay
Intradialytic Parenteral Nutrition 07/30/04 Recommended B4164-B5200
Intraoperative Neurophysiologic Monitoring
10/01/1307/01/1407/01/1510/01/17
No92585, 95829, 95867, 95868, 95925-95927, 95930, 95955,95940, 95941, G0453, 0333T
EMG, Somatosensory-evoked potentials, Visual-evoked potentials
Invasive Prenatal (Fetal) Diagnostic Testing04/01/1504/01/18
Yes 81228, 81229, 81405, 81470
Islet Transplantation
10/01/09 10/01/1104/01/1307/01/15
Yes, through Case Management
48160, 48999, G0341, G0342, G0343, S2102
Isolated Small Bowel Transplant
04/01/10 04/01/1204/01/13 04/01/1401/01/15
Yes, through Case Management
44132, 44133, 44135, 44136, 44715, 44720, 44721
Keratoprosthesis04/01/1010/01/1510/01/16
Recommended 65770, L8609, C1818 Artificial cornea
Kidney Transplant
10/01/09 10/01/11 07/01/1207/01/1301/01/15
Yes, through Case Management
50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340,
50360, 50365, 50547
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
01/01/12 Recommended 81479 KIF6
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KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer
07/01/1207/01/1407/01/1510/01/1607/01/1707/01/18
Yes81210, 81275, 81276, 81311,
81403, 81404, 88363
Laboratory Testing for HIV Tropism
07/01/10 07/01/1207/01/1407/01/15
Recommended 87999 Trofile test for maraviroc, Selzentry, SensiTrop
Laboratory Tests for Heart Transplant Rejection07/01/1307/01/14
Recommended0085T, 86849 81595, 0055U
AlloMap™ (XDx, Inc.)Breath Test, Heartsbreath (Menssana Research)
grade2R/grade 3
Light Therapy for Psoriasis 07/01/16 Yes96900, 96912, 96920, 96921,
96922
Laser Treatment, Photomedex; XTRAC, Targeted Phototherapy, Psoralens with Ultraviolet A (PUVA), VTRAC,
BClear, ExciliteLight Therapy for Vitiligo 07/01/18 Yes 96912, 96999, J8999 Psoralens with Ultraviolet A (PUVA)
Lipid Apheresis 10/01/0907/01/1504/01/18
Recommended 36516, S2120, 0342T LDL or Familial hypercholesterolemia apheresis
Liver Transplant and Combined Liver-Kidney Transplant
01/01/10 01/01/12 04/01/12 04/01/1307/01/1407/01/18
Yes, through Case Management
47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144,
47145, 47146, 47147Hepatic Transplant
Low-Level Laser Therapy 04/01/10 04/01/1104/01/17
Recommended S8948, 97026 MicroLight, Low Level Laser, Carpal Tunnel Syndrome
Lung and Lobar Lung Transplant
01/01/10 01/01/12 10/01/1207/01/1307/01/14
Yes, through Case Management
32850, 32851, 32852, 32853, 32854, 32855, 32856, S2060, S2061
Lung Volume Reduction Surgery for Severe Emphysema
01/01/11 01/01/1201/01/1508/01/18
No32491, 32672,
G0302, G0303, G0304, G0305
Lysis of Epidural Adhesions 01/01/06 04/01/12 04/01/13
Recommended 62263, 62264, 64999 Racz procedure
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Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
01/01/18 No 55700, 55705, 55706
Magnetic Resonance-Guided Focused Ultrasound
07/01/04 07/01/1307/01/1407/01/15
Recommended 0071T, 0072T, 0398TExAblate 2000
High Intensity Ultrasound Ablation
Magnetoencephalography/Magnetic Source Imaging04/01/11 04/01/12
Recommended 95965, 95966, 95967, S8035 MSI (Magnetic Source Imaging)
Manipulation Under Anesthesia 07/15/09 10/01/1108/01/18
No 22505, 00640
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
07/01/10 07/01/12
Recommended 95012, 83987, 94799
Measurement of Serum Antibodies to Infliximab and Adalimumab
04/01/15 Recommended 84999Serum infliximab and antichimeric antibodies, Anser IFX,
Anser ADA, HACA, ATI, ATA, Remicade, Humira, Prometheus
Meniscal Allografts and Other Meniscus Implants 04/01/10 04/01/12 01/01/13
No 29868, G0428 Menaflex
Microprocessor-Controlled Prostheses for the Lower Limb
03/01/09 10/01/11 07/01/1207/01/1308/01/18
NoL5856, L5857, L5858, L5859, L5969,
L5973, L5999 C-Leg, Intelligent Prosthesis, knee, iPED foot prosthesis,
Adaptive knee prosthesis, Power foot or knee, Proprio Foot
Microwave Tumor Ablation 07/01/13 Recommended 32998, 47382, 50592Microwave coagulation therapy, MWA
MTX-180, VivaWave, Tri-Loop, MicroSurgeon, Microsulis, NeuWave Certus 140, Covidien
Miscellaneous Genetic and Molecular Diagnostic Tests10/01/1710/1/18
Recommended 81327 ColoVantage, SEPT9, methylated DNA
Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
10/01/09 10/01/1107/01/1404/01/1504/01/1610/01/1610/01/1701/01/1804/01/18
No
81235, 88363, 81275, 81403, 88342, 88365, 81404, 81405, 81406, 81210, 88271, 88274,
88275, 84075, 0022U
EGFR, Erlotinib, gefitinib, Iressa, Tarceva, afatinib, ROS1, BRAF
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Molecular Markers in Fine Needle Aspirates of the Thyroid
10/01/1510/01/1601/01/1704/01/1807/01/18
Yes81545, 81599, 84999, 0018U,
0026UMutation Analysis, miRInform, Veracyte, Afirma, ThyGenX,
ThyraMIR, Thyroseq
Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus
01/01/10 10/01/1210/01/1410/01/16
Recommended 84999, 89240 PathFinderTG
Multigene Expression Assay for Predicting Recurrence in Colon Cancer
01/01/11 10/01/1310/01/16
Recommended 81525, 84999, 88299Microchip Array, Tumor Gene Expression, Colon Cancer Oncotype Test, Colon Cancer Tumor Gene Expression,
ColonPRS, Coloprint, Genefx, OncoDefender
Multimarker Serum Testing Related to Ovarian Cancer
04/01/11 04/01/13 04/01/1404/01/18
Yes 81500, 81503, 0003UProteomic-based testing,
OVA1 or OVA 1, ROMA, Overa
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
04/01/15 No87481, 87491, 87512, 87591,
87661, 87999
Myoelectric Prosthetic Components for the Upper Limb
10/01/10 01/01/13 01/01/1408/01/18
No
L6025, L6026, L6715, L6880, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7190,
L7191
Bionic hand, electrically powered prosthesis
Negative Pressure Wound Therapy in the Outpatient Setting
01/01/11 10/01/11 07/01/1207/01/1307/01/1507/01/18
No
E2402, A6550, A7000, A7001, A9272, 97605, 97606, 97607, 97608, K0743, K0744, K0745,
K0746
Wound Vac, Versatile 1™; RENASYS EZ, RENASYS GO
Nerve Graft With Radical Prostatectomy 05/01/06 Recommended 64999 Genitofemoral Nerve Graft, Prostatectomy Neurofeedback 04/01/09 Recommended 90875, 90876, 90901, E0746
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
04/01/1704/01/18
No0001M, 0002M, 0003M, 91200,
0346TFibroSpect, FibroSure, Serum Markers, Liver Fibrosis, ASH
test, NASH test, HCV, elastography
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
01/01/11 01/01/1207/01/14
Recommended82172, 82664, 83695, 83700, 83701, 83704, 84181, 84999,
0052U
Apolipoprotein A-1, B, or E; HDL Subclass Testing, Lipoprotein A, Small-Density Lipoproteins, Small-Diameter
Lipoproteins
Occipital Nerve Stimulation 01/01/11 Recommended
61885, 61886, 64553, 64568, 64569, 64570, 64999
L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689,
L8679
Occipital Neurostimulation
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Occlusion of Uterine Arteries Using Transcatheter Embolization
07/01/11 01/01/1301/01/15
No 37241, 37242, 37243, 37244 Fibroids, UFE, UAE, Leiomyomas
Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
08/30/0401/01/18
Recommended96570, 96571, J9600,
31641, 43229Hematoporphyrin, Photofrin®, Photochemotherapy,
Photoradiation therapy, Photosensitizing therapy
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
07/01/10 01/01/1401/01/1501/01/1601/01/18
No33254, 33255, 33256, 33257, 33258, 33259, 33265, 33266
Hybrid ablationCox-maze, Cox
Optical Coherance Tomography of the Anterior Eye Segment
10/01/11 10/01/1207/01/14
Recommended 92132
AC Cornea OCTAnterior Segment Optical Imaging
Closed Angle GlaucomaVisante OCTStratus OCT
Orthognathic Surgery 01/01/06 01/01/14
No
21083, 21084, 21085, 21088, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21181, 21182, 21183, 21184, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21247, 21255, 21270,
21275, 21295, 21296
Orthopedic Applications of Platelet-Rich Plasma 10/01/15 Recommended0232T, P9020, S0157, S9055,
G0460, 0481TOrthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
01/01/11 10/01/1310/01/15
Recommended 38206, 38230, 38232, 38241Mesenchymal stem cells, MSCs, Tissue engineering;
Regenexx™ procedure
Orthoptic/Vision Therapy01/01/10 04/01/1104/01/12
Yes 92065, V2799 Training, eye
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
07/01/10 07/01/1410/01/1601/01/18
NoE0481, E0483, E0484, A7025,
A7026, S8185, 94669
Flutter device, Acapella, The Vest® Airway clearance System, Percussionaire device, High Frequency Chest
Compression, Intrapulmonary Percussive Ventilation (IPV), Percussionaire, ThAIRapy Vest, Vest Airway clearance, Lung
flute
Outpatient Pulmonary Rehabilitation 07/01/1107/01/1407/01/15
NoS9473, G0237, G0238, G0239, G0302, G0303, G0304, G0305,
G0424
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Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
01/01/11 Recommended 36012, 37204Embolization Therapy, Ovarian Vein, for Pelvic Congestion
Syndrome; Positron Emission Tomography
Panniculectomy and Abdominoplasty 01/01/16 Yes 15830, 15834, 15847, 15877
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
01/01/1007/01/14
NoE0740,
53899, G0283
Magnetic therapy, MyoTrac Infiniti, InCare PRS, Pathway, NeoControl, Neotonus Model 1000, Pathway CTS 2000,
InCare PRS
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
10/01/1310/01/1410/01/1510/01/1610/01/18
No 22513, 22514, 22515 Kiva
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy
10/01/09 Recommended 64999
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
04/01/09 Recommended 22526, 22527 ArthroCare, Intradiscal biacuplasty
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
01/01/1607/01/1608/01/18
No 0281T Watchman, lariat
Percuraneous Tibial Nerve Stimulation
01/01/10 10/01/12 10/01/1310/01/1510/01/18
No 64566, 64999, 97014, 97032 PerQ, SANS system, Urgent®, Neuromodulation system
Percutaneous Vertebroplasty and Sacroplasty 10/01/1310/01/1610/01/17
Recommended 22510, 22511, 22512, 0200T,
0201T
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
01/01/11 01/01/12 01/01/1410/01/1408/01/18
No 52327, L8603, L8604, L8606 Deflux, VUR
Pharmacogenetic Testing for Pain Management 07/01/15 Yes81225, 81226, 81227, 81291,
81401, 0032U, 0033U
Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines
07/01/10 07/01/1201/01/15
Yes81401, 82491, 81335, 0034U
Modifier 9A Pro-Predict Rx TPMT, Pro-Predict Rx 6MP, Nudix Hydrolase
(NUDT15)
Photodynamic Therapy for Choroidal Neovascularization01/01/1410/01/18
No67221, 67225, J2503, J2778, J3396,
C9257, J0178
Age-Related Macular Degeneration; Bevacizumab, Macugen, Pegaptanib, Ranibizumab,
Visudyne therapy, Lucentis, Verteporfin, Ocular Histoplasmosis
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Placental and Umbilical Cord Blood as a Source of Stem Cells
10/01/11Yes, through Case
ManagementS2140, S2142, S2150
Serotonin receptor gene, Dopamine receptor gene, opioid receptor gene
Plasma Exchange
10/01/10 10/01/1210/01/1401/01/16
Yes36514, P9041, P9045, P9046,
P9047 Plasmapheresis, therapeutic apheresis
Plugs for Anal Fistula Repair01/01/1101/01/16
Recommended 46707 Anal fistula plug
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
01/01/11 01/01/1204/01/12 04/01/13 04/01/1401/01/17
No
E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
07/01/1307/01/1401/01/17
No E0676Deep Vein Thrombus
Prevention DVT
Preimplantation Genetic Testing01/01/12 01/01/13 01/01/14
Recommended88271, 88272, 88273, 88274, 88275, 88291, 89290, 89291
Assisted reproductive techniques may be subject to specific contractual restrictions that supersede this Protocol. For
most of our contracts this is an exclusion and therefore PGT is not covered.
PGD
Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
01/01/11 Recommended No specific codeAutologous Cell Transplant, BioHeart, Heart Disease;
Cellular Cardiomyoplasty, Progenitor cell implantation or transplantation
Prolotherapy 07/01/09 Recommended M0076
Prostatic Urethral Lift07/01/1704/01/18
No 52441, 52442 Urolift, Spanner
Protein and Genetic Testing for Prostate Cancer
01/01/1010/01/1107/01/1507/01/1610/01/1701/01/18
No 81313, 81479, 0021U, 0053U PCA3, uPM3, PCA Test
Quantitative Sensory Testing07/15/0404/01/12
Recommended0106T, 0107T, 0108T, 0109T,
0110T, G0255QST, Medi-Dx 7000™
Neurometer®
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Radioembolization for Primary and Metastatic Tumors of the Liver
01/01/11 01/01/12 10/01/12 10/01/1310/01/1410/01/1508/01/18
NoS2095, C2616, 37243, 75894,
77399, 77778, 79445Sir Spheres, TheraSpheres, SIRT, Selective Internal Radiation
Therapy
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
01/01/10 01/01/13 01/01/14
No20982, 50592, 32998, 50542,
76940RFA
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
01/01/10 01/01/1101/01/1201/01/15
No 47370, 47380, 47382, 76940 RFA
Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
04/01/15 No78800, 78801, 78802, 78803,
78804, A9507ProstaScint, Indium-111 capromab pendetide
Reconstructive Breast Surgery/Management of Breast Implants
01/01/0604/01/12 04/01/1304/01/14
Yes
11920, 19316, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19499, S2066, S2067,
S2068, L8600
TRAM, Adipose-derived Stem Cells
Reduction Mammaplasty for Breast-Related Symptoms
04/01/1004/01/12 01/01/1404/01/1504/01/16
Yes 19318
Sacral Nerve Neuromodulation/Stimulation
01/01/10 01/01/11 01/01/13 01/01/1401/01/1501/01/16
Recommended
64561, 64581, 64585, 64590, 64595, 95970, 95971, 95972, 95973, A4290, E0745, E1399,
L8680, L8685, L8686, L8687, L8688, L8679
Interstim device
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
05/01/1004/01/1201/01/15
No 55700, 55705, 55706, G0416 TTMB, transperineal template-guided mapping
Scintimammography and Gamma Imaging of the Breast and Axilla
08/01/10 10/01/1107/01/1501/01/17
RecommendedS8080, A4641, A4642, A9500,
A9502, A9568, A9572Miraluma®, Radionuclide scanning, breast; Gammagram,
gammogram
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Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
10/01/0804/01/1204/01/13
Recommended S2230, V5095, 69799 Vibrant sound bridge, Soundtec Device
Sensory Integration Therapy and Auditory Integration Therapy
10/01/0904/01/1304/01/1504/01/16
Recommended 97533 Auditory integration
Small Bowel/Liver and Multivisceral Transplant
10/01/09 10/01/11 07/01/1207/01/14
Yes, through Case Management
44120, 44121, 44132, 44133, 44715, 44720, 44721, 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145,
47146, 47147, S2053, S2054, S2055
Spinal Cord and Dorsal Root Ganglion Stimulation
07/01/0907/01/1407/01/1504/01/1710/01/1704/01/18
Yes
63650, 63655, 63685, 63688, 95970, 95971, 95972, 95973,
L8680, L8685, L8686, L8687, L8688, 63661, 63662, 63663, 63664, L8679
Electrical nerve stimulation
Stem Cell Therapy for Peripheral Arterial Disease10/01/1110/01/18
Recommended 0263T, 0264T, 0265T
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
07/01/11 01/01/1303/01/1407/01/1507/01/16
Recommended
77373, 77435, G0173, G0251, G0339, G0340, 77371, 77372, 77432, 61796, 61797, 61798, 61799, 61800, 63620, 63621,
61781, 61782, 61783
Gamma Knife, Cyber Knife, Helium Radio surgery, Linear Accelerator Radiosurgery, LINAC, Neutron Beam
Radiosurgery, Proton Beam Radiosurgery
Subtalar Arthroereisis 10/01/08 No S2117, 0335TExtraosseous Talotarsal Stabilization
MBA Implant, HyProCureSurgical Treatment of Bilateral Gynecomastia 04/01/15 Yes 19300 Mastectomy
Surgical Treatment of Femoroacetabular Impingement01/01/10 10/01/13
Recommended29914, 29915, 29916, 27299,
29999FAI, CAM or Pincer type impingement, Hip arthroscopy,
femoral or osteochondral osteoplasty, labrum, labral repair
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
10/01/1007/01/1508/01/18
No21199, 41512, 41530, 42145,
42299, S2080, C9727UPPP, LAUP or Pillar Palatal
Surgical Ventricular Restoration 11/01/0704/01/18
Recommended 33548DOR procedure, SAVER, SVR, Ventricular Restoration or
remodeling
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Temporomandibular Joint Dysfunction
04/15/08 01/01/11 01/01/12 01/01/13 01/01/1401/01/1501/01/1601/01/17
No
20605, 21010, 21050, 21060, 21070, 21073, 21116, 21240, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 70328, 70330, 70332, 70336, 70486, 70487, 70488, 70350, 70355, E1399, E1700, E1701, E1702, S3900, S8262, 96002, 96003, 96004, 97010, 97024, 97026, 97033, 97810, 97811, 97813,
97814, J7321, J7323, J7324, J7325, J7326
Bitestrip, Gothic Arch Tracing, TMJ Dysfunction (TMD)
Thermography 01/01/00 Recommended 93799
Total Artificial Hearts and Implantable Ventricular Assist Devices
04/01/10 04/01/1104/01/1204/01/13 07/01/1307/01/15
No
0051T, 0052T, 0053T, 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33992, 33993, 33999, 93750, Q0478, Q0479, L9900, 33927, 33928, 33929
HeartMate I & II
Transanal Radiofrequency Treatment of Fecal Incontinence
10/01/09 Recommended 0288T, 46999 Secca procedure
Transcatheter Aortic Valve Implantation for Aortic Stenosis
07/01/12 04/01/13 04/01/1404/01/1504/01/1708/01/18
No33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368,
33369TAVI, TAVR
Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
07/01/11 07/01/1207/01/1307/01/1808/01/18
No37241, 37242, 37243, 75894,
Q0083TACE
Transcatheter Mitral Valve Repair04/01/1608/01/18
No 0345T, 33418, 33419 MitraClip
Transcatheter Pulmonary Valve Implantation10/01/12 10/01/13
Recommended 0262T, 33477 Pulmonary valve prosthesis, endovascular implantation
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
07/01/0607/01/1308/15/1401/01/16
Yes 90867, 90868, 90869 NeoPulse, NeuroStar
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Transcutaneous Electrical Nerve Stimulation
01/01/10 01/01/1310/01/1401/01/16
No64550, E0720, E0730, E0731, A4595, A4630, A4556, A4557,
A4558 TENS
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
01/01/0504/01/12 04/01/1304/01/18
Recommended 43210, 43257, 43499 EndoCinch, GERD, NDO Plicator, Esophyx
Transmyocardial Revascularization 04/01/1001/01/1508/01/18
No 33140, 33141 HeartLaser, Eclipse TMR 2000
Treatment of Hyperhidrosis
04/01/10 04/01/12 04/01/1304/01/1401/01/16
Recommended 32664, 97024, 97033, 15876, 15877, 15878, 15879, 26989,
64818, 69676
Sympathectomy, Gustatory, Iontophoresis, Excessive Sweating
Treatment of Tinnitus
01/01/10 01/01/1310/01/1710/01/18
Recommended97014, 97026, 92507, 90832-90838, 90875, 90876, 90901
E0720, S8948Sound Therapy
Treatment of Varicose Veins/Venous Insufficiency
01/01/11 07/01/1307/01/1507/01/1607/01/18
No
36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765,
37766, 37780, 37785, 37799, S2202
Cryoablation, Endoluminal Radiofrequency, Endoluminal Laser Ablation, Endovenous Radiofrequency, Endovenous
Laser Ablation, Radiofrequency Ablation, Saphenous Reflux, Sclerotherapy, Spider Veins, Telangiectatic Veins,
Transilluminated Powered Phlebectomy, Cryosurgery, Diomed 810 nm Surgical Laser; Endoluminal Cryosurgery; Endovenous Laser Therapy (EVLT), Varicose Veins; Erbe
Erbokryo cryosurgical unit RFSFlex; VNUS Closure Procedure; FAST, SEPS Subfascial Endoscopic Perforation
Surgery; TRIVEX system, Microfoam sclerotherapy
Tumor Treating Fields Therapy01/01/1607/01/1610/01/18
Recommended E0766, A4555 NovoTTF-100A, Novocure
Ultrasound Accelerated Fracture Healing Device
04/15/08 10/01/1104/01/1204/01/1304/01/1401/01/18
Yes E0760, 20979 Exogen
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Urinary Tumor Markers for Bladder Cancer 01/01/13 No 88120, 88121, 0012M, 0013MBladder Tumor Antigen
(BTA) Test, FISH, ImmunoCyt, NMP-22, Cxbladder
Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer
01/01/1101/01/1501/01/18
No 81479, 81599Genetic Predisposition or Genetic Markers, Breast Cancer,
OncoVue, BREVAGen
Vagus Nerve Stimulation07/01/09 04/01/1301/01/15
No
61885, 61886, 64553, 64568, 64569, 64570, 95974, 95975,
L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689,
0312T, 0313T, 0314T, 0315T, 0316T, 0317T, L8689
NeuroCybernetic Prosthesis (NCP®) system
Vectra® DA Blood Test for Rheumatoid Arthritis 01/01/17 Recommended 81490 ZBC85
Vertebral Axial Decompression 04/15/08 Recommended 97012, S9090 VAX-D, DRX 9000, Accu Spine, Antalgic Trak or spinal
decompression
Vestibular Function Testing 10/01/17 No92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546,
92547
Viscocanalostomy and Canaloplasty04/01/1204/01/18
No 66174, 66175iTrack, Trabectome, Trabeculectomy
Viscoanalostomy
Wearable Cardioverter Defibrillators
10/01/09 04/01/13 04/01/1407/01/1408/01/17
YesK0606, K0607, K0608, K0609,
93745, 93292LifeVest; ICD, Wearable; LifeCor WCD System; AICD,
Wearable Vest, Zoll Live Vest
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
07/01/17 No81415, 81416, 81417, 81425,
81426, 81427, 0036UExaCT-1
Whole Gland Cryoablation of Prostate Cancer10/01/0910/01/1410/01/15
No 55873
Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon
01/01/10 01/01/11 01/01/13 01/01/1401/01/15
Yes 91110, 91111, 91299, 0335T PillCam and Given AGILE patency, M2A Capsule Camera,
Given Capsule Endoscopy