PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE …

Service

Elective or Emergency Inpatient

Dialysis Treatment (Out-of-network services only)

Home Health, Hospice Care

Home Infusion

Elective surgery at a Hospital or Ambulatory Surgical Facility

(Out-of-Network services only)

Other Procedures Requiring Prior Authorization

Specialty Pharmacy

Service Category Procedure Code Code DescriptionMedical Policy No/

GuidelineMedical Policy Title Updates

Advanced Imaging- Advanced Imaging Services: MRI, MRA,

PET, PET-CT, CT, CTA, Nuclear Medicine (excludes Cardiac

Advanced Imaging)

77021 Mri Guidance Ndl Plmt Rs&I AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website

https://aimspecialtyhealth.com

Retire effective

01/01/2022



Advanced Imaging)

77022 Mri Gdn Parnchyma Tiss Abltj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

01/01/2022



Advanced Imaging)

S8042Magnetic Resonance Imaging (Mri)

Low-FieldAIM Clinical Guidelines

Call 1-844-377-1285 or Access Website


Retire effective

01/01/2022



Advanced Imaging)

S8085

Fluorine-18 Fluorodeoxyglucose (F-

18 Fdg) Imaging Using Dual-Head

Coincidence Detection System

(Non-Dedicated Pet Scan)

AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

01/01/2022



Advanced Imaging)

S8092

Electron Beam Computed

Tomography (Also Known As

Ultrafast Ct Cine Ct)



Retire effective

01/01/2022

Orthopedic Prodecures - Functional Neuromuscular

Electrical Stimulation (FNMES)/Percutaneous and Implanted

Nerve Stimulation and Neuromodulation

E0764

Functional Neuromuscular

Stimulation Transcutaneous

Stimulation Of Sequential Muscle

Groups Of Ambulation With

Computer Control Used For

Walking By Spinal Cord Injured

Entire System After Completion

Of Training Program

MED201.033 Functional Neuromuscular Electrical StimulationRetire effective

01/01/2022

MEDICAL SURGICAL SERVICES

2021 Commercial Outpatient Benefit Preauthorization Procedure Code List

This list includes Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes related to services/categories for which benefit preauthorization may be

required as of 01/01/2021 for commercial, fully insured, standard plans/networks,

This is not an exhaustive listing of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member

benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

Benefit preauthorization for some services/categories must be obtained through Blue Cross and Blue Shield of Montana (BCBSMT). Benefit preauthorization for other services/categories must be obtained

through a utilization management vendor.

It is imperative that providers check eligibility and benefits for each patient prior to rendering services to confirm benefits, benefit preauthorization/pre-notification requirements and utilization management

vendors that must be used, if applicable. Providers may submit online eligibility and benefits inquiries (electronic 270 transactions) via the Availity® Provider Portal or other preferred web vendor portal.

Services performed without benefit preauthorization, if required, may be denied for payment and providers may not seek reimbursement from BCBSMT members. Obtaining benefit preauthorization/pre-

notification is not a substitute for confirming eligibility and benefits.

PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.

Dialysis Treatment provided by an Out-of-network provider.

Skilled home health care provided by a licensed home health or hospice agency.

Outpatient Infusion therapy provided by a licensed home infusion agency.

Outpatient elective surgery performed at an out of network hospital or ambulatory surgery facility. Specific service requiring

preauthorization are listed in the table below.

Specific service requiring preauthorization are listed in the table below.

Refer to 2021 Specialty Drugs Preauthorization List for Infusion Site of Care on Claims and Eligibility, Predetermination and

Preauthorization section on bcbsmt.com/provider.

PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE 01/01/2021Updated November 2021 to reference changes that will be effective January 2022

• Preauthorization is required by BCBSMT for certain services to determine in advance the Medical Necessity or Experiment Investigational and/or Unproven nature of certain care and services based on MCG

Criteria, Medical Policy and Member benefits. The list below describes the services that require preauthorization.

• Predetermination is a process used to submit requests for review of coverage decisions in accordance with medical policy and member contracts for a service (i.e., procedure, supply, drug or device) used to

diagnose or treat an illness or condition. A predetermination is recommended if a provider is uncertain if the service meets medical policy criteria. Contact Provider Customer Service to determine if a service not

on this list is subject to medical necessity review.

• Not all requirements apply to each product in these networks (Blue Preferred PPOSM

, Blue OptionsSM

, Blue Focus POSSM

, Managed CareSM

or TraditionalSM

). It is imperative that providers check eligibility and

benefits and verify preauthorization requirements through Availity®.

Medical/Surgical Services Requiring Preauthorization

Description

Admission to a licensed Acute Care Facility, Skilled Nursing Facility, Long Term Care Facility inpatient Admissions.

November 2021 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 1/41




E0770

Functional Electrical Stimulator

Transcutaneous Stimulation Of

Nerve And/Or Muscle Groups Any

Type Complete System Not

Otherwise Specified

MED201.033 Functional Neuromuscular Electrical StimulationRetire effective

01/01/2022

Radiation Therapy 77401 Radiation Treatment Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

01/01/2022

Radiation Therapy 77423 Neutron Beam Tx Complex AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

01/01/2022

Radiation Therapy 77600 Hyperthermia Treatment AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

01/01/2022



Retire effective

01/01/2022



Retire effective

01/01/2022



Retire effective

01/01/2022



Retire effective

01/01/2022

Molecular Genetic Lab Testing 0168UFtl Aneuploidy Trisomy 21 18 13

Dna Mat Plsm AlgAIM Clinical Guidelines



Retire effective

01/01/2022

Add effective 04/01/2021

Molecular Genetic Lab Testing 0250UOnc Sld Org Neo Trgt Gen Seq Dna

Alys 505 GenesAIM Clinical Guidelines


https://aimspecialtyhealth.comAdd effective 01/01/2022

Molecular Genetic Lab Testing 0258U Ai Psor Mrna 50-100 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0260U Rare Ds Id Opt Genome Mapg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0262U Onc Sld Tum Rt-Pcr 7 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0264U Rare Ds Id Opt Genome Mapg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0265U Rar Do Whl Gn&Mtcdrl Dna Als AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0266U Unxpl Cnst Hrtbl Do Gn Xprs AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0267U Rare Do Id Opt Gen Mapg&Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0268U Hem Ahus Gen Seq Alys 15 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0269U Hem Aut Dm Cgen Trmbctpna 14 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0270U Hem Cgen Coagj Do 20 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0271U Hem Cgen Neutropenia 23 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0272U Hem Genetic Bld Do 51 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0273U Hem Gen Hyprfibrnlysis 8 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0274U Hem Gen Pltlt Do 43 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0276U Hem Inh Thrombocytopenia 23 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0277U Hem Gen Pltlt Funcj Do 31 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0278U Hem Gen Pltlt Funcj Do 31 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70336 Magnetic Image Jaw Joint AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website

https://aimspecialtyhealth.com_



Advanced Imaging)

70450 Ct Head/Brain W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70460 Ct Head/Brain W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70470 Ct Head/Brain W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70480 Ct Orbit/Ear/Fossa W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70481 Ct Orbit/Ear/Fossa W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70482 Ct Orbit/Ear/Fossa W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70486 Ct Maxillofacial W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70487 Ct Maxillofacial W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70488 Ct Maxillofacial W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

70490 Ct Soft Tissue Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70491 Ct Soft Tissue Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70492 Ct Sft Tsue Nck W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70496 Ct Angiography Head AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70498 Ct Angiography Neck AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70540 Mri Orbit/Face/Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70542 Mri Orbit/Face/Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70543 Mri Orbt/Fac/Nck W/O &W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70544 Mr Angiography Head W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70545 Mr Angiography Head W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70546 Mr Angiograph Head W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70547 Mr Angiography Neck W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70548 Mr Angiography Neck W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70549 Mr Angiograph Neck W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70551 Mri Brain Stem W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70552 Mri Brain Stem W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70553 Mri Brain Stem W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70554 Fmri Brain By Tech AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

70555 Fmri Brain By Phys/Psych AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71250 Ct Thorax W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71260 Ct Thorax W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71270 Ct Thorax W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71271 Ct Thorax Lung Cancer Scr C- AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71275 Ct Angiography Chest AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71550 Mri Chest W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71551 Mri Chest W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71552 Mri Chest W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

71555 Mri Angio Chest W Or W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72125 Ct Neck Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72126 Ct Neck Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

72127 Ct Neck Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72128 Ct Chest Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72129 Ct Chest Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72130 Ct Chest Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72131 Ct Lumbar Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72132 Ct Lumbar Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72133 Ct Lumbar Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72141 Mri Neck Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72142 Mri Neck Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72146 Mri Chest Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72147 Mri Chest Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72148 Mri Lumbar Spine W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72149 Mri Lumbar Spine W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72156 Mri Neck Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72157 Mri Chest Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72158 Mri Lumbar Spine W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72159 Mr Angio Spine W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72191 Ct Angiograph Pelv W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72192 Ct Pelvis W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72193 Ct Pelvis W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72194 Ct Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72195 Mri Pelvis W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72196 Mri Pelvis W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72197 Mri Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

72198 Mr Angio Pelvis W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73200 Ct Upper Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73201 Ct Upper Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73202 Ct Uppr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73206 Ct Angio Upr Extrm W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73218 Mri Upper Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

73219 Mri Upper Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73220 Mri Uppr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73221 Mri Joint Upr Extrem W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73222 Mri Joint Upr Extrem W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73223 Mri Joint Upr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73225 Mr Angio Upr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73700 Ct Lower Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73701 Ct Lower Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73702 Ct Lwr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73706 Ct Angio Lwr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73718 Mri Lower Extremity W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73719 Mri Lower Extremity W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73720 Mri Lwr Extremity W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73721 Mri Jnt Of Lwr Extre W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73722 Mri Joint Of Lwr Extr W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73723 Mri Joint Lwr Extr W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

73725 Mr Ang Lwr Ext W Or W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74150 Ct Abdomen W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74160 Ct Abdomen W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74170 Ct Abdomen W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74174 Ct Angio Abd&Pelv W/O&W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74175 Ct Angio Abdom W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74176 Ct Abd & Pelvis W/O Contrast AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74177 Ct Abd & Pelv W/Contrast AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74178 Ct Abd & Pelv 1/> Regns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74181 Mri Abdomen W/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74182 Mri Abdomen W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74183 Mri Abdomen W/O & W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74185 Mri Angio Abdom W Orw/O Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74261 Ct Colonography Dx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

74262 Ct Colonography Dx W/Dye AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74263 Ct Colonography Screening AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74712 Mri Fetal Sngl/1St Gestation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

74713 Mri Fetal Ea Addl Gestation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

75635 Ct Angio Abdominal Arteries AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76376 3D Render W/Intrp Postproces AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76377 3D Render W/Intrp Postproces AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76380 Cat Scan Follow-Up Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76390 Mr Spectroscopy AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76391 Mr Elastography AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

76497 Ct Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021



Advanced Imaging)

76498 Mri Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021



Advanced Imaging)

76975 Gi Endoscopic Ultrasound AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

07/01/2021



Advanced Imaging)

77046 Mri Breast C- Unilateral AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

77047 Mri Breast C- Bilateral AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

77048 Mri Breast C-+ W/Cad Uni AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

77049 Mri Breast C-+ W/Cad Bi AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

77078 Ct Bone Density Axial AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

77084 Magnetic Image Bone Marrow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78012 Thyroid Uptake Measurement AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78013 Thyroid Imaging W/Blood Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78014 Thyroid Imaging W/Blood Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78015 Thyroid Met Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78016 Thyroid Met Imaging/Studies AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78018 Thyroid Met Imaging Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78020 Thyroid Met Uptake AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78070 Parathyroid Planar Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78071 Parathyrd Planar W/Wo Subtrj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78072 Parathyrd Planar W/Spect&Ct AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78075 Adrenal Cortex & Medulla Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

78102 Bone Marrow Imaging Ltd AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78103 Bone Marrow Imaging Mult AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78104 Bone Marrow Imaging Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78185 Spleen Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78195 Lymph System Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78201 Liver Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78202 Liver Imaging With Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78215 Liver And Spleen Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78216 Liver & Spleen Image/Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78226 Hepatobiliary System Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78227 Hepatobil Syst Image W/Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78230 Salivary Gland Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78231 Serial Salivary Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78232 Salivary Gland Function Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78258 Esophageal Motility Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78261 Gastric Mucosa Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78262 Gastroesophageal Reflux Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78264 Gastric Emptying Imag Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)





Advanced Imaging)





Advanced Imaging)

78278 Acute Gi Blood Loss Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78290 Meckels Divert Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78291 Leveen/Shunt Patency Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78300 Bone Imaging Limited Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78305 Bone Imaging Multiple Areas AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78306 Bone Imaging Whole Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78315 Bone Imaging 3 Phase AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78445 Vascular Flow Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78456 Acute Venous Thrombus Image AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78457 Venous Thrombosis Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

78458 Ven Thrombosis Images Bilat AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78579 Lung Ventilation Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78580 Lung Perfusion Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78582 Lung Ventilat&Perfus Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78597 Lung Perfusion Differential AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78598 Lung Perf&Ventilat Diferentl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78600 Brain Image < 4 Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78601 Brain Image W/Flow < 4 Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78605 Brain Image 4+ Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78606 Brain Image W/Flow 4 + Views AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78608 Brain Imaging (Pet) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78609 Brain Imaging (Pet) AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78610 Brain Flow Imaging Only AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78630 Cerebrospinal Fluid Scan AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78635 Csf Ventriculography AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78645 Csf Shunt Evaluation AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78650 Csf Leakage Imaging AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78660 Nuclear Exam Of Tear Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78700 Kidney Imaging Morphol AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78701 Kidney Imaging With Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78707 K Flow/Funct Image W/O Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78708 K Flow/Funct Image W/Drug AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78709 K Flow/Funct Image Multiple AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78725 Kidney Function Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78730 Urinary Bladder Retention AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78740 Ureteral Reflux Study AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78761 Testicular Imaging W/Flow AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78800 Rp Loclzj Tum 1 Area 1 D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78801 Rp Loclzj Tum 2+Area 1+D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78802 Rp Loclzj Tum Whbdy 1 D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website





Advanced Imaging)

78803 Rp Loclzj Tum Spect 1 Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78804 Rp Loclzj Tum Whbdy 2+D Img AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78811 Pet Image Ltd Area AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78812 Pet Image Skull-Thigh AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78813 Pet Image Full Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78814 Pet Image W/Ct Lmtd AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78815 Pet Image W/Ct Skull-Thigh AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78816 Pet Image W/Ct Full Body AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78830 Rp Loclzj Tum Spect W/Ct 1 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78831 Rp Loclzj Tum Spect 2 Areas AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78832 Rp Loclzj Tum Spect W/Ct 2 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

78999 Nuclear Diagnostic Exam AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retired effective

01/01/2021



Advanced Imaging)

0042T Ct Perfusion W/Contrast Cbf AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website




Advanced Imaging)

C8900Magnetic Resonance Angiography

With Contrast AbdomenAIM Clinical Guidelines





Advanced Imaging)


Without Contrast AbdomenAIM Clinical Guidelines





Advanced Imaging)

C8902

Magnetic Resonance Angiography

Without Contrast Followed By With

Contrast Abdomen





Advanced Imaging)

C8903Magnetic Resonance Imaging With

Contrast Breast; UnilateralAIM Clinical Guidelines





Advanced Imaging)

C8905

Magnetic Resonance Imaging


Contrast Breast; Unilateral





Advanced Imaging)

C8906Magnetic Resonance Imaging With

Contrast Breast; BilateralAIM Clinical Guidelines





Advanced Imaging)

C8908

Magnetic Resonance Imaging


Contrast Breast; Bilateral





Advanced Imaging)

C8909


With Contrast Chest (Excluding

Myocardium)





Advanced Imaging)

C8910


Without Contrast Chest (Excluding

Myocardium)





Advanced Imaging)

C8911



Contrast Chest (Excluding

Myocardium)





Advanced Imaging)


With Contrast Lower ExtremityAIM Clinical Guidelines





Advanced Imaging)


Without Contrast Lower ExtremityAIM Clinical Guidelines





Advanced Imaging)

C8914



Contrast Lower Extremity





Advanced Imaging)


With Contrast PelvisAIM Clinical Guidelines





Advanced Imaging)


Without Contrast PelvisAIM Clinical Guidelines






Advanced Imaging)

C8920



Contrast Pelvis





Advanced Imaging)

C8931


With Contrast Spinal Canal And

Contents





Advanced Imaging)

C8932


Without Contrast Spinal Canal And

Contents





Advanced Imaging)

C8933



Contrast Spinal Canal And Contents





Advanced Imaging)


With Contrast Upper ExtremityAIM Clinical Guidelines





Advanced Imaging)


Without Contrast Upper ExtremityAIM Clinical Guidelines





Advanced Imaging)

C8936



Contrast Upper Extremity





Advanced Imaging)

G0219

Pet Imaging Whole Body;

Melanoma For Non-Covered

Indications





Advanced Imaging)

G0235Pet Imaging Any Site Not

Otherwise SpecifiedAIM Clinical Guidelines





Advanced Imaging)

G0252

Pet Imaging Full And Partial-Ring

Pet Scanners Only For Initial

Diagnosis Of Breast Cancer And/Or

Surgical Planning For Breast Cancer

(E. G. Initial Staging Of Axillary

Lymph Nodes)





Advanced Imaging)

G0297Low Dose Ct Scan (Ldct) For Lung

Cancer ScreeningAIM Clinical Guidelines



Retire effective

03/31/2021



Advanced Imaging)

S8037Magnetic Resonance

Cholangiopancreatography (Mrcp)AIM Clinical Guidelines



Home Health, Hospice Care 99500 Home Visit PrenatalMCG

OB401.017

Clinical Guidelines

Home Uterine Activity Monitoring_

Home Health, Hospice Care 99501 Home Visit Postnatal MCG Clinical Guidelines _Home Health, Hospice Care 99502 Home Visit Nb Care MCG Clinical Guidelines _Home Health, Hospice Care 99503 Home Visit Resp Therapy MCG Clinical Guidelines _Home Health, Hospice Care 99504 Hhome Visit Mech Ventilator MCG Clinical Guidelines _Home Health, Hospice Care 99505 Home Visit Stoma Care MCG Clinical Guidelines _

Home Health, Hospice Care 99506 Home Visit Im InjectionMCG

RX501.062

Clinical Guidelines

Progesterone Therapy as a Technique to Reduce

Preterm Delivery in High-Risk Pregnancies

_

Home Health, Hospice Care 99507 Home Visit Cath Maintain MCG Clinical Guidelines _

Home Health, Hospice Care 99509 Home Visit Day Life ActivityMCG

ADM1001.014

Clinical Guidelines

Custodial Care_

Home Health, Hospice Care 99511 Home Visit Fecal/Enema Mgmt MCG Clinical Guidelines _Home Health, Hospice Care 99600 Home Visit Nos MCG Clinical Guidelines _

Home Health, Hospice Care G0151

Services Performed By A Qualified

Physical Therapist In The Home

Health Or Hospice Setting Each 15

Minutes

MCG

PSY301.014

THE803.010

Guidelines

Autism Spectrum Disorders (ASD)

Physical Therapy (PT) and Occupational Therapy

(OT) Services

_



Occupational Therapist In The

Home Health Or Hospice Setting

Each 15 Minutes

MCG

PSY301.014

THE803.010

Clinical Guidelines



(OT) Services

_



Speech-Language Pathologist In

The Home Health Or Hospice

Setting Each 15 Minutes

MCG

PSY301.014

THE803.014

Clinical Guidelines


Speech-Language Therapy (SLT)

_


Services Of Clinical Social Worker

In Home Health Or Hospice

Settings, Each 15 Minutes

MCG Clinical Guidelines _

Home Health, Hospice Care G0156 HHCP-svs of aide,ea 15 min MCG _ _



Physical Therapist Assistant In The


Each 15 Minutes

MCG

PSY301.014

THE803.010

Guidelines



(OT) Services

_



Occupational Therapist Assistant In

The Home Health Or Hospice


MCG

PSY301.014

THE803.010

Clinical Guidelines



(OT) Services

_




Physical Therapist In The Home

Health Setting In The

Establishment Or Delivery Of A

Safe And Effective Physical Therapy

Maintenance Program Each 15

Minutes

MCG

PSY301.014

THE803.010

Guidelines



(OT) Services

_



Occupational Therapist In The

Home Health Setting In The


Safe And Effective Occupational

Therapy Maintenance Program

Each 15 Minutes

MCG

PSY301.014

THE803.010

Clinical Guidelines



(OT) Services

_



Speech-Language Pathologist In

The Home Health Setting In The


Safe And Effective Speech-

Language Pathology Maintenance

Program Each 15 Minutes

MCG

PSY301.014

THE803.014

Clinical Guidelines


Speech-Language Therapy (SLT)

_


Skilled Services By A Registered

Nurse (Rn) In The Delivery Of

Management & Evaluation Of The

Plan Of Care; Each 15 Minutes (The

Patient'S Underlying Condition Or

Complication Requires An Rn To

Ensure That Essential Non-Skilled

Care Achieve Its Purpose In The

Home Health Or Hospice Setting)



Direct Skilled Nursing Services Of A

Registered Nurse (Rn) In The Home

Health Or Hospice Setting Each 15

Minutes



Direct Skilled Nursing Services Of A

License Practical Nurse (Lpn) In The


Each 15 Minutes



Face-To-Face Home Health Nursing

Visit By A Rural Health Clinic (Rhc)

Or Federally Qualified Health

Center (Fqhc) In An Area With A

Shortage Of Home Health

Agencies. (Services Limited To Rn

Or Lpn Only).



Skilled Services Of A Registered

Nurse (Rn) For The Observation

And Assessment Of The Patient'S

Condition Each 15 Minutes (The

Change In The Patient'S Condition

Requires Skilled Nursing Personnel

To Identify And Evaluate The

Patient'S Need For Possible

Modification Of Treatment In The

Home Health Or Hospice Setting)



Skilled Services Of A Licensed

Practical Nurse (Lpn) For The

Observation And Assessment Of

The Patient'S Condition Each 15

Minutes (The Change In The

Patient'S Condition Requires Skilled

Nursing Personnel To Identify And

Evaluate The Patient'S Need For

Possible Modification Of

Treatment In The Home Health Or

Hospice Setting)



Skilled Services Of A Registered

Nurse (Rn) In The Training And/Or

Education Of A Patient Or Family

Member In The Home Health Or

Hospice Setting Each 15 Minutes



Skilled Services Of A Licensed

Practical Nurse (Lpn) In The

Training And/Or Education Of A

Patient Or Family Member In The


Each 15 Minutes




Services Performed By Chaplain In

The Hospice Setting Each 15

Minutes



Services Performed By Dietary

Counselor In The Hospice Setting

Each 15 Minutes



Services Performed By Other

Counselor In The Hospice Setting

Each 15 Minutes



Services Performed By Other

Qualified Therapist In The Hospice



Home Health, Hospice Care Q5001

Hospice Or Home Health Care

Provided In Patient'S

Home/Residence


Home Health, Hospice Care Q5002Hospice Or Home Health Care

Provided In Assisted Living FacilityMCG Clinical Guidelines _


Hospice Care Provided In Nursing

Long Term Care Facility (Ltc) Or

Non-Skilled Nursing Facility (Nf)


Home Health, Hospice Care Q5004Hospice Care Provided In Skilled

Nursing Facility (Snf)MCG Clinical Guidelines _

Home Health, Hospice Care Q5005Hospice Care Provided In Inpatient

HospitalMCG Clinical Guidelines _


Hospice FacilityMCG Clinical Guidelines _

Home Health, Hospice Care Q5007Hospice Care Provided In Long

Term Care FacilityMCG Clinical Guidelines _


Psychiatric FacilityMCG Clinical Guidelines _


Hospice Or Home Health Care

Provided In Place Not Otherwise

Specified (Nos)


Home Health, Hospice Care Q5010Hospice Home Care Provided In A

Hospice FacilityMCG Clinical Guidelines _

Home Health, Hospice Care S5108Home Care Training To Home Care

Client, Per 15 Minutes

MCG

PSY301.021

Clinical Guidelines

Applied Behavior Analysis (ABA) for Autism

Spectrum Disorder (ASD) Diagnosis

_

Home Health, Hospice Care S5109Home Care Training To Home Care

Client, Per SessionMCG Clinical Guidelines _

Home Health, Hospice Care S5110Home Care Training, Family; Per 15

Minutes

MCG

PSY301.021

Clinical Guidelines



_

Home Health, Hospice Care S5111Home Care Training, Family; Per

Session

MCG

PSY301.021

Clinical Guidelines



_

Home Health, Hospice Care S5115Home Care Training, Non-Family;

Per 15 MinutesMCG Clinical Guidelines _

Home Health, Hospice Care S5116Home Care Training, Non-Family;

Per SessionMCG Clinical Guidelines _

Home Health, Hospice Care S5125Attendant Care Services; Per 15

MinutesMCG Clinical Guidelines _

Home Health, Hospice Care S5126 Attendant Care Services; Per Diem MCG Clinical Guidelines _

Home Health, Hospice Care S5180Home Health Respiratory Therapy,

Initial EvaluationMCG Clinical Guidelines _

Home Health, Hospice Care S5181Home Health Respiratory Therapy,

Nos, Per DiemMCG Clinical Guidelines _

Home Health, Hospice Care S9097 Home Visit Wound Care MCG Clinical Guidelines _

Home Health, Hospice Care S9098

Home Visit Phototherapy Services

(E. G. Bili-Lite) Including

Equipment Rental Nursing Services

Blood Draw Supplies And Other

Services Per Diem



Home Health Aide Or Certified

Nurse Assistant, Providing Care In

The Home; Per Hour



Nursing Care In The Home; By

Registered Nurse Per Hour (Use

For General Nursing Care Only Not

To Be Used When Cpt Codes 99500-

99602 Can Be Used)

MCG

RX501.062

Clinical Guidelines



_

Home Health, Hospice Care S9124Nursing Care In The Home; By

Licensed Practical Nurse Per Hour

MCG

RX501.062

Clinical Guidelines



_

Home Health, Hospice Care S9126Hospice Care, In The Home, Per

DiemMCG Clinical Guidelines _



Home Management Of Preterm

Labor Including Administrative

Services Professional Pharmacy

Services Care Coordination And

All Necessary Supplies Or

Equipment (Drugs And Nursing

Visits Coded Separately) Per Diem

(Do Not Use This Code With Any

Home Infusion Per Diem Code)

MCG

RX501.062

Clinical Guidelines



_


Home Management Of Preterm

Premature Rupture Of Membranes

(Pprom) Including Administrative



All Necessary Supplies Or






Home Health, Hospice Care T1004Services Of A Qualified Nursing

Aide, Up To 15 MinutesMCG Clinical Guidelines _

Home Health, Hospice Care T1030 RN home care per diem MCG _ Add effective 3/1/2021Home Health, Hospice Care T1031 LPN home care per diem MCG _ Add effective 3/1/2021

Home Health, Hospice Care T1502

Administration Of Oral,

Intramuscular And/Or

Subcutaneous Medication By

Health Care Agency/Professional,

Per Visit


Home Health, Hospice Care T1503

Administration Of Medication,

Other Than Oral And/Or Injectable,

By A Health Care

Agency/Professional, Per Visit


Home Hemodialysis 99512 Home Visit For Hemodialysis THE802.002Daily Hemodialysis and Hemodialysis in the Home

Setting_

Home Hemodialysis S9335

Home Therapy Hemodialysis;

Administrative Services

Professional Pharmacy Services

Care Coordination And All

Necessary Supplies And Equipment

(Drugs And Nursing Services Coded

Separately) Per Diem

THE802.002Daily Hemodialysis and Hemodialysis in the Home

Setting_

Home Infusion Therapy (HIT) 99601 Home Infusion/Visit 2 Hrs MCG Clinical Guidelines _Home Infusion Therapy (HIT) 99602 Home Infusion Each Addtl Hr MCG Clinical Guidelines _

Home Infusion Therapy (HIT) B4034

Enteral Feeding Supply Kit; Syringe

Fed Per Day Includes But Not

Limited To Feeding/Flushing

Syringe Administration Set Tubing

Dressings Tape

MCG

MED201.011

Clinical Guidelines

Nutritional Support_


Enteral Feeding Supply Kit; Pump




Dressings Tape

MCG

MED201.011

Clinical Guidelines



Enteral Feeding Supply Kit; Gravity




Dressings Tape

MCG

MED201.011

Clinical Guidelines



Enteral Formula For Adults Used

To Replace Fluids And Electrolytes

(E.G. Clear Liquids) 500 Ml = 1 Unit

MCG

MED201.011

Clinical Guidelines



Enteral Formula For Pediatrics

Used To Replace Fluids And

Electrolytes (E.G. Clear Liquids)

500 Ml = 1 Unit

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B4104Additive For Enteral Formula (E.G.

Fiber)

MCG

MED201.011

Clinical Guidelines



Enteral Formula Manufactured

Blenderized Natural Foods With

Intact Nutrients Includes Proteins

Fats Carbohydrates Vitamins And

Minerals May Include Fiber

Administered Through An Enteral

Feeding Tube 100 Calories = 1 Unit

MCG

MED201.011

Clinical Guidelines




Enteral Formula Nutritionally

Complete With Intact Nutrients

Includes Proteins Fats

Carbohydrates Vitamins And




MCG

MED201.011

Clinical Guidelines




Complete Calorically Dense (Equal

To Or Greater Than 1. 5 Kcal/Ml)

With Intact Nutrients Includes

Proteins Fats Carbohydrates

Vitamins And Minerals May

Include Fiber Administered

Through An Enteral Feeding Tube

100 Calories = 1 Unit

MCG

MED201.011

Clinical Guidelines




Complete Hydrolyzed Proteins

(Amino Acids And Peptide Chain)

Includes Fats Carbohydrates


Include Fiber Administered



MCG

MED201.011

Clinical Guidelines




Complete For Special Metabolic

Needs Excludes Inherited Disease

Of Metabolism Includes Altered

Composition Of Proteins Fats

Carbohydrates Vitamins And/Or




MCG

MED201.011

Clinical Guidelines




Incomplete/Modular Nutrients

Includes Specific Nutrients

Carbohydrates (E. G. Glucose

Polymers) Proteins/Amino Acids

(E. G. Glutamine Arginine) Fat (E.

G. Medium Chain Triglycerides) Or

Combination Administered



MCG

MED201.011

Clinical Guidelines




Nutritionally Complete With Intact

Nutrients Includes Proteins Fats



And/Or Iron Administered



MCG

MED201.011

Clinical Guidelines




Nutritionally Complete Soy Based

With Intact Nutrients Includes

Proteins Fats Carbohydrates


Include Fiber And/Or Iron



MCG

MED201.011

Clinical Guidelines




Nutritionally Complete Calorically

Dense (Equal To Or Greater Than

0.7 Kcal/Ml) With Intact Nutrients

Includes Proteins Fats





MCG

MED201.011

Clinical Guidelines




Hydrolyzed/Amino Acids And

Peptide Chain Proteins Includes

Fats Carbohydrates Vitamins And




MCG

MED201.011

Clinical Guidelines



Parenteral Nutrition Solution:

Carbohydrates (Dextrose) 50% Or

Less (500 Ml = 1 Unit) - Homemix

MCG

MED201.011

Clinical Guidelines




Parenteral Nutrition Solution;

Amino Acid 3. 5% (500 Ml = 1

Unit) - Homemix

MCG

MED201.011

Clinical Guidelines




Amino Acid 5. 5% Through 7%

(500 Ml = 1 Unit) - Homemix

MCG

MED201.011

Clinical Guidelines




Amino Acid 7% Through 8. 5%


MCG

MED201.011

Clinical Guidelines



Parenteral Nutrition Solution:

Amino Acid Greater Than 8. 5%


MCG

MED201.011

Clinical Guidelines




Carbohydrates (Dextrose) Greater

Than 50% (500 Ml=1 Unit) -

Homemix

MCG

MED201.011

Clinical Guidelines



Parenteral Nutrition Solution Not

Otherwise Specified 10 Grams

Lipids

MCG

MED201.011

Clinical Guidelines




Compounded Amino Acid And

Carbohydrates With Electrolytes

Trace Elements And Vitamins

Including Preparation Any

Strength 10 To 51 Grams Of

Protein - Premix

MCG

MED201.011

Clinical Guidelines









Protein - Premix

MCG

MED201.011

Clinical Guidelines









Protein - Premix

MCG

MED201.011

Clinical Guidelines








Strength Over 100 Grams Of

Protein - Premix

MCG

MED201.011

Clinical Guidelines



Parenteral Nutrition; Additives

(Vitamins Trace Elements Heparin

Electrolytes) Homemix Per Day

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B4220Parenteral Nutrition Supply Kit;

Premix Per Day

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B4222Parenteral Nutrition Supply Kit;

Home Mix Per Day

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B4224Parenteral Nutrition

Administration Kit Per Day

MCG

MED201.011

Clinical Guidelines



Parenteral Nutrition Solution





Strength Renal-Aminosyn-Rf

Nephramine Renamine-Premix

MCG

MED201.011

Clinical Guidelines








Strength Hepatic Hepatamine-

Premix

MCG

MED201.011

Clinical Guidelines








Strength Stress-Branch Chain

Amino Acids-Freamine-Hbc-Premix

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B9002Enteral Nutrition Infusion Pump

Any Type

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B9004Parenteral Nutrition Infusion Pump

Portable

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B9006Parenteral Nutrition Infusion Pump

Stationary

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) B9998 Noc For Enteral SuppliesMCG

MED201.011

Clinical Guidelines



Home Infusion Therapy (HIT) B9999 Noc For Parenteral SuppliesMCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) E0779

Ambulatory Infusion Pump

Mechanical Reusable For Infusion

8 Hours Or Greater

MCG

RX504.015

RX501.056

Clinical Guidelines

Levodopa-Carbidopa Enteral Suspension (e.g.

Duopa) for The Treatment of Parkinson Disease

Advanced Therapies for Pharmacologic Treatment

of Pulmonary Hypertension

_


Ambulatory Infusion Pump

Mechanical Reusable For Infusion

Less Than 8 Hours

MCG

RX501.056

Clinical Guidelines



_


Ambulatory Infusion Pump Single

Or Multiple Channels Electric Or

Battery Operated With

Administrative Equipment Worn

By Patient

MCG

SUR702.013

RX504.015

Clinical Guidelines

Delivery of Anesthesia for Postoperative Pain

Control by Continuous Infusion Using Elastomeric

Infusion Pump

Levodopa-Carbidopa Enteral Suspension (e.g.

Duopa) for The Treatment of Parkinson Disease.

_


Infusion Pump Implantable Non-

Programmable (Includes All

Components E. G. Pump

Catheter Connectors Etc. )

MCG

SUR707.008

Clinical Guidelines

Implantable Infusion Pump for Pain and Spasticity_


Infusion Pump System Implantable

Programmable (Includes All

Components E. G. Pump

Catheter Connectors Etc. )

MCG

SUR707.008

Clinical Guidelines

Implantable Infusion Pump for Pain and Spasticity_

Home Infusion Therapy (HIT) E0784External Ambulatory Infusion

Pump Insulin

MCG

DME101.005

Clinical Guidelines

Glucose Monitoring and Insulin Delivery Devices

for Managing Diabetes

_

Home Infusion Therapy (HIT) E0791Parenteral Infusion Pump

Stationary Single Or Multi-Channel

MCG

MED201.011

Clinical Guidelines


Home Infusion Therapy (HIT) K0455

Infusion Pump Used For

Uninterrupted Parenteral

Administration Of Medication (E.

G. Epoprostenol Or Treprostinol)

MCG

RX501.056

Clinical Guidelines



_

Home Infusion Therapy (HIT) Q0081Infusion Therapy Using Other Than

Chemotherapeutic Drugs Per VisitMCG Clinical Guidelines _

Home Infusion Therapy (HIT) Q0083

Chemotherapy Administration By

Other Than Infusion Technique

Only (Eg Subcutaneous

Intramuscular Push) Per Visit


Home Infusion Therapy (HIT) Q0084Chemotherapy Administration By

Infusion Technique Only Per VisitMCG Clinical Guidelines _

Home Infusion Therapy (HIT) Q0085

Chemotherapy Administration By

Both Infusion Technique And Other

Techique(S) (Eg Subcutaneous

Intramuscular Push) Per Visit


Home Infusion Therapy (HIT) S5035

Home Infusion Therapy, Routine

Service Of Infusion Device (Eg.

Pump Maintenance)


Home Infusion Therapy (HIT) S5036Home Infusion Therapy, Repair Of

Infusion Device (Eg. Pump Repair)MCG Clinical Guidelines _


Home Infusion Therapy Catheter

Care / Maintenance Not

Otherwise Classified; Includes





(Drugs And Nursing Visits Coded




Home Infusion Therapy, Catheter

Care / Maintenance, Simple (Single

Lumen), Includes Administrative

Services, Professional Pharmacy

Services, Care Coordination And All

Necessary Supplies And

Equipment, (Drugs And Nursing

Visits Coded Separately), Per Diem





Care / Maintenance, Complex

(More Than One Lumen), Includes

Administrative Services,

Professional Pharmacy Services,

Care Coordination, And All



Separately), Per Diem




Care / Maintenance, Implanted

Access Device, Includes







(Use This Code For Interim

Maintenance Of Vascular Access

Not Currently In Use)



Home Infusion Therapy, All

Supplies Necessary For Restoration

Of Catheter Patency Or Declotting




Supplies Necessary For Catheter

Repair




Supplies (Including Catheter)

Necessary For A Peripherally

Inserted Central Venous Catheter

(Picc) Line Insertion




Supplies (Including Catheter)

Necessary For A Midline Catheter

Insertion



Home Infusion Therapy, Insertion

Of Peripherally Inserted Central

Venous Catheter (Picc), Nursing

Services Only (No Supplies Or

Catheter Included)



Midline Venous Catheter, Nursing

Services Only (No Supplies Or

Catheter Included)



Home Administration Of

Aerosolized Drug Therapy (E. G. ,

Pentamidine); Administrative


Services, Care Coordination, All






Home Management Of Gestational

Hypertension, Includes






Separately); Per Diem (Do Not Use

This Code With Any Home Infusion

Per Diem Code)



Home Management Of Postpartum

Hypertension, Includes






Separately), Per Diem (Do Not Use


Per Diem Code)




Home Management Of

Preeclampsia, Includes





(Drugs And Nursing Services Coded

Separately); Per Diem (Do Not Use


Per Diem Code)



Home Management Of Gestational

Diabetes, Includes Administrative


Services, Care Coordination, And

All Necessary Supplies And


Visits Coded Separately); Per Diem





Home Infusion Therapy, Pain

Management Infusion;







(Do Not Use This Code With S9326,

S9327 Or S9328)



Home Infusion Therapy,

Continuous (Twenty-Four Hours Or

More) Pain Management Infusion;










Intermittent (Less Than Twenty-

Four Hours) Pain Management

Infusion; Administrative Services,








Home Infusion Therapy, Implanted

Pump Pain Management Infusion;










Chemotherapy Infusion;






Separately), Per Diem (Do Not Use

This Code With S9330 Or S9331)




Continuous (Twenty-Four Hours Or

More) Chemotherapy Infusion;











Intermittent (Less Than Twenty-

Four Hours) Chemotherapy

Infusion; Administrative Services,









Continuous Anticoagulant Infusion

Therapy (E. G. Heparin),










Immunotherapy, Administrative


Services, Care Coordination, And






Home Therapy; Enteral Nutrition;





(Enteral Formula And Nursing Visits

Coded Separately) Per Diem

MCG

MED201.011

Clinical Guidelines



Home Therapy; Enteral Nutrition

Via Gravity; Administrative Services






MCG

MED201.011

Clinical Guidelines




Via Pump; Administrative Services






MCG

MED201.011

Clinical Guidelines




Via Bolus; Administrative Services






MCG

MED201.011

Clinical Guidelines



Home Infusion Therapy Anti-

Hemophilic Agent Infusion Therapy

(E. G. Factor Viii); Administrative








Home Infusion Therapy Alpha-1-

Proteinase Inhibitor (E. G.

Prolastin); Administrative Services









Home Infusion Therapy

Uninterrupted Long-Term

Controlled Rate Intravenous Or

Subcutaneous Infusion Therapy (E.

G. Epoprostenol); Administrative









Sympathomimetic/Inotropic Agent

Infusion Therapy (E. G.

Dobutamine); Administrative


Services Care Coordination All






Home Infusion Therapy Tocolytic

Infusion Therapy; Administrative









Continuous Or Intermittent Anti-

Emetic Infusion Therapy;





(Drugs And Visits Coded





Continuous Insulin Infusion

Therapy; Administrative Services








Home Infusion Therapy Chelation







MCG

PSY301.014

THE801.008

Clinical Guidelines


Chelation Therapy

_


Home Infusion Therapy Enzyme

Replacement Intravenous Therapy;

(E. G. Imiglucerase); Administrative









Tumor Necrosis Factor Intravenous

Therapy; (E. G. Infliximab);









Home Infusion Therapy Diuretic

Intravenous Therapy;











Spasmotic Therapy; Administrative








Home Infusion Therapy Total

Parenteral Nutrition (Tpn);





Including Standard Tpn Formula

(Lipids Specialty Amino Acid

Formulas Drugs Other Than In

Standard Formula And Nursing


(Do Not Use With Home Infusion

Codes S9365-S9368 Using Daily

Volume Scales)

MCG

MED201.011

Clinical Guidelines




Parenteral Nutrition (Tpn); One

Liter Per Day Administrative




Equipment Including Standard Tpn

Formula (Lipids Specialty Amino

Acid Formulas Drugs Other Than

In Standard Formula And Nursing


MCG

MED201.011

Clinical Guidelines




Parenteral Nutrition (Tpn); More

Than One Liter But No More Than

Two Liters Per Day Administrative




Equipment Including Standard Tpn

Formula (Lipids Specialty Amino

Acid Formulas Drugs Other Than

In Standard Formula And Nursing


MCG

MED201.011

Clinical Guidelines





Than Two Liters But No More Than

Three Liters Per Day










MCG

MED201.011

Clinical Guidelines





Than Three Liters Per Day










MCG

MED201.011

Clinical Guidelines



Home Therapy Intermittent Anti-

Emetic Injection Therapy;










Home Therapy; Intermittent

Anticoagulant Injection Therapy (E.

G. Heparin); Administrative






(Do Not Use This Code For Flushing

Of Infusion Devices With Heparin

To Maintain Patency)



Home Infusion Therapy Hydration






Separately) Per Diem (Do Not Use

With Hydration Therapy Codes

S9374-S9377 Using Daily Volume

Scales)




Therapy; One Liter Per Day










Therapy; More Than One Liter But

No More Than Two Liters Per Day










Therapy; More Than Two Liters But

No More Than Three Liters Per Day










Therapy; More Than Three Liters

Per Day Administrative Services



Necessary Supplies (Drugs And

Nursing Visits Coded Separately)

Per Diem



Home Infusion Therapy Infusion

Therapy Not Otherwise Classified;










Corticosteroid Infusion;










Home Infusion Therapy Antibiotic

Antiviral Or Antifungal Therapy;






Separately) Per Diem (Do Not Use

This Code With Home Infusion

Codes For Hourly Dosing Schedules

S9497-S9504)





Once Every 3 Hours;











Once Every 24 Hours;











Once Every 12 Hours;











Once Every 8 Hours Administrative









Antiviral Or Antifungal; Once

Every 6 Hours; Administrative









Antiviral Or Antifungal; Once

Every 4 Hours; Administrative








Routine Venipuncture For

Collection Of Specimen(S) Single

Home Bound Nursing Home Or

Skilled Nursing Facility Patient




Home Therapy; Hematopoietic

Hormone Injection Therapy (E. G.

Erythropoietin G-Csf Gm-Csf);







MCG

RX501.069

Clinical Guidelines

Erythropoiesis-Stimulating Agents (ESAs)_


Home Transfusion Of Blood

Product(S); Administrative Services




(Blood Products Drugs And

Nursing Visits Coded Separately)

Per Diem



Home Injectable Therapy Not

Otherwise Classified Including









Home Injectable Therapy; Growth

Hormone Including Administrative






MCG

RX501.040

Clinical Guidelines

Human Growth Hormone (GH)

Orthognathic Surgery

_


Home Injectable Therapy

Interferon Including









Home Injectable Therapy;

Hormonal Therapy (E. G. ;

Leuprolide Goserelin) Including







MCG

RX501.041

Clinical Guidelines

Gonadotropin-Releasing Hormone (GnRH) Agonists

and Antagonists

_


Home Injectable Therapy

Palivizumab Including







MCG

RX504.009

Clinical Guidelines

Respiratory Syncytial Virus (RSV)

Immunoprophylaxis

_


Home Therapy Irrigation Therapy

(E. G. Sterile Irrigation Of An Organ

Or Anatomical Cavity); Including








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Molecular Genetic Lab Testing 81525 Oncology Colon Mrna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


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Molecular Genetic Lab Testing 81535 Oncology Gynecologic AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 81536 Oncology Gynecologic AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 81538 Oncology Lung AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 81539 Oncology Prostate Prob Score AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 81540 Oncology Tum Unknown Origin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81541 Onc Prostate Mrna 46 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81542 Onc Prostate Mrna 22 Cnt Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81545 Oncology Thyroid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retired effective

01/01/2021

Molecular Genetic Lab Testing 81546Onc Thyr Mrna 10,196 Genes Fine

Ndl Aspirate AlgAIM Clinical Guidelines



Molecular Genetic Lab Testing 81551 Onc Prostate 3 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81552 Onc Uveal Mlnma Mrna 15 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81554 Pulm Ds Ipf Mrna 190 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81595 Cardiology Hrt Trnspl Mrna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 81596 Nfct Ds Chrnc Hcv 6 Assays AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 81599 Unlisted Maaa AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 84999 Clinical Chemistry Test AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0001U Rbc Dna Hea 35 Ag 11 Bld Grp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0002M Liver Dis 10 Assays W/Ash AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0003M Liver Dis 10 Assays W/Nash AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0004M Scoliosis Dna Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0005U Onco Prst8 3 Gene Ur Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0006M Onc Hep Gene Risk Classifier AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0007M Onc Gastro 51 Gene Nomogram AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0011M Onc Prst8 Ca Mrna 12 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0012M Onc Mrna 5 Gen Rsk Urthl Ca AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0012U Germln Do Gene Reargmt Detcj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0013M Onc Mrna 5 Gen Recr Urthl Ca AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0013U Onc Sld Org Neo Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0014U Hem Hmtlmf Neo Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0016M Onc Bladder Mrna 209 Gen Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0016UOnc Hmtlmf Neo Rna Bcr/Abl1

Bld/Bne MarrowAIM Clinical Guidelines



Molecular Genetic Lab Testing 0017M Onc Dlbcl Mrna 20 Genes Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0017UOnc Hmtlmf Neo Jak2 Mutation

Dna Bld/Bne MarrowAIM Clinical Guidelines



Molecular Genetic Lab Testing 0018U Onc Thyr 10 Microrna Seq Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0019U Onc Rna Tiss Predict Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0022U Trgt Gen Seq Dna&Rna 23 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0023UOnc Aml Dna Gntyp Int Tandem

Dup Detcj/NondetcjAIM Clinical Guidelines



Molecular Genetic Lab Testing 0026U Onc Thyr Dna&Mrna 112 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0027UJak2 Gene Analysis Trgt Seq Alys

Exons 12-14AIM Clinical Guidelines



Molecular Genetic Lab Testing 0029U Rx Metab Advrs Trgt Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website



Molecular Genetic Lab Testing 0030U Rx Metab Warf Trgt Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0031U Cyp1A2 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0032U Comt Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0033U Htr2A Htr2C Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0034U Tpmt Nudt15 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0036U Xome Tum & Nml Spec Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0037U Trgt Gen Seq Dna 324 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0040UBcr/Abl1 Gene Tlcj Alys Major Bp

QuantitativeAIM Clinical Guidelines



Molecular Genetic Lab Testing 0045U Onc Brst Dux Carc Is 12 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0046UFlt3 Gene Int Tandem Dupl

Variants QuantitativeAIM Clinical Guidelines



Molecular Genetic Lab Testing 0047U Onc Prst8 Mrna 17 Gene Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0048U Onc Sld Org Neo Dna 468 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0049U Npm1 Gene Analysis Quantitative AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0050U Trgt Gen Seq Dna 194 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0053U Onc Prst8 Ca Fish Alys 4 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0055U Card Hrt Trnspl 96 Dna Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0056U Hem Aml Dna Gene Reargmt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0060U Twn Zyg Gen Seq Alys Chrms2 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0067U Onc Brst Imhchem Prfl 4 Bmrk AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0069U Onc Clrct Microrna Mir-31-3P AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0070U Cyp2D6 Gen Com&Slct Rar Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0071U Cyp2D6 Full Gene Sequence AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0072U Cyp2D6 Gen Cyp2D6-2D7 Hybrid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0073U Cyp2D6 Gen Cyp2D7-2D6 Hybrid AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0074U Cyp2D6 Nonduplicated Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0075U Cyp2D6 5' Gene Dup/Mlt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0076U Cyp2D6 3' Gene Dup/Mlt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0078U Pain Mgt Opi Use Gnotyp Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0079U Cmprtv Dna Alys Mlt Snps AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0084U Rbc Dna Gnotyp 10 Bld Groups AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retire effective

03/31/2021

Molecular Genetic Lab Testing 0087U Crd Hrt Trnspl Mrna 1283 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0088U Trnsplj Kdn Algrft Rej 1494 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0089U Onc Mlnma Prame & Linc00518 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0090U Onc Cutan Mlnma Mrna 23 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0094U Genome Rapid Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0101U Hered Colon Ca Do 15 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0102U Hered Brst Ca Rltd Do 17 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0103U Hered Ova Ca Pnl 24 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0104U Hered Pan Ca Pnl 32 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Retired effective

01/01/2021

Molecular Genetic Lab Testing 0111U Onc Colon Ca Kras&Nras Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0113U Onc Prst8 Pca3&Tmprss2-Erg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0114U Gi Barretts Esoph Vim&Ccna1 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0118U Trnsplj Don-Drv Cll-Fr Dna AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0120U Onc B Cll Lymphm Mrna 58 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0129U Hered Brst Ca Rltd Do Panel AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website



Molecular Genetic Lab Testing 0130U Hered Colon Ca Do Mrna Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0131U Hered Brst Ca Rltd Do Pnl 13 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0132U Hered Ova Ca Rltd Do Pnl 17 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0133U Hered Prst8 Ca Rltd Do 11 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0134U Hered Pan Ca Mrna Pnl 18 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0135U Hered Gyn Ca Mrna Pnl 12 Gen AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0136U Atm Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0137U Palb2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0138U Brca1 Brca2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0153U Onc Breast Mrna 101 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0154UOnc Urothelial Cancer Rna Rt-Pcr

Fgfr3 Gene AlysAIM Clinical Guidelines



Molecular Genetic Lab Testing 0155UOnc Brst Ca Dna Pik3Ca Gene Alys

Brst Tum TissAIM Clinical Guidelines



Molecular Genetic Lab Testing 0156U Copy Number Sequence Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0157U Apc Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0158U Mlh1 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0159U Msh2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0160U Msh6 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0161U Pms2 Mrna Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0162U Hered Colon Ca Trgt Mrna Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0169U Nudt15&Tpmt Gene Com Vrnt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0170U Neuro Asd Rna Next Gen Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0171U Trgt Gen Seq Alys Pnl Dna 23 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0203U Ai Ibd Mrna Xprsn Prfl 17 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0204U Onc Thyr Mrna Xprsn Alys 593 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0205U Oph Amd Alys 3 Gene Variants AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0208U Onc Mtc Mrna Xprsn Alys 108 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0209U Cytog Const Alys Interrog AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0211U Onc Pan-Tum Dna&Rna Gnrj Seq AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0212U Rare Ds Gen Dna Alys Proband AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0213U Rare Ds Gen Dna Alys Ea Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0214U Rare Ds Xom Dna Alys Proband AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0215U Rare Ds Xom Dna Alys Ea Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0216U Neuro Inh Ataxia Dna 12 Com AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0217U Neuro Inh Ataxia Dna 51 Gene AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0218U Neuro Musc Dys Dmd Seq Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0228U Onc Prst8 Ma Molec Prfl Alg AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0229U Bcat1 Promoter Mthyltn Alys AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0230U Ar Full Sequence Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0231U Cacna1A Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0232U Cstb Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0233U Fxn Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0234U Mecp2 Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0235U Pten Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0236U Smn1&Smn2 Full Gene Analysis AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0237U Car Ion Chnlpthy Gen Seq Pnl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website



Molecular Genetic Lab Testing 0238U Onc Lnch Syn Gen Dna Seq Aly AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0239U Trgt Gen Seq Alys Pnl 311+ AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0242U Trgt Gen Seq Alys Pnl 55-74 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0244U Onc Solid Orgn Dna 257 Genes AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing 0245U Onc Thyr Mut Alys 10 Gen&37 AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing G9143

Warfarin Responsiveness Testing

By Genetic Technique Using Any

Method Any Number Of

Specimen(S)




Ras (Kras And Nras) Gene Mutation

Testing Performed Before Initiation

Of Anti-Egfr Moab



Retire effective

07/01/2021


Ras (Kras And Nras) Gene Mutation

Testing Not Performed Before

Initiation Of Anti-Egfr Moab



Retire effective

07/01/2021

Molecular Genetic Lab Testing S3800Genetic Testing For Amyotrophic

Lateral Sclerosis (Als)AIM Clinical Guidelines



Molecular Genetic Lab Testing S3840

Dna Analysis For Germline

Mutations Of The Ret Proto-

Oncogene For Susceptibility To

Multiple Endocrine Neoplasia Type

2



Molecular Genetic Lab Testing S3841 Genetic Testing For Retinoblastoma AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Molecular Genetic Lab Testing S3842Genetic Testing For Von Hippel-

Lindau DiseaseAIM Clinical Guidelines




Dna Analysis Of The Connexin 26

Gene (Gjb2) For Susceptibility To

Congenital Profound Deafness



Molecular Genetic Lab Testing S3845Genetic Testing For Alpha-

ThalassemiaAIM Clinical Guidelines



Molecular Genetic Lab Testing S3846Genetic Testing For Hemoglobin E

Beta-ThalassemiaAIM Clinical Guidelines



Molecular Genetic Lab Testing S3849Genetic Testing For Niemann-Pick

DiseaseAIM Clinical Guidelines



Molecular Genetic Lab Testing S3850Genetic Testing For Sickle Cell

AnemiaAIM Clinical Guidelines




Dna Analysis For Apoe Epsilon 4

Allele For Susceptibility To

Alzheimer'S Disease



Molecular Genetic Lab Testing S3853Genetic Testing For Myotonic

Muscular DystrophyAIM Clinical Guidelines




Gene Expression Profiling Panel For

Use In The Management Of Breast

Cancer Treatment




Genetic Testing Sodium Channel

Voltage-Gated Type V Alpha

Subunit (Scn5A) And Variants For

Suspected Brugada Syndrome




Comprehensive Gene Sequence

Analysis For Hypertrophic

Cardiomyopathy




Genetic Analysis For A Specific

Gene Mutation For Hypertrophic

Cardiomyopathy (Hcm) In An

Individual With A Known Hcm

Mutation In The Family




Comparative Genomic

Hybridization (Cgh) Microarray

Testing For Developmental Delay

Autism Spectrum Disorder And/Or

Intellectual Disability



Non Emergent Air Ambulance: Fixed Wing and Rotary A0430

Ambulance Service Conventional

Air Services Transport One Way

(Fixed Wing)

ADM1001.005 Ambulance and Medical Transport Services _

Non Emergent Air Ambulance: Fixed Wing and Rotary A0431

Ambulance Service Conventional

Air Services Transport One Way

(Rotary Wing)

ADM1001.005 Ambulance and Medical Transport Services _

Non Emergent Air Ambulance: Fixed Wing and Rotary A0435Fixed Wing Air Mileage Per Statute

MileADM1001.005 Ambulance and Medical Transport Services _

Non Emergent Air Ambulance: Fixed Wing and Rotary A0436Rotary Wing Air Mileage Per

Statute MileADM1001.005 Ambulance and Medical Transport Services _


Orthopedic Procedures-Artificial Intervertebral Disc 22856 Cerv Artific Diskectomy SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22857 Lumbar Artif Diskectomy SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22858 Second Level Cer Diskectomy SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22861 Revise Cerv Artific Disc SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22862 Revise Lumbar Artif Disc SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22864 Remove Cerv Artif Disc SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 22865 Remove Lumb Artif Disc SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 0095T Rmvl Artific Disc Addl Crvcl SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 0098T Rev Artific Disc Addl SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 0163T Lumb Artif Diskectomy Addl SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 0164T Remove Lumb Artif Disc Addl SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Artificial Intervertebral Disc 0165T Revise Lumb Artif Disc Addl SUR712.028 Artificial Intervertebral Disc _

Orthopedic Procedures-Lumbar Spinal Fusion 20930 Sp Bone Algrft Morsel Add-On SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 20931 Sp Bone Algrft Struct Add-On SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 20936 Sp Bone Agrft Local Add-On SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 20937 Sp Bone Agrft Morsel Add-On SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 20938 Sp Bone Agrft Struct Add-On SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22533 Lat Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22534 Lat Thor/Lumb Addl Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22558 Lumbar Spine Fusion SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22585 Additional Spinal Fusion SUR712.036 Lumbar Spinal Fusion _


Orthopedic Procedures-Lumbar Spinal Fusion 22614 Spine Fusion Extra Segment SUR712.036 Lumbar Spinal Fusion _




Orthopedic Procedures-Lumbar Spinal Fusion 22633 Lumbar Spine Fusion Combined SUR712.036 Lumbar Spinal Fusion _


Orthopedic Procedures-Lumbar Spinal Fusion 22800 Post Fusion </6 Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22802 Post Fusion 7-12 Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22804 Post Fusion 13/> Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22808 Ant Fusion 2-3 Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22810 Ant Fusion 4-7 Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22812 Ant Fusion 8/> Vert Seg SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22840 Insert Spine Fixation Device SUR712.036 Lumbar Spinal Fusion _








Orthopedic Procedures-Lumbar Spinal Fusion 22848 Insert Pelv Fixation Device SUR712.036 Lumbar Spinal Fusion _

Orthopedic Procedures-Lumbar Spinal Fusion 22853 Insj Biomechanical DeviceSUR712.040

SUR712.036

Interspinous Fixation (Fusion) Devices

Lumbar Spinal Fusion_


SUR712.036




SUR712.036






A4595Electrical Stimulator Supplies 2

Lead Per Month (E. G. Tens Nmes)

MED201.033

MED205.032

Functional Neuromuscular Electrical Stimulation

Percutaneous and Implanted Nerve Stimulation

and Neuromodulation

Retire effective 4/30/2021




E0760Osteogenesis Stimulator Low

Intensity Ultrasound Non-InvasiveMED201.033 Functional Neuromuscular Electrical Stimulation

Retire effective

04/30/2021


Pain Management - Spinal Cord Stimulation 63650 Implant Neuroelectrodes SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root

Ganglion (DRG) Stimulation_

Pain Management - Spinal Cord Stimulation 63655 Implant Neuroelectrodes SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63661 Remove Spine Eltrd Perq Aray SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63662 Remove Spine Eltrd Plate SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63663 Revise Spine Eltrd Perq Aray SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63664 Revise Spine Eltrd Plate SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63685 Insrt/Redo Spine N Generator SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation 63688 Revise/Remove Neuroreceiver SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation C1822

Generator Neurostimulator

(Implantable) High Frequency

With Rechargeable Battery And

Charging System

SUR712.009Spinal Cord Stimulation (SCS) and Dorsal Root


Pain Management - Spinal Cord Stimulation/Percutaneuos

& Implanted Nerve Stimulation and NeuromodulationL8679

Implantable Neurostimulator

Pulse Generator Any Type

SUR712.009

MED205.032

Spinal Cord Stimulation (SCS) and Dorsal Root

Ganglion (DRG) Stimulation


and Neuromodulation

_




Electrode Each

SUR712.009

MED205.032




and Neuromodulation

_



Implantable Neurostimulator Pulse

Generator Single Array

Rechargeable Includes Extension

SUR712.009

MED205.032




and Neuromodulation

_




Generator Single Array Non-


SUR712.009

MED205.032




and Neuromodulation

_




Generator Dual Array


SUR712.009

MED205.032




and Neuromodulation

_




Generator Dual Array Non-


SUR712.009

MED205.032




and Neuromodulation

_

Percutaneous and Implanted Nerve Stimulation and

Neuromodulation64555 Implant Neuroelectrodes MED205.032


and Neuromodulation_










Neuromodulation64585 Revise/Remove Neuroelectrode MED205.032




Neuromodulation64590 Insrt/Redo Pn/Gastr Stimul MED205.032




Neuromodulation64595 Revise/Rmv Pn/Gastr Stimul MED205.032




Neuromodulation64999 Nervous System Surgery MED205.032




Neuromodulation95970 Alys Npgt W/O Prgrmg MED205.032




Neuromodulation95971 Alys Smpl Sp/Pn Npgt W/Prgrm MED205.032




Neuromodulation95972 Alys Cplx Sp/Pn Npgt W/Prgrm MED205.032




NeuromodulationL8681

Patient Programmer (External) For

Use With Implantable

Programmable Neurostimulator

Pulse Generator Replacement Only

MED205.032Percutaneous and Implanted Nerve Stimulation






Radiofrequency ReceiverMED205.032





Radiofrequency Transmitter

(External) For Use With


Radiofrequency Receiver





External Recharging System For

Battery (Internal) For Use With


Replacement Only





External Recharging System For

Battery (External) For Use With


Replacement Only



Radiation Therapy 19294Prep Tumor Cavity Iort W/Partial

MastectomyAIM Clinical Guidelines



Radiation Therapy 19296Plmt Expandable Cath Brst

Following Prtl MastAIM Clinical Guidelines



Radiation Therapy 19297Plmt Expandable Cath Brst

Concurrent Prtl MastAIM Clinical Guidelines



Radiation Therapy 19298Plmt Radthx Brachytx Brst

Following Prtl MastAIM Clinical Guidelines



Radiation Therapy 20555Placement Needles Muscle

Subsequent RadioelementAIM Clinical Guidelines



Radiation Therapy 31643Brnchsc W/Plmt Cath Intrcv

Radioelmnt ApplAIM Clinical Guidelines



Radiation Therapy 32701Thorax Stereotactic Radiation

Target W/Tx CourseAIM Clinical Guidelines



Radiation Therapy 41019Placement Needle Head/Neck

Radioelement ApplicatAIM Clinical Guidelines



Radiation Therapy 43499 Unlisted Procedure Esophagus AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 47999 Unlisted Procedure Biliary Tract AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 55860Expos Prostate Any Approach Insj

Radioact SubstAIM Clinical Guidelines



Radiation Therapy 55862Expos Prostate Insj Radioact Sbst

W/Lymph BxAIM Clinical Guidelines



Radiation Therapy 55865Expos Prostate Insj Radioac Sbst

W/Bi Pelv LymphAIM Clinical Guidelines



Radiation Therapy 55874Transperineal Plmt Biodegradable

Matrl 1/Mlt NjxAIM Clinical Guidelines



Radiation Therapy 55875Transperineal Plmt Ndl/Caths

Prostate Radj InsjAIM Clinical Guidelines



Radiation Therapy 55899Unlisted Procedure Male Genital

SystemAIM Clinical Guidelines



Radiation Therapy 55920Placement Needle Pelvic Organ

Radioelement ApplAIM Clinical Guidelines



Radiation Therapy 57155Insertion Uterine

Tandem&/Vaginal OvoidsAIM Clinical Guidelines



Radiation Therapy 57156 Insertion Vaginal Radiation Device AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 58346Insertion Heyman Capsules Clinical

BrachytherapyAIM Clinical Guidelines



Radiation Therapy 61796Stereotactic Radiosurgery 1 Simple

Cranial LesAIM Clinical Guidelines



Radiation Therapy 61797Strtctc Radiosurgery Ea Addl

Cranial Les SimpleAIM Clinical Guidelines



Radiation Therapy 61798Stereotactic Radiosurgery 1

Complex Cranial LesAIM Clinical Guidelines



Radiation Therapy 61799Strtctc Radiosurgery Ea Addl

Cranial Les ComplexAIM Clinical Guidelines



Radiation Therapy 61800Appl Strtctc Headframe

Stereotactic RadiosurgeryAIM Clinical Guidelines



Radiation Therapy 63620Stereotactic Radiosurgery 1 Spinal

LesionAIM Clinical Guidelines



Radiation Therapy 63621Stereotactic Radiosurgery Ea Addl

Spinal LesionAIM Clinical Guidelines



Radiation Therapy 67218Dstrj Lesion Retina 1/> Sess Radj

ImpltjAIM Clinical Guidelines



Radiation Therapy 76873Us Transrct Prstate Vol Brachytx

Plnning SpxAIM Clinical Guidelines



Radiation Therapy 76965Us Guidance Interstitial

Radioelment ApplicationAIM Clinical Guidelines



Radiation Therapy 77014 Ct Scan For Therapy Guide AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 772953-D Radiotherapy Plan Dose-

Volume HistogramsAIM Clinical Guidelines



Radiation Therapy 77301Ntsty Modul Radthx Pln Dose-Vol

HistosAIM Clinical Guidelines



Radiation Therapy 77316Brachytx Isodose Pln Smpl

W/Dosimetry CalAIM Clinical Guidelines



Radiation Therapy 77317Brachytx Isodose Pln Intermed




Radiation Therapy 77318Brachytx Isodose Pln Cplx




Radiation Therapy 77338 Design Mlc Device For Imrt AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77370 Spec Medical Radj Physics Consltj AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website



Radiation Therapy 77371 Srs Multisource AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77372 Srs Linear Based AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77373 Sbrt Delivery AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77385 Ntsty Modul Rad Tx Dlvr Smpl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77386 Ntsty Modul Rad Tx Dlvr Cplx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77387 Guidance For Radj Tx Dlvr AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website








Radiation Therapy 77424 Io Rad Tx Delivery By X-Ray AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77425 Io Rad Tx Deliver By Elctrns AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77432Steretctc Radiation Tx

Management Cranial LesionAIM Clinical Guidelines



Radiation Therapy 77435Stereotactic Body Radiation

ManagementAIM Clinical Guidelines



Radiation Therapy 77469Intraoperative Radiation Treatment

ManagementAIM Clinical Guidelines



Radiation Therapy 77470 Special Treatment Procedure AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77520 Proton Trmt Simple W/O Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77522 Proton Trmt Simple W/Comp AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77523 Proton Trmt Intermediate AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77525 Proton Treatment Complex AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77750 Infuse Radioactive Materials AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77761 Apply Intrcav Radiat Simple AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77762 Apply Intrcav Radiat Interm AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77763 Apply Intrcav Radiat Compl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77767 Hdr Rdncl Skn Surf Brachytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77768 Hdr Rdncl Skn Surf Brachytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77770 Hdr Rdncl Ntrstl/Icav Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website






Radiation Therapy 77778 Apply Interstit Radiat Compl AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 77790Supervision Handling Loading

Radiation SourceAIM Clinical Guidelines



Radiation Therapy 79005 Nuclear Rx Oral Admin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 79101 Nuclear Rx Iv Admin AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 79403 Hematopoietic Nuclear Tx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 0394T Hdr Elctrnc Skn Surf Brchytx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy 0395T Hdr Elctr Ntrst/Ntrcv Brchtx AIM Clinical GuidelinesCall 1-844-377-1285 or Access Website


Radiation Therapy A9508Iodine I-131 Iobenguane Sulfate,

Diagnostic, Per 0.5 MillicurieAIM Clinical Guidelines



Radiation Therapy A9513Lutetium Lu 177 Dotatate

Therapeutic 1 MillicurieAIM Clinical Guidelines



Radiation Therapy A9528

Iodine I-131 Sodium Iodide

Capsule(S), Diagnostic, Per

Millicurie




Iodine I-131 Sodium Iodide,

Diagnostic, Per Microcurie (Up To

100 Microcuries)




Yttrium Y-90 Ibritumomab

Tiuxetan Therapeutic Per

Treatment Dose Up To 40

Millicuries



Radiation Therapy A9590Iodine I-131, Iobenguane, 1

MillicurieAIM Clinical Guidelines



Radiation Therapy A9600Strontium Sr-89 Chloride,

Therapeutic, Per MillicurieAIM Clinical Guidelines





Samarium Sm-153 Lexidronam,

Therapeutic, Per Treatment Dose,

Up To 150 Millicuries



Radiation Therapy A9606Radium Ra-223 Dichloride,

Therapeutic, Per MicrocurieAIM Clinical Guidelines



Radiation Therapy G0339

Image-Guided Robotic Linear

Accelerator-Based Stereotactic

Radiosurgery Complete Course Of

Therapy In One Session Or First

Session Of Fractionated Treatment




Image-Guided Robotic Linear

Accelerator-Based Stereotactic

Radiosurgery Delivery Including

Collimator Changes And Custom

Plugging Fractionated Treatment

All Lesions Per Session Second

Through Fifth Sessions Maximum

Five Sessions Per Course Of

Treatment




Low Dose Rate (Ldr) Prostate

Brachytherapy Services, Composite

Rate



Radiation Therapy G6001Ultrasonic Guidance For Placement

Of Radiation Therapy FieldsAIM Clinical Guidelines




Stereoscopic X-Ray Guidance For

Localization Of Target Volume For

The Delivery Of Radiation Therapy




Radiation Treatment Delivery

Single Treatment Area Single Port

Or Parallel Opposed Ports Simple

Blocks Or No Blocks: Up To 5Mev







Blocks Or No Blocks: 6-10Mev







Blocks Or No Blocks: 11-19Mev







Blocks Or No Blocks: 20Mev Or

Greater




Radiation Treatment Delivery 2

Separate Treatment Areas 3 Or

More Ports On A Single Treatment

Area Use Of Multiple Blocks: Up

To 5Mev







Area Use Of Multiple Blocks: 6-

10Mev







Area Use Of Multiple Blocks: 11-

19Mev







Area Use Of Multiple Blocks: 20

Mev Or Greater




Radiation Treatment Delivery 3 Or

More Separate Treatment Areas

Custom Blocking Tangential Ports

Wedges Rotational Beam

Compensators Electron Beam; Up

To 5Mev








Compensators Electron Beam; 6-

10Mev









Compensators Electron Beam; 11-

19Mev








Compensators Electron Beam;

20Mev Or Greater




Intensity Modulated Treatment

Delivery Single Or Multiple

Fields/Arcs Via Narrow Spatially

And Temporally Modulated Beams

Binary Dynamic Mlc Per

Treatment Session




Compensator-Based Beam

Modulation Treatment Delivery Of

Inverse Planned Treatment Using 3

Or More High Resolution (Milled

Or Cast) Compensator Convergent

Beam Modulated Fields Per

Treatment Session




Intra-Fraction Localization And

Tracking Of Target Or Patient

Motion During Delivery Of

Radiation Therapy (Eg 3D

Positional Tracking Gating 3D

Surface Tracking) Each Fraction Of

Treatment



Radiation Therapy Q3001Radioelements For Brachytherapy,

Any Type, EachAIM Clinical Guidelines



Radiation Therapy S8030

Scleral Application Of Tantalum

Ring(S) For Localization Of Lesions

For Proton Beam Therapy



Sleep Study: Facility based polysomnography/pap titration 95807 Sleep Study Attended MED204.005Diagnosis and Medical Management of Obstructive

Sleep Apnea Syndrome_

Sleep Study: Facility based polysomnography/pap titration 95808 Polysom Any Age 1-3> ParamMED204.005

MED201.049

Diagnosis and Medical Management of Obstructive

Sleep Apnea Syndrome

Polysomnography for Non-Respiratory Sleep

Disorders

_

Sleep Study: Facility based polysomnography/pap titration 95810 Polysom 6/> Yrs 4/> ParamMED204.005

MED201.049




Disorders

_

Sleep Study: Facility based polysomnography/pap titration 95811 Polysom 6/>Yrs Cpap 4/> ParmMED204.005

MED201.049




Disorders

_

Transplant Evaluations and Transplants 32851 Lung Transplant Single SUR703.010 Lung and Lobar Lung Transplant _

Transplant Evaluations and Transplants 32852 Lung Transplant With Bypass SUR703.010 Lung and Lobar Lung Transplant _

Transplant Evaluations and Transplants 32853 Lung Transplant Double SUR703.010 Lung and Lobar Lung Transplant _

Transplant Evaluations and Transplants 32854 Lung Transplant With Bypass SUR703.010 Lung and Lobar Lung Transplant _

Transplant Evaluations and Transplants 33935 Transplantation Heart/Lung SUR703.006 Heart/Lung Transplant _

Transplant Evaluations and Transplants 33945 Transplantation Of Heart SUR703.005 Heart Transplant _

Transplant Evaluations and Transplants 38204 Bl Donor Search Management _Refer to applicable Hematopoietic Cell

Transplantation policies_

Transplant Evaluations and Transplants 38205 Harvest Allogeneic Stem Cell _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38206 Harvest Auto Stem Cells _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38207 Cryopreserve Stem Cells _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38208 Thaw Preserved Stem Cells _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38209 Wash Harvest Stem Cells _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38210 T-Cell Depletion Of Harvest _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38211 Tumor Cell Deplete Of Harvst _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38212 Rbc Depletion Of Harvest _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38213 Platelet Deplete Of Harvest _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38214 Volume Deplete Of Harvest _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38215 Harvest Stem Cell Concentrte _Refer to applicable Hematopoietic Cell



Transplant Evaluations and Transplants 38230 Bone Marrow Harvest Allogen _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38232 Bone Marrow Harvest Autolog _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38240 Transplt Allo Hct/Donor _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38241 Transplt Autol Hct/Donor _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38242 Transplt Allo Lymphocytes _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 38243 Transplj Hematopoietic Boost _Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants 44135 Intestine Transplnt CadaverSUR703.014

SUR703.009

Isolated Small Bowel Transplant

Small Bowel/Liver and Multivisceral Transplant _

Transplant Evaluations and Transplants 44136 Intestine Transplant LiveSUR703.014

SUR703.009



Transplant Evaluations and Transplants 47135 Transplantation Of LiverSUR703.014

SUR703.009



Transplant Evaluations and Transplants 48160 Pancreas Removal/Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants 48554 Transpl Allograft Pancreas SUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants 50360 Transplantation Of Kidney #REF!

Kidney Transplant

Liver Transplant and Combined Liver-Kidney

Transplant

Pancreas and Related Organ Tissue Transplantation

_

Transplant Evaluations and Transplants 50365 Transplantation Of Kidney #REF!

Kidney Transplant


Transplant

Pancreas and Related Organ Tissue

Transplantation

_

Transplant Evaluations and Transplants 50380 Reimplantation Of KidneySUR703.008

SUR703.013


Transplant

Pancreas and Related Organ Tissue

Transplantation

_

Transplant Evaluations and Transplants 0584T Perq Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants 0585T Laps Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants 0586T Open Islet Cell Transplant SUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants G0341

Percutaneous Islet Cell Transplant,

Includes Portal Vein

Catheterization And Infusion

SUR703.013 Pancreas and Related Organ Tissue Transplantation _


Laparoscopy For Islet Cell

Transplant, Includes Portal Vein




Laparotomy For Islet Cell

Transplant, Includes Portal Vein



Transplant Evaluations and Transplants S2053Transplantation Of Small Intestine

And Liver AllograftsSUR703.009 Small Bowel/Liver and Multivisceral Transplant _

Transplant Evaluations and Transplants S2054Transplantation Of Multivisceral

Organs

SUR703.013

SUR703.009

Pancreas and Related Organ Tissue Transplantation

Small Bowel/Liver and Multivisceral Transplant_

Transplant Evaluations and Transplants S2060 Lobar Lung Transplantation SUR703.010 Lung and Lobar Lung Transplant _

Transplant Evaluations and Transplants S2065Simultaneous Pancreas Kidney

TransplantationSUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants S2102Islet Cell Tissue Transplant From

Pancreas; AllogeneicSUR703.013 Pancreas and Related Organ Tissue Transplantation _

Transplant Evaluations and Transplants S2140Cord Blood Harvesting For

Transplantation, Allogeneic_

Refer to applicable Hematopoietic Cell


Transplant Evaluations and Transplants S2142Cord Blood-Derived Stem-Cell

Transplantation, Allogeneic_

Refer to applicable Hematopoietic Cell



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