comprehensive code list · 2019-12-18 · v1.2019 effective: 1/1/2019 category cpt® code. cpt ®...

Radiology - Advanced Imaging 2Cardiology 11Interventional Pain 18Spine Surgery 22Joint Services (Hip/Knee/Shoulder) 37Radiation Therapy 50Lab Management 55Medical Oncology - Medicare 66Medical Oncology - Commercial 72

Network Health Plan WIComprehensive Code List

V1.2019 Effective: 1/1/2019

Category CPT®

Code CPT® Code DescriptionCommercial

Requires Prior Authorization

MedicareRequires Prior Authorization

Allowed Billing Groupings

BMRI 77046 Magnetic resonance imaging, breast, without contrast material; unilateral Yes YesBMRI 77047 Magnetic resonance imaging, breast, without contrast material; bilateral Yes Yes

BMRI 77048Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral

Yes Yes

BMRI 77049Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

Yes Yes

CT 70450 Computed tomography, head or brain; without contrast material Yes Yes 70450, 70460, 70470

CT 70460 Computed tomography, head or brain; with contrast material(s) Yes Yes 70450, 70460, 70470

CT 70470 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections Yes Yes 70450, 70460, 70470

CT 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Yes Yes 70480, 70481, 70482

CT 70481 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Yes Yes 70480, 70481, 70482

CT 70482 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections Yes Yes 70480, 70481, 70482

CT 70486 Computed tomography, maxillofacial area; without contrast material Yes Yes 70486, 70487, 70488, 76380

CT 70487 Computed tomography, maxillofacial area; with contrast material(s) Yes Yes 70486, 70487, 70488, 76380

CT 70488 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections Yes Yes 70486, 70487, 70488,

76380

CT 70490 Computed tomography, soft tissue neck; without contrast material Yes Yes 70490, 70491, 70492, 72125, 72126, 72127

Network Health Plan WI Prior Authorization Procedure List: Radiology - Advanced Imaging

*C-CODES APPLY TO MEDICARE MEMBERSHIP ONLY

V1.2019 Effective: 1/1/2019

Category CPT®





CT 70491 Computed tomography, soft tissue neck; with contrast material(s) Yes Yes 70490, 70491, 70492, 72125, 72126, 72127

CT 70492 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections Yes Yes 70490, 70491, 70492,

72125, 72126, 72127

CT 70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 70496

CT 70498 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 70498

CT 71250 Computed tomography, thorax; without contrast material Yes Yes71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170

CT 71260 Computed tomography, thorax; with contrast material(s) Yes Yes71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170

CT 71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections Yes Yes

71250, 71260, 71270, 72192, 72193, 72194, 74150, 74160, 74170

CT 71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 71275

CT 71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) Yes Yes 71550, 71551, 71552

CT 71551 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) Yes Yes 71550, 71551, 71552

CT 71552Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

Yes Yes 71550, 71551, 71552

CT 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) Yes Yes 71555, C8909, C8910,

C8911

CT 72125 Computed tomography, cervical spine; without contrast material Yes Yes 72125, 72126, 72127, 70490, 70491, 70492

V1.2019 Effective: 1/1/2019

Category CPT®





CT 72126 Computed tomography, cervical spine; with contrast material Yes Yes 72125, 72126, 72127, 70490, 70491, 70492

CT 72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72125, 72126, 72127,

70490, 70491, 70492

CT 72128 Computed tomography, thoracic spine; without contrast material Yes Yes 72128, 72129, 72130

CT 72129 Computed tomography, thoracic spine; with contrast material Yes Yes 72128, 72129, 72130

CT 72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72128, 72129, 72130

CT 72131 Computed tomography, lumbar spine; without contrast material Yes Yes 72131, 72132, 72133

CT 72132 Computed tomography, lumbar spine; with contrast material Yes Yes 72131, 72132, 72133

CT 72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Yes Yes 72131, 72132, 72133

CT 72191 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 72191

CT 72192 Computed tomography, pelvis; without contrast material Yes Yes

72192, 72193,72194, 71250,71260, 71270,74150, 74160,

74170

CT 72193 Computed tomography, pelvis; with contrast material(s) Yes Yes

72192, 72193,72194, 71250,71260, 71270,74150, 74160,

74170

CT 72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections Yes Yes

72192, 72193,72194, 71250,71260, 71270,74150, 74160,

74170

CT 73200 Computed tomography, upper extremity; without contrast material Yes Yes 73200, 73201,73202

CT 73201 Computed tomography, upper extremity; with contrast material(s) Yes Yes 73200, 73201,73202

V1.2019 Effective: 1/1/2019

Category CPT®





CT 73202 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Yes Yes 73200, 73201,

73202

CT 73206 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 73206

CT 73700 Computed tomography, lower extremity; without contrast material Yes Yes 73700, 73701, 73702

CT 73701 Computed tomography, lower extremity; with contrast material(s) Yes Yes 73700, 73701, 73702

CT 73702 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections Yes Yes 73700, 73701, 73702

CT 73706 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 73706

CT 74150 Computed tomography, abdomen; without contrast material Yes Yes

74150, 74160,74170, 71250,71260, 71270,72192, 72193,

72194

CT 74160 Computed tomography, abdomen; with contrast material(s) Yes Yes

74150, 74160,74170, 71250,71260, 71270,72192, 72193,

72194

CT 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections Yes Yes

74150, 74160,74170, 71250,71260, 71270,72192, 72193,

72194

CT 74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 74174

CT 74175 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing Yes Yes 74175

CT 74176 Computed tomography, abdomen and pelvis; without contrast material Yes Yes 74176, 74177,74178

CT 74177 Computed tomography, abdomen and pelvis; with contrast material(s) Yes Yes 74176, 74177,74178

CT 74178 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Yes Yes 74176, 74177,

74178

V1.2019 Effective: 1/1/2019

Category CPT®





CT 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Yes Yes 74261, 74262

CT 74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed Yes Yes 74261, 74262

CT 74263 Computed tomographic (CT) colonography, screening, including image postprocessing Yes Yes 74263

CT 75635Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

Yes Yes 75635

CT 76380 Computed tomography, limited or localized follow-up study Yes Yes 76380, 70486,70487, 70488

CT 76497 Unlisted computed tomography procedure (eg, diagnostic, interventional) Yes Yes 76497

CT G0297 Low-dose CT For Lung Cancer Screening Yes Yes G0297, 70486,70487, 70488

CT S8092 CT Electron Beam (also known as Ultrafast CT, Cine CT), for calcium scoring Yes Yes S8092MR 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) Yes Yes 70336

MR 70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Yes Yes 72141, 72142, 72156,

70540, 70542, 70543

MR 70542 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Yes Yes 70551, 70552, 70553, 70540, 70542, 70543

MR 70543 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70551, 70552, 70553,

70540, 70542, 70543,

MR 70544 Magnetic resonance angiography, head; without contrast material(s) Yes Yes 70544, 70545, 70546

MR 70545 Magnetic resonance angiography, head; with contrast material(s) Yes Yes 70544, 70545, 70546

MR 70546 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70544, 70545, 70546

MR 70547 Magnetic resonance angiography, neck; without contrast material(s) Yes Yes 70547, 70548, 70549

MR 70548 Magnetic resonance angiography, neck; with contrast material(s) Yes Yes 70547, 70548, 70549

MR 70549 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 70547, 70548, 70549

V1.2019 Effective: 1/1/2019

Category CPT®





MR 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material Yes Yes 70551, 70552, 70553,

70540, 70542, 70543

MR 70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Yes Yes 70551, 70552, 70553,

70540, 70542, 70543

MR 70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences Yes Yes 70551, 70552, 70553,

70540, 70542, 70543

MR 70554Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration

Yes Yes 70554, 70555

MR 70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing Yes Yes 70554, 70555

MR 72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material Yes Yes 72141, 72142, 72156,

70540, 70542, 70543

MR 72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) Yes Yes 72141, 72142, 72156,

70540, 70542, 70543

MR 72146 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material Yes Yes 72146, 72147, 72157

MR 72147 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) Yes Yes 72146, 72147, 72157

MR 72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material Yes Yes 72148, 72149, 72158

MR 72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) Yes Yes 72148, 72149, 72158

MR 72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical Yes Yes 72156, 70540, 70542,

70543, 72141, 72142

MR 72157 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic Yes Yes 72157, 72146, 72147

MR 72158 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar Yes Yes 72158, 72148, 72149

MR 72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) Yes Yes 72159, C8931,

C8932, C8933

MR 72195 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) Yes Yes 72195, 72196, 72197

V1.2019 Effective: 1/1/2019

Category CPT®





MR 72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Yes Yes 72195, 72196,72197

MR 72197 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 72195, 72196, 72197

MR 72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) Yes Yes 72198, C8918,C8919, C8920

MR 73218 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Yes Yes 73218, 73219, 73220

MR 73219 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Yes Yes 73218, 73219, 73220

MR 73220 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 73218, 73219,

73220

MR 73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Yes Yes 73221, 73222,

73223

MR 73222 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Yes Yes 73221, 73222,

73223

MR 73223 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes 73221, 73222,

73223

MR 73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s) Yes Yes 73225, C8934,C8935, C8936

MR 73718 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Yes Yes

73718, 73719,73720, 73721,73722, 73723

MR 73719 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Yes Yes

73718, 73719,73720, 73721,73722, 73723

MR 73720 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes

73718, 73719,73720, 73721,73722, 73723

MR 73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Yes Yes

73721, 73722,73723, 73718,73719, 73720,72195, 72196,

72197

MR 73722 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) Yes Yes

73718, 73719,73720, 73721,73722, 73723

V1.2019 Effective: 1/1/2019

Category CPT®





MR 73723 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Yes Yes

73718, 73719,73720, 73721,73722, 73723

MR 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) Yes Yes 73725, C8912,C8913, C8914

MR 74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) Yes Yes 74181, 74182,74183, S8037

MR 74182 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) Yes Yes 74181, 74182,74183, S8037

MR 74183 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences Yes Yes 74181, 74182, 74183,

S8092

MR 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) Yes Yes 74185, C8900,C8901, C8902

MR 74712 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation Yes Yes 74712, 78491,

78492, 74713

MR 74713Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)

Yes Yes 74713, 78491,78492, 74712

MR 76390 Magnetic resonance spectroscopy Yes Yes 76390MR 76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional) Yes Yes 76498

MR 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral Yes Yes

77058, 77059,C8903, C8904,C8905, C8906,C8907, C8908

MR 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral Yes Yes

77059, 77059,C8903, C8904,C8905, C8906,C8907, C8908

MR 77084 Magnetic resonance (eg, proton) imaging, bone marrow blood supply Yes Yes 77084MR S8035 Magnetic Source Imaging (MSI) Yes Yes S8035

MR S8037 Magnetic resonance cholangiopancreatography (MRCP) Yes Yes S8037, 74181,74182, 74183

MR S8042 MRI Low Field Yes Yes S8042MRI 76391 Magnetic resonance (eg, vibration) elastography Yes Yes

V1.2019 Effective: 1/1/2019

Category CPT®





MRI C8937 Computer-aided detection, including computer algorithm analysis of breast mri image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation (list separately in addition to code for primary procedure)

No Yes

PET 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation Yes Yes 78459, 78491,78492

PET 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress Yes Yes 78459, 78491,

78492

PET 78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress Yes Yes 78459, 78491,

78492PET 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation Yes Yes 78608, 78609PET 78609 Brain imaging, positron emission tomography (PET); perfusion evaluation Yes Yes 78609, 78609

PET 78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) Yes Yes78811, 78812,78813, 78814,78815, 78816

PET 78812 Positron emission tomography (PET) imaging; skull base to mid-thigh Yes Yes78811, 78812,78813, 78814,78815, 78816

PET 78813 Positron emission tomography (PET) imaging; whole body Yes Yes78811, 78812,78813, 78814,78815, 78816

PET 78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

Yes Yes78811, 78812,78813, 78814,78815, 78816

PET 78815 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh Yes Yes

78811, 78812,78813, 78814,78815, 78816

PET 78816 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body Yes Yes

78811, 78812,78813, 78814,78815, 78816,

G0219CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

V1.2019 Effective: 7/1/2019

Category CPT®





Catheterization 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed Yes No 93451

Catheterization 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Yes No 93452

Catheterization 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Yes No 93453

Catheterization 93454Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461

Catheterization 93455

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461

Catheterization 93456Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461


Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461


Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461

Network Health Plan WIPrior Authorization Procedure List: Cardiology


V1.2019 Effective: 7/1/2019

Category CPT®






Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461


Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461


Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Yes No 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461

Catheterization 93530 Right heart catheterization, for congenital cardiac anomalies Yes No 93530

Catheterization 93531 Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies Yes No 93531

Catheterization 93532Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde left heart catheterization, for congenital cardiac anomalies

Yes No 93532

Catheterization 93533Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies

Yes No 93533

CT 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Yes No 75571

CT 75572Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)

Yes No 75572

CT 75573

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)

Yes No 75573

V1.2019 Effective: 7/1/2019

Category CPT®





CT 75574

Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

Yes No 75574

CT 0501T

Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordantdata, interpretation and report

Yes No

CT 0502T

Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission

Yes No

CT 0503T

Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model

Yes No

CT 0504T

Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

Yes No

Echo 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete Yes No 93303, 93304, +93320, +93321, +93325

Echo 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Yes No 93303, 93304, +93320,

+93321, +93325

Echo 93306Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

Yes No 93306, 93307, 93308, C8924

V1.2019 Effective: 7/1/2019

Category CPT®





Echo 93307Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

Yes No 93306, 93307, 93308, C8924

Echo 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Yes No 93306, 93307, 93308,

+93321, +93325

Echo 93312Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report

Yes No 93312, 93313, 99314, +93320, +93321, +93325

Echo 93313 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Yes No 93312, 93313, 99314,

+93320, +93321, +93325

Echo 93314 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only Yes No 93312, 93313, 99314,

+93320, +93321, +93325

Echo 93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Yes No 93315, 93316, 93317,

+93320, +93321, +93325

Echo 93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only Yes No 93315, 93316, 93317,

+93320, +93321, +93325

Echo 93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only Yes No 93315, 93316, 93317,

+93320, +93321, +93325

Echo 93318

Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis

Yes No 93318

Echo 93320Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete

Yes No add on code, must be billed with another code

Echo 93321

Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging)

Yes No add on code, must be billed with another code

Echo 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) Yes No add on code, must be billed

with another code

Echo 93350

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report;

Yes No 93350, 93351, +93320, +93321, +93325

V1.2019 Effective: 7/1/2019

Category CPT®





Echo 93351

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional

Yes No 93350, 93351, +93320, +93321, +93325

MR 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material; Yes No

75557, 75559,75561, 75563,

+75565

MR 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging Yes No

75557, 75559,75561, 75563,

+75565

MR 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; Yes No

75557, 75559,75561, 75563,

+75565

MR 75563Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

Yes No75557, 75559,75561, 75563,

+75565

MR 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Yes No

75557, 75559,75561, 75563,

+75565Nuc Card 78414 Non-Imaging Heart Function Yes NoNuc Card 78428 Cardiac Shunt Imaging Yes No

Nuc Card 78451

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78452

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78453Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

V1.2019 Effective: 7/1/2019

Category CPT®





Nuc Card 78454

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique Yes No

78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification Yes No

78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78472Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing

Yes No 78472, 78473, 78494, +78496

Nuc Card 78473Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification

Yes No 78472, 78473, 78494, +78496

Nuc Card 78481Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78483Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

Yes No78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481,

78483, 78499

Nuc Card 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing Yes No 78472, 78473, 78494,

+78496

Nuc Card 78496Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure)

Yes No 78472, 78473, 78494, +78496

Nuc Card 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine Yes No 78499

V1.2019 Effective: 7/1/2019

Category CPT®





PET 0482T Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (list separately in addition to code for primary procedure) Yes No

CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

V1.2019 Effective: 1/1/2019

Category CPT®





Internventional Pain 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance

(fluoroscopy or CT) including arthrography when performed Yes Yes 27096

Internventional Pain 62263

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days

Yes Yes 62263, 62264


Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day

Yes Yes 62263, 62264

Internventional Pain 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline

solutions), with or without other therapeutic substance; subarachnoid Yes Yes 62280, 62281, 62282


Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic

Yes Yes 62280, 62281, 62282


Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Yes Yes 62280, 62281, 62282


Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327

Network Health Plan WIPrior Authorization Procedure List: Interventional Pain


V1.2019 Effective: 1/1/2019

Category CPT®






Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327


Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Yes Yes 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327

Internventional Pain 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging

guidance (fluoroscopy or CT); cervical or thoracic, single level Yes Yes 64479, 64480


Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Yes Yes 64479, 64480

V1.2019 Effective: 1/1/2019

Category CPT®





Internventional Pain 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging

guidance (fluoroscopy or CT); lumbar or sacral, single level Yes Yes 64483, 64484


Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Yes Yes 64483, 64484


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495


Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Yes Yes 64490, 64491, 64492, 64493, 64494, 64495

Internventional Pain 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Yes Yes 64510, 64520

Internventional Pain 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Yes Yes 64510, 64520

Internventional Pain 64620 Destruction by neurolytic agent, intercostal nerve Yes Yes 64620

Internventional Pain 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging

guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Yes Yes 64633, 64634, 64635, 64636

V1.2019 Effective: 1/1/2019

Category CPT®






Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Yes Yes 64633, 64634, 64635, 64636

Internventional Pain 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging

guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Yes Yes 64633, 64634, 64635, 64636


Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Yes Yes 64633, 64634, 64635, 64636

Internventional Pain 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with

ultrasound guidance, cervical or thoracic; single level Yes Yes 0228T, 0229T, 0230T, 0231T

Internventional Pain 0229T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

Yes Yes 0228T, 0229T, 0230T, 0231T

Internventional Pain 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with

ultrasound guidance, lumbar or sacral; single level Yes Yes 0228T, 0229T, 0230T, 0231T

Internventional Pain 0231T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Yes Yes 0228T, 0229T, 0230T, 0231T

Internventional Pain M0076 Prolotherapy Yes Yes M0076


V1.2019 Effective: 7/1/2019


Category CPT® Code CPT® Code DescriptionCommercial




Spine Surgery 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) Yes No 20930, 20931

Spine Surgery 20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) Yes No 20930, 20931

Spine Surgery 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) Yes No 20974, 20975, 20979

Spine Surgery 20975 Electrical stimulation to aid bone healing; invasive (operative) Yes No 20974, 20975, 20979

Spine Surgery 20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Yes No 20974, 20975, 20979

Spine Surgery 22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical Yes No 22100, 22101, 22103,

22110, 22112, 22116

Spine Surgery 22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic Yes No

22100, 22101, 22103, 22110, 22112, 22114,

22116

Spine Surgery 22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar Yes No 22101, 22102, 22103,

22112, 22114, 22116

Spine Surgery 22103Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure)

Yes No22100, 22101, 22103, 22110, 22112, 22114,

22116

Spine Surgery 22110 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical Yes No 22100, 22101, 22103,

22110, 22112, 22116

Spine Surgery 22112 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic Yes No

22100, 22101, 22103, 22110, 22112, 22114,

22116

Spine Surgery 22114 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar Yes No 22101, 22102, 22103,

22112, 22114, 22116

Network Health Plan WI - Prior Authorization Procedure List: Spine Surgery

V1.2019 Effective: 7/1/2019





Spine Surgery 22116Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)

Yes No22100, 22101, 22103, 22110, 22112, 22114,

22116

Spine Surgery 22206 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic Yes No

22206, 22207, 22208, 22210, 22212, 22214,

22216

Spine Surgery 22207 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar Yes No 22206, 22207, 22208,

22212, 22214, 22216

Spine Surgery 22208Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)

Yes No22206, 22207, 22208, 22210, 22212, 22214,

22216

Spine Surgery 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical Yes No 22206, 22208, 22210,

22212, 22214, 22216

Spine Surgery 22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic Yes No

22206, 22207, 22208, 22210, 22212, 22214,

22216

Spine Surgery 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar Yes No 22206, 22207, 22208,

22212, 22214, 22216

Spine Surgery 22216 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) Yes No

22206, 22207, 22208, 22210, 22212, 22214,

22216

Spine Surgery 22220 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical Yes No 22220, 22222, 22226

Spine Surgery 22222 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic Yes No 22220, 22222, 22224,

22226

Spine Surgery 22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar Yes No 22222, 22224, 22226

Spine Surgery 22226Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)

Yes No 22220, 22222, 22224, 22226

Spine Surgery 22505 Manipulation of spine requiring anesthesia, any region Yes No 22505

Spine Surgery 22510Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Yes No 22510, 22511, 22512, 22513, 22514, 22515

Spine Surgery 22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Yes No 22510, 22511, 22512,

22513, 22514, 22515

V1.2019 Effective: 7/1/2019





Spine Surgery 22512

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

Yes No 22510, 22511, 22512, 22513, 22514, 22515

Spine Surgery 22513

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

Yes No 22510, 22511, 22512, 22513, 22514, 22515

Spine Surgery 22514

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

Yes No 22510, 22511, 22512, 22513, 22514, 22515

Spine Surgery 22515

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

Yes No 22510, 22511, 22512, 22513, 22514, 22515

Spine Surgery 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level Yes No

22520, 22521, 22522, 22523, 22524, 22525,

22526, 22527

Spine Surgery 22527Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure)

Yes No22520, 22521, 22522, 22523, 22524, 22525,

22526, 22527

Spine Surgery 22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Yes No 22532, 22533, 22534

Spine Surgery 22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Yes No 22532, 22533, 22534

Spine Surgery 22534Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)

Yes No 22532, 22533, 22534

Spine Surgery 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process Yes No 22548, 22551, 22552,

22554, 22556, 22585

Spine Surgery 22551Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

Yes No 22548, 22551, 22552, 22554, 22556, 22585

V1.2019 Effective: 7/1/2019





Spine Surgery 22552

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)

Yes No22548, 22551, 22552, 22554, 22556, 22585,

22558

Spine Surgery 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 Yes No 22548, 22551, 22552,

22554, 22556, 22585

Spine Surgery 22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Yes No

22548, 22551, 22552, 22554, 22556, 22585,

22558

Spine Surgery 22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Yes No 22552, 22556, 22558,

22585

Spine Surgery 22585Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

Yes No22548, 22551, 22552, 22554, 22556, 22585,

22558

Spine Surgery 22586Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

Yes No 22586

Spine Surgery 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) Yes No22590, 22595, 22600, 22610, 22614, 22632,

22634

Spine Surgery 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) Yes No22590, 22595, 22600, 22610, 22614, 22632,

22634

Spine Surgery 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Yes No

22590, 22595, 22600, 22610, 22614, 22632,

22634

Spine Surgery 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) Yes No

22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) Yes No

22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) Yes No

22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Yes No

22610, 22612, 22614, 22630, 22632, 22633,

22634

V1.2019 Effective: 7/1/2019





Spine Surgery 22632Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

Yes No

22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22633Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

Yes No22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22634

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

Yes No

22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633,

22634

Spine Surgery 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Yes No 22800, 22802, 22804

Spine Surgery 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Yes No 22800, 22802, 22804

Spine Surgery 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Yes No 22800, 22802, 22804

Spine Surgery 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments Yes No 22808, 22810, 22812

Spine Surgery 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments Yes No 22808, 22810, 22812

Spine Surgery 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Yes No 22808, 22810, 22812

Spine Surgery 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments Yes No 22818, 22819

Spine Surgery 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments Yes No 22818, 22819

Spine Surgery 22830 Exploration of spinal fusion Yes No 22830

Spine Surgery 22840

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

Yes No 22840, 22841, 22842, 22843, 22844

Spine Surgery 22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Yes No 22840, 22841, 22842,

22843, 22844

V1.2019 Effective: 7/1/2019





Spine Surgery 22842Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

Yes No 22840, 22841, 22842, 22843, 22844

Spine Surgery 22843Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

Yes No 22840, 22841, 22842, 22843, 22844

Spine Surgery 22844Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

Yes No 22840, 22841, 22842, 22843, 22844

Spine Surgery 22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847

Spine Surgery 22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847

Spine Surgery 22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) Yes No 22845, 22846, 22847

Spine Surgery 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) Yes No 22848

Spine Surgery 22849 Reinsertion of spinal fixation device Yes No 22849

Spine Surgery 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) Yes No 22850

Spine Surgery 22853

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when conjunction with interbody arthrodesis, each interspace (List performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)

Yes No 22853, 22854, 22859

Spine Surgery 22854

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

Yes No 22853, 22854, 22859

Spine Surgery 22856Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

Yes No 22856, 22858 22861

V1.2019 Effective: 7/1/2019





Spine Surgery 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar Yes No 22857, 22862

Spine Surgery 22858

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

Yes No 22856, 22858 22861

Spine Surgery 22859

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous efect (List separately in addition to code for primary procedure)

Yes No 22853, 22854, 22859

Spine Surgery 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical Yes No 22856,22858, 22861

Spine Surgery 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar Yes No 22857, 22862

Spine Surgery 22867Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

Yes No 22867, 22868, 22869, 22870

Spine Surgery 22868Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)

Yes No 22867, 22868, 22869, 22870

Spine Surgery 22869Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level

Yes No 22867, 22868, 22869, 22870

Spine Surgery 22870Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)

Yes No 22867, 22868, 22869, 22870

Spine Surgery 27279Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

Yes No 27279, 27280, 27282, 27284, 27286

Spine Surgery 27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed Yes No 27279, 27280, 27282,

27284, 27286

V1.2019 Effective: 7/1/2019





Spine Surgery 62287

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

Yes No 62287

Spine Surgery 62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar Yes No 62292

Spine Surgery 62350Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy

Yes No 62350, 62351

Spine Surgery 62351Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy

Yes No 62350, 62351

Spine Surgery 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Yes No 62360, 62361, 62362

Spine Surgery 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump Yes No 62360, 62361, 62362

Spine Surgery 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Yes No 62360, 62361, 62362

Spine Surgery 62380Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

Yes No 62380

Spine Surgery 63001Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical

Yes No 63001, 63003, 63015, 63016

Spine Surgery 63003Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic

Yes No63001, 63003, 63005, 63012, 63015, 63016,

63017

Spine Surgery 63005Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

Yes No 63003, 63005, 63011, 63012, 63016, 63017

Spine Surgery 63011Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral

Yes No 63005, 63011, 63012, 63016, 63017

Spine Surgery 63012Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

Yes No 63003, 63005, 63011, 63012, 63016, 63017

V1.2019 Effective: 7/1/2019





Spine Surgery 63015Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical

Yes No 63001, 63003, 63015, 63016

Spine Surgery 63016Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic

Yes No63001, 63003, 63005, 63012, 63015, 63016,

63017

Spine Surgery 63017Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar

Yes No 63003, 63005, 63011, 63012, 63016, 63017

Spine Surgery 63020Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical

Yes No 63020, 63035, 63040, 63043

Spine Surgery 63030Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

Yes No 63030, 63035, 63042, 63044

Spine Surgery 63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

Yes No63020, 63030, 63035, 63040, 63042, 63043,

63044

Spine Surgery 63040Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical

Yes No 63020, 63035, 63043

Spine Surgery 63042Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

Yes No 63030, 63035, 63042, 63044

Spine Surgery 63043

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)

Yes No 63020, 63035, 63040, 63043

Spine Surgery 63044

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)

Yes No 63030, 63035, 63042, 63044

Spine Surgery 63045Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical

Yes No 63045, 63046, 63048

Spine Surgery 63046Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic

Yes No 63045, 63046, 63047, 63048

V1.2019 Effective: 7/1/2019





Spine Surgery 63047Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

Yes No 63046, 63047, 63048

Spine Surgery 63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

Yes No 63045, 63046, 63047, 63048

Spine Surgery 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; Yes No 63050, 63051

Spine Surgery 63051

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)

Yes No 63050, 63051

Spine Surgery 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic Yes No 63055, 63056, 63057

Spine Surgery 63056

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

Yes No 63055, 63056, 63057

Spine Surgery 63057Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)

Yes No 63055, 63056, 63057

Spine Surgery 63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment Yes No 63064, 63066

Spine Surgery 63066Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure)

Yes No 63064, 63066

Spine Surgery 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Yes No 63075, 63076, 63077,

63078

Spine Surgery 63076Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)

Yes No 63075, 63076, 63077, 63078

Spine Surgery 63077 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace Yes No 63075, 63076, 63077,

63078

Spine Surgery 63078Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure)

Yes No 63075, 63076, 63077, 63078

V1.2019 Effective: 7/1/2019





Spine Surgery 63081Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment

Yes No 63081, 63082

Spine Surgery 63082Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure)

Yes No 63081, 63082

Spine Surgery 63085Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment

Yes No 63085, 63086

Spine Surgery 63086Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure)

Yes No 63085, 63086

Spine Surgery 63087Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment

Yes No 63087, 63088

Spine Surgery 63088

Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure)

Yes No 63087, 63088

Spine Surgery 63090Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment

Yes No 63090, 63091

Spine Surgery 63091

Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure)

Yes No 63090, 63091

Spine Surgery 63101Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment

Yes No 63101, 63102, 63103

Spine Surgery 63102Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment

Yes No 63101, 63102, 63103

V1.2019 Effective: 7/1/2019





Spine Surgery 63103

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure)

Yes No 63101, 63102, 63103

Spine Surgery 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar Yes No 63170

Spine Surgery 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments Yes No 63180, 63182

Spine Surgery 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments Yes No 63180, 63182

Spine Surgery 63185 Laminectomy with rhizotomy; 1 or 2 segments Yes No 63185, 63190, 63295

Spine Surgery 63190 Laminectomy with rhizotomy; more than 2 segments Yes No 63185, 63190, 63295

Spine Surgery 63191 Laminectomy with section of spinal accessory nerve Yes No 63191

Spine Surgery 63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) Yes No

63172, 63173, 63185, 63190, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287,

63290, 63295

Spine Surgery 63650 Percutaneous implantation of neurostimulator electrode array, epidural Yes No 63650

Spine Surgery 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Yes No 63655

Spine Surgery 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Yes No 63663

Spine Surgery 63664Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

Yes No 63664

Spine Surgery 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Yes No 63685

V1.2019 Effective: 7/1/2019





Spine Surgery 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver Yes No 63688

Spine Surgery 0163TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure)

Yes No 0163T

Spine Surgery 0164T Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) Yes No 0164T

Spine Surgery 0165TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

Yes No 0165T

Spine Surgery 0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed

Yes No 0200T, 0201T

Spine Surgery 0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed

Yes No 0200T, 0201T

Spine Surgery 0202TPosterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine

Yes No 0202T

Spine Surgery 0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Spine Surgery 0214TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Spine Surgery 0215T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Spine Surgery 0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Spine Surgery 0217TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

V1.2019 Effective: 7/1/2019





Spine Surgery 0218T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Yes No 0213T, 0214T, 0215T, 0216T, 0217T, 0218T

Spine Surgery 0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical Yes No 0219T, 0220T, 0222T

Spine Surgery 0220T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic Yes No 0219T, 0220T, 0222T

Spine Surgery 0221T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar Yes No 0221T, 0220T, 0222T

Spine Surgery 0222T

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure)

Yes No 0219T, 0220T, 0221T, 0222T

Spine Surgery 0275T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Yes No 0275T

Spine Surgery C1767 Generator, neurostimulator (implantable), nonrechargeable No No C1767

Spine Surgery C1778 Lead, neurostimulator (implantable) No No C1778

Spine Surgery C1787 Patient programmer, neurostimulator No No C1787

Spine Surgery C1816 Receiver and/or transmitter, neurostimulator (implantable) No No C1816

Spine Surgery C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system No No C1820

Spine Surgery C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) No No C1883

Spine Surgery C1897 Lead, neurostimulator test kit (implantable) No No C1897

Spine Surgery E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications Yes No E0748

V1.2019 Effective: 7/1/2019





Spine Surgery E0749 Osteogenesis stimulator, electrical, surgically implanted Yes No E0749

Spine Surgery E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive Yes No E0760

Spine Surgery L8680 Implantable neurostimulator electrode, each Yes No L8680

Spine Surgery L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only Yes No L8681

Spine Surgery L8682 Implantable neurostimulator radiofrequency receiver Yes No L8682

Spine Surgery L8683 Radio frequency transmitter (external) for use with implantable neurostimulator radio frequency receiver Yes No L8683

Spine Surgery L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension Yes No L8685

Spine Surgery L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension Yes No L8686

Spine Surgery L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Yes No L8687

Spine Surgery L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension Yes No L8688

Spine Surgery L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only Yes No L8689

Spine Surgery L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only Yes No L8695

Spine Surgery S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar Yes No S2348

Spine Surgery S2350 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace Yes No S2350, S2351

Spine Surgery S2351Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace (List separately in addition to code for primary procedure)

Yes No S2350, S2351


V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 23000 Removal of subdeltoid calcareous deposits, open Yes Yes 23000, 23020

Joint Surgery 23020 Capsular contracture release (eg, Sever type procedure) Yes Yes 23000, 23020

Joint Surgery 23100 Arthrotomy, glenohumeral joint, including biopsy Yes Yes 23100, 23101, 23105, 23106, 23107

Joint Surgery 23101 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage Yes Yes 23100, 23101, 23105, 23106,

23107

Joint Surgery 23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy Yes Yes 23100, 23101, 23105, 23106, 23107

Joint Surgery 23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy Yes Yes 23100, 23101, 23105, 23106, 23107

Joint Surgery 23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body Yes Yes 23100, 23101, 23105, 23106,

23107

Joint Surgery 23120 Claviculectomy; partial Yes Yes 23120

Joint Surgery 23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release Yes Yes 23130

Joint Surgery 23190 Ostectomy of scapula, partial (eg, superior medial angle) Yes Yes 23190

Joint Surgery 23395 Muscle transfer, any type, shoulder or upper arm; single Yes Yes 23395, 23397, 23430, 23440

Joint Surgery 23397 Muscle transfer, any type, shoulder or upper arm; multiple Yes Yes 23395, 23397, 23430, 23440

Network Health Plan WIPrior Authorization Procedure List: Joint Services (Hip/Knee/Shoulder)


V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 23405 Tenotomy, shoulder area; single tendon Yes Yes 23405, 23406

Joint Surgery 23406 Tenotomy, shoulder area; multiple tendons through same incision Yes Yes 23405, 23406

Joint Surgery 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute Yes Yes 23410, 23412

Joint Surgery 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic Yes Yes 23410, 23412

Joint Surgery 23415 Coracoacromial ligament release, with or without acromioplasty Yes Yes 23415, 23420

Joint Surgery 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Yes Yes

23395, 23397, 23405, 23406, 23410, 23412, 23415, 23420,

23430, 23440

Joint Surgery 23430 Tenodesis of long tendon of biceps Yes Yes 23395, 23397, 23430, 23440

Joint Surgery 23440 Resection or transplantation of long tendon of biceps Yes Yes 23395, 23397, 23430, 23440

Joint Surgery 23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation Yes Yes 23450, 23455, 23460, 23462, 23465, 23466

Joint Surgery 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) Yes Yes 23450, 23455, 23460, 23462, 23465, 23466

Joint Surgery 23460 Capsulorrhaphy, anterior, any type; with bone block Yes Yes 23450, 23455, 23460, 23462, 23465, 23466

Joint Surgery 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer Yes Yes 23450, 23455, 23460, 23462, 23465, 23466

Joint Surgery 23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block Yes Yes 23450, 23455, 23460, 23462, 23465, 23470

Joint Surgery 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability Yes Yes 23450, 23455, 23460, 23462, 23465, 23470

Joint Surgery 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty Yes Yes 23470, 23472

Joint Surgery 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Yes Yes 23470, 23472

Joint Surgery 23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component Yes Yes 23473, 23472

Joint Surgery 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Yes Yes 23473, 23472

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 23480 Osteotomy, clavicle, with or without internal fixation; Yes Yes 23480

Joint Surgery 23800 Arthrodesis, glenohumeral joint; Yes Yes 23800, 23802

Joint Surgery 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) Yes Yes 23800, 23802

Joint Surgery 27033 Arthrotomy, hip, including exploration or removal of loose or foreign body Yes Yes 27033

Joint Surgery 27035 Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves Yes Yes 27035

Joint Surgery 27036Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas)

Yes Yes 27036

Joint Surgery 27050 Arthrotomy, with biopsy; sacroiliac joint Yes Yes 27050, 27052, 27054

Joint Surgery 27052 Arthrotomy, with biopsy; hip joint Yes Yes 27050, 27052, 27054

Joint Surgery 27054 Arthrotomy with synovectomy, hip joint Yes Yes 27050, 27052, 27054

Joint Surgery 27060 Excision; ischial bursa Yes Yes 27060, 27062,

Joint Surgery 27062 Excision; trochanteric bursa or calcification Yes Yes 27060, 27062,

Joint Surgery 27080 Coccygectomy, primary Yes Yes 27080

Joint Surgery 27090 Removal of hip prosthesis; (separate procedure) Yes Yes 27090, 27091

Joint Surgery 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer Yes Yes 27090, 27091

Joint Surgery 27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) Yes Yes 27122, 27125, 27130

Joint Surgery 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Yes Yes 27122, 27125, 27130

Joint Surgery 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Yes Yes 27122, 27125, 27130

Joint Surgery 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Yes Yes 27132

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft Yes Yes 27134, 27137, 27138

Joint Surgery 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft Yes Yes 27134, 27137, 27138

Joint Surgery 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft Yes Yes 27134, 27137, 27138

Joint Surgery 27140 Osteotomy and transfer of greater trochanter of femur (separate procedure) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27146 Osteotomy, iliac, acetabular or innominate bone; Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27147 Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27156 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip Yes Yes 27140, 27146, 27147, 27151,

27156, 27158, 27161, 27165

Joint Surgery 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27161 Osteotomy, femoral neck (separate procedure) Yes Yes 27140, 27146, 27147, 27151, 27156, 27158, 27161, 27165

Joint Surgery 27165 Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast Yes Yes 27140, 27146, 27147, 27151,

27156, 27158, 27161, 27165

Joint Surgery 27282 Arthrodesis, symphysis pubis (including obtaining graft) Yes Yes 27279, 27280, 27282, 27284, 27286

Joint Surgery 27284 Arthrodesis, hip joint (including obtaining graft); Yes Yes 27279, 27280, 27282, 27284, 27286

Joint Surgery 27286 Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy Yes Yes 27279, 27280, 27282, 27284, 27286

Joint Surgery 27330 Arthrotomy, knee; with synovial biopsy only Yes Yes 27330. 27331, 27332, 27333, 27334, 27335

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies Yes Yes 27330. 27331, 27332, 27333,

27334, 27335

Joint Surgery 27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral Yes Yes 27330. 27331, 27332, 27333,

27334, 27335

Joint Surgery 27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral Yes Yes 27330. 27331, 27332, 27333,

27334, 27335

Joint Surgery 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior Yes Yes 27330. 27331, 27332, 27333, 27334, 27335

Joint Surgery 27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area Yes Yes 27330. 27331, 27332, 27333, 27334, 27335

Joint Surgery 27340 Excision, prepatellar bursa Yes Yes 27340, 23745, 27347

Joint Surgery 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) Yes Yes 27340, 23745, 27347

Joint Surgery 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee Yes Yes 27340, 23745, 27347

Joint Surgery 27350 Patellectomy or hemipatellectomy Yes Yes 27350, 27420, 27422, 27424

Joint Surgery 27403 Arthrotomy with meniscus repair, knee Yes Yes 27403

Joint Surgery 27405 Repair, primary, torn ligament and/or capsule, knee; collateral Yes Yes 27405, 27407, 27409

Joint Surgery 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate Yes Yes 27405, 27407, 27409

Joint Surgery 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments Yes Yes 27405, 27407, 27409

Joint Surgery 27412 Autologous chondrocyte implantation, knee Yes Yes 27412, 27415, 27416

Joint Surgery 27415 Osteochondral allograft, knee, open Yes Yes 27412, 27415, 27416

Joint Surgery 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) Yes Yes 27412, 27415, 27416

Joint Surgery 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) Yes Yes 27418

Joint Surgery 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) Yes Yes 27350, 27420, 27422, 27424

Joint Surgery 27422 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) Yes Yes 27350, 27420, 27422, 27424

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 27424 Reconstruction of dislocating patella; with patellectomy Yes Yes 27350, 27420, 27422, 27424

Joint Surgery 27425 Lateral retinacular release, open Yes Yes 27425, 27427, 27428, 27429

Joint Surgery 27427 Ligamentous reconstruction (augmentation), knee; extra-articular Yes Yes 27425, 27427, 27428, 27429

Joint Surgery 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open) Yes Yes 27425, 27427, 27428, 27429

Joint Surgery 27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular Yes Yes 27425, 27427, 27428, 27429

Joint Surgery 27438 Arthroplasty, patella; with prosthesis Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27440 Arthroplasty, knee, tibial plateau; Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy Yes Yes 27438, 27440, 27441, 27442,

27443, 27445, 27446, 27447

Joint Surgery 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Yes Yes 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

Joint Surgery 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Yes Yes 27438, 27440, 27441, 27442,

27443, 27445, 27446, 27447

Joint Surgery 27486 Revision of total knee arthroplasty, with or without allograft; 1 component Yes Yes 27486, 27487, 27488

Joint Surgery 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Yes Yes 27486, 27487, 27488

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee Yes Yes 27486, 27487, 27488

Joint Surgery 27580 Arthrodesis, knee, any technique Yes Yes 27580

Joint Surgery 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29820 Arthroscopy, shoulder, surgical; synovectomy, partial Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29821 Arthroscopy, shoulder, surgical; synovectomy, complete Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29822 Arthroscopy, shoulder, surgical; debridement, limited Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29823 Arthroscopy, shoulder, surgical; debridement, extensive Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29826Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)

Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29828 Arthroscopy, shoulder, surgical; biceps tenodesis Yes Yes

29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827,

29828

Joint Surgery 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916

Joint Surgery 29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916

Joint Surgery 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum Yes Yes 29860, 29861, 29862, 29863,

29914, 29915, 29916

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29863 Arthroscopy, hip, surgical; with synovectomy Yes Yes 29860, 29861, 29862, 29863, 29914, 29915, 29916

Joint Surgery 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29873 Arthroscopy, knee, surgical; with lateral release Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29880Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29881Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Yes Yes

29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Joint Surgery 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863

V1.2019 Effective: 1/1/2019

Category CPT®





Joint Surgery 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863

Joint Surgery 29916 Arthroscopy, hip, surgical; with labral repair Yes Yes 29914, 29915, 29916, 29860, 29861, 29862, 29863


V1.2019 Effective: 10/31/2019

CPT® Code CPT® Code DescriptionCommercial




Brachytherapy

77750 Infusion or instillation of radioelement solution (includes 3-month follow-up care) Yes Yes 77750

77761 Intracavitary radiation source application; simple Yes Yes 77761

77762 Intracavitary radiation source application; intermediate Yes Yes 77761, 77762

77763 Intracavitary radiation source application; complex Yes Yes 77761, 77762, 77763

77767 HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel Yes Yes 77767

77768 HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions Yes Yes 77767, 77768

77770 HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel Yes Yes 77770

77771 HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 12 channels Yes Yes 77770, 77771

77772 HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels Yes Yes 77770, 77771, 77772

77778 Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed Yes Yes 77778

0394T HDR electronic brachytherapy, skin surface application, per fraction Yes Yes

0395T HDR electronic brachytherapy, interstitial or intracavitary treatment, per fraction Yes Yes

Network Health Plan WIPrior Authorization Procedure List: Radiation Therapy


V1.2019 Effective: 10/31/2019





Stereotactic Radiation Therapy

77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Yes Yes 77371

77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Yes Yes 77372, G0339

77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Yes Yes 77373, G0339, G0340

G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment Yes Yes G0339

G0340

Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment

Yes Yes G0340

Intensity Modulated Radiation Therapy (IMRT)

77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Yes Yes 77385

77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Yes Yes 77385, 77386

G6015Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session

Yes Yes G6015

G6016Compensator-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

Yes Yes G6015, G6016

V1.2019 Effective: 10/31/2019





Neutron Beam Radiation Therapy

77423High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)

Yes Yes 77423

Intraoperative Radiation Therapy (IORT)77424 Intraoperative radiation treatment delivery, x-ray, single treatment session Yes Yes 77424

77425 Intraoperative radiation treatment delivery, electrons, single treatment session Yes Yes 77425

Proton Beam Radiation Therapy77520 Proton treatment delivery; simple, without compensation Yes Yes 7752077522 Proton treatment delivery; simple, with compensation Yes Yes 77520, 7752277523 Proton treatment delivery; intermediate Yes Yes 77520, 77522, 77523

77525 Proton treatment delivery; complex Yes Yes 77520, 77522, 77523, 77525

Hyperthermia Treatment

77600 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) Yes Yes 77600

77605 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) Yes Yes 77600, 77605

77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators Yes Yes 77600, 77605, 77610

77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators Yes Yes 77600, 77605, 77610, 77615

77620 Hyperthermia generated by intracavitary probe(s) Yes Yes 77600, 77605, 77610, 77615, 77620

Radiation Treatment Management

G6017Intra-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

Yes Yes

V1.2019 Effective: 10/31/2019





Radiation Treatment Delivery77401 Radiation treatment delivery, superficial and/or ortho voltage, per day Yes Yes 7740177402 Radiation treatment delivery, >1 MeV; simple Yes Yes 77402

77407 Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks;>=1 MeV; intermediate Yes Yes 77402, 77407

77412

Radiation treatment delivery; three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam; >=1 MeV; complex

Yes Yes 77402, 77407, 77412

G6003 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5mev Yes Yes G6003

G6004 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-10mev Yes Yes G6003, G6004

G6005 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 11-19mev Yes Yes G6003, G6004, G6005

G6006 Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater Yes Yes G6003, G6004, G6005,

G6006

G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev Yes Yes G6003, G6004, G6005,

G6006, G6007

G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev Yes Yes G6003, G6004, G6005,

G6006, G6007, G6008

G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev Yes Yes

G6003, G6004, G6005,G6006, G6007, G6008,

G6009

G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater Yes Yes

G6003, G6004, G6005,G6006, G6007, G6008,

G6009, G6010

G6011Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev

Yes YesG6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011

G6012 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev Yes Yes

G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,

G6012

G6013Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev

Yes Yes

G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,

G6012, G6013

V1.2019 Effective: 10/31/2019





G6014Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater

Yes Yes

G6003, G6004, G6005,G6006, G6007, G6008, G6009, G6010, G6011,G6012, G6013, G6014

Radiologic Guidance77014 Computed tomography guidance for placement of radiation therapy fields Yes Yes 77014

77387 Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed Yes Yes 77387

G6001 Ultrasonic guidance for placement of radiation therapy fields Yes Yes G6001

G6002Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy Yes Yes G6001, G6002, 77014

Therapeutic Radiopharmaceuticals79101 Radiopharmaceutical, therapy, by intravenous administration Yes Yes 79101A9606 Radium RA-223 dichloride, therapeutic, per microcurie (Xofigo) Yes Yes A9606

79005 Radiopharmaceutical therapy, by oral administration; used for I-131 treatment Yes Yes 79005

79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion Yes Yes 79403

A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi Yes Yes A9513

A9543 Yttrium 90 Ibritumomab Tiuxetan (Zevalin) Yes Yes A9543

C9408 Iodine i-131 iobenguane, therapeutic, 1 millicurie No Yes C9408


Network Health of Wisconsin

The following codes are under management for members who have health benefits covered by Network Health of Wisconsin,administered by eviCore healthcare.

Lab Program Effective 2/1/2019

Procedure Code Full Description How Code is Managed Effective Date Termination DateLegend:

Requires Prior Authorization- Requests containing these codes should be submitted directly to eviCore

81162BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of largegene rearrangements

Requires Prior Authorization 01/01/16 None

81163 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis Requires Prior Authorization 01/01/19 None

81164 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None

81165 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequenceanalysis Requires Prior Authorization 01/01/19 None

81166 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; fullduplication/deletion anlaysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None

81167 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; fullduplication/deletion analysis (ie, detection of large gene rearrangements) Requires Prior Authorization 01/01/19 None

81173 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation)gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None

81174 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation)gene analysis; known familial variant Requires Prior Authorization 01/01/19 None

81185 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full genesequence Requires Prior Authorization 01/01/19 None

81186 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; knownfamilial variant Requires Prior Authorization 01/01/19 None

81189 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None81190 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant (s) Requires Prior Authorization 01/01/19 None

81201 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;full gene sequence Requires Prior Authorization 01/01/13 None

81202 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;known familial variants Requires Prior Authorization 01/01/13 None

81203 APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis;duplication/deletion variants Requires Prior Authorization 01/01/13 None

81212 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants Requires Prior Authorization 01/01/12 None

81215 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; known familial variant Requires Prior Authorization 01/01/12 None

81216 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None

81217 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; knownfamilial variant Requires Prior Authorization 01/01/12 None

81221 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familialvariants Requires Prior Authorization 01/01/12 None

Page 1 of 11

Procedure Code Full Description How Code is Managed Effective Date Termination Date

81222 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis;duplication/deletion variants Requires Prior Authorization 01/01/12 None

81223 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full genesequence Requires Prior Authorization 01/01/12 None

81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis,common variants (eg, *2, *3, *4, *8, *17) Requires Prior Authorization 01/01/12 None

81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) Requires Prior Authorization 01/01/12 None

81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *5, *6) Requires Prior Authorization 01/01/12 None

81228Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copynumber variants (eg, bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization[CGH] microarray analysis)


81229 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copynumber and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities Requires Prior Authorization 01/01/12 None

81230 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, commonvariant(s) (eg, *2, *22) Requires Prior Authorization 01/01/18 None

81231 CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, commonvariants (eg, *2, *3, *4, *5, *6, *7) Requires Prior Authorization 01/01/18 None

81232 DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), geneanalysis, common variant(s) (eg, *2A, *4, *5, *6) Requires Prior Authorization 01/01/18 None

81238 F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence Requires Prior Authorization 01/01/18 None

81248 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familialvariant(s) Requires Prior Authorization 01/01/18 None

81249 G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full genesequence Requires Prior Authorization 01/01/18 None

81252 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; fullgene sequence Requires Prior Authorization 01/01/13 None

81253 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; knownfamilial variants Requires Prior Authorization 01/01/13 None

81257HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean,alpha3.7, alpha4.2, alpha20.5, Constant Spring)


81258 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; known familial variant Requires Prior Authorization 01/01/18 None

81259 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; full gene sequence Requires Prior Authorization 01/01/18 None

81269 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbHdisease), gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/18 None

81277 Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy numberand loss-of-heterozygosity variants for chromosomal abnormalities Requires Prior Authorization 01/01/20 None

81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant Requires Prior Authorization 01/01/18 None81286 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None81289 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant (s) Requires Prior Authorization 01/01/19 None

81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, commonvariants (eg, 677T, 1298C) Requires Prior Authorization 01/01/12 None

81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None

81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None

81294 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None

Page 2 of 11


81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None

81296 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None

81297 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None

81298 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; full sequence analysis Requires Prior Authorization 01/01/12 None

81299 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; known familial variants Requires Prior Authorization 01/01/12 None

81300 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) geneanalysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None

81302 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None81303 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant Requires Prior Authorization 01/01/12 None81304 MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None81306 NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) Requires Prior Authorization 01/01/19 None81307 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence Requires Prior Authorization 01/01/20 None81308 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant Requires Prior Authorization 01/01/20 None

81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specificantigen]) ratio (eg, prostate cancer) Requires Prior Authorization 01/01/15 None

81317 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; full sequence analysis Requires Prior Authorization 01/01/12 None

81318 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; known familial variants Requires Prior Authorization 01/01/12 None

81319 PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) gene analysis; duplication/deletion variants Requires Prior Authorization 01/01/12 None

81321 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; full sequence analysis Requires Prior Authorization 01/01/13 None

81322 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; known familial variant Requires Prior Authorization 01/01/13 None

81323 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) geneanalysis; duplication/deletion variant Requires Prior Authorization 01/01/13 None

81325 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressurepalsies) gene analysis; full sequence analysis Requires Prior Authorization 01/01/13 None

81326 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressurepalsies) gene analysis; known familial variant Requires Prior Authorization 01/01/13 None

81327 SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis Requires Prior Authorization 01/01/17 None

81328 SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), geneanalysis, common variant(s) (eg, *5) Requires Prior Authorization 01/01/18 None

81335 TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) Requires Prior Authorization 01/01/18 None81336 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence Requires Prior Authorization 01/01/19 None

81337 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familialsequence variant(s) Requires Prior Authorization 01/01/19 None

81346 TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg,tandem repeat variant) Requires Prior Authorization 01/01/18 None

81350 UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugatedhyperbilirubinemia [Gilbert syndrome]) gene analysis, common variants (eg, *28, *36, *37) Requires Prior Authorization 01/01/12 None

81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, commonvariant(s) (eg, -1639G>A, c.173+1000C>T) Requires Prior Authorization 01/01/12 None

Page 3 of 11


81361 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); commonvariant(s) (eg, HbS, HbC, HbE) Requires Prior Authorization 01/01/18 None

81362 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familialvariant(s) Requires Prior Authorization 01/01/18 None

81363 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy);duplication/deletion variant(s) Requires Prior Authorization 01/01/18 None

81364 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full genesequence Requires Prior Authorization 01/01/18 None

81400 Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniquessuch as restriction enzyme digestion or melt curve analysis) Requires Prior Authorization 01/01/12 None

81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typicallyusing nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) Requires Prior Authorization 01/01/12 None

81402Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants[typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor generearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD])


81403Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletionvariants of 2-5 exons)


81404Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanningor duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat bySouthern blot analysis)


81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) Requires Prior Authorization 01/01/12 None

81406 Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of 26-50 exons) Requires Prior Authorization 01/01/12 None

81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutationscanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) Requires Prior Authorization 01/01/12 None

81408 Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) Requires Prior Authorization 01/01/12 None

81410Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV,arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes,including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK


81411Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV,arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2,MYH11, and COL3A1


81412Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familialdysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysispanel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP,MCOLN1, and SMPD1


81413Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergicpolymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A


81414Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergicpolymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2genes, including KCNH2 and KCNQ1


81415 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Requires Prior Authorization 01/01/15 None

81416 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparatorexome (eg, parents, siblings) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/15 None

81417 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtainedexome sequence (eg, updated knowledge or unrelated condition/syndrome) Requires Prior Authorization 01/01/15 None

81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chatsyndrome), circulating cell-free fetal DNA in maternal blood Requires Prior Authorization 01/01/17 None

81425 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Requires Prior Authorization 01/01/15 None

81426 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparatorgenome (eg, parents, siblings) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/15 None

Page 4 of 11


81427 Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtainedgenome sequence (eg, updated knowledge or unrelated condition/syndrome) Requires Prior Authorization 01/01/15 None

81430Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysispanel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1,MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1


81431 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysispanel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes Requires Prior Authorization 01/01/15 None

81432Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, alwaysincluding BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53


81433Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1,MSH2, and STK11


81434Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomicsequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS,PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A


81435Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11


81436Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes,including MLH1, MSH2, EPCAM, SMAD4, and STK11


81437Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignantpheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL


81438Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignantpheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB,SDHC, SDHD, and VHL


81439Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic rightventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN)


81440Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, mustinclude analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1,PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP


81442Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome,LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of atleast 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2,and SOS1


81443

Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg,Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachsdisease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, mustinclude sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR,DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)


81445Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis whenperformed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA,PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants orrearrangements, if performed


81448Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysispanel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2,MPZ, REEP1, SPAST, SPG11, SPTLC1)


81450Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNAanalysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS,KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants orrearrangements, or isoform expression or mRNA expression levels, if performed


81455

Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNAanalysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2,EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR,PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, ifperformed


Page 5 of 11


81460Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, andstroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, andretinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must includesequence analysis of entire mitochondrial genome with heteroplasmy detection


81465 Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressiveexternal ophthalmoplegia), including heteroplasmy detection, if performed Requires Prior Authorization 01/01/15 None

81470X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysispanel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2


81471X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion geneanalysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2


81479 Unlisted molecular pathology procedure Requires Prior Authorization 01/01/13 None

81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognosticalgorithm reported as a disease activity score Requires Prior Authorization 01/01/16 None

81493 Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing wholeperipheral blood, algorithm reported as a risk score Requires Prior Authorization 01/01/16 None

81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausalstatus, algorithm reported as a risk score Requires Prior Authorization 01/01/13 None

81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin,transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score Requires Prior Authorization 01/01/14 None

81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores Requires Prior Authorization 01/01/14 None

81518Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithms reported as percentage risk formetastatic recurrence and likelihood of benefit from extended endocrine therapy


81519 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixedparaffin-embedded tissue, algorithm reported as recurrence score Requires Prior Authorization 01/01/15 None

81520 Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score Requires Prior Authorization 01/01/18 None

81521Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeepinggenes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related torisk of distant metastasis


81522 Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping),utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score Requires Prior Authorization 01/01/20 None

81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score Requires Prior Authorization 01/01/16 None

81528Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRASmutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reportedas a positive or negative result


81535 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology,predictive algorithm reported as a drug response score; first single drug or drug combination Requires Prior Authorization 01/01/16 None

81536Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology,predictive algorithm reported as a drug response score; each additional single drug or drug combination (Listseparately in addition to code for primary procedure)


81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic andpredictive algorithm reported as good versus poor overall survival Requires Prior Authorization 01/01/16 None

81539 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA,and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score Requires Prior Authorization 01/01/17 None

81540Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype


81541Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specificmortality risk score


Page 6 of 11


81542 Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixedparaffin-embedded tissue, algorithm reported as metastasis risk score Requires Prior Authorization 01/01/20 None

81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as acategorical result (eg, benign or suspicious) Requires Prior Authorization 01/01/16 None

81551Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1),utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detectionon repeat biopsy


81552Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported asrisk of metastasis


81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score Requires Prior Authorization 01/01/16 None

81596Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin,apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scoresfor fibrosis and necroinflammatory activity in liver


81599 Unlisted multianalyte assay with algorithmic analysis Requires Prior Authorization 01/01/13 None84999 Unlisted chemistry procedure Requires Prior Authorization 01/01/93 None

0001U Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 bloodgroups, utilizing whole blood, common RBC alleles reported Requires Prior Authorization 02/01/17 None

0002MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT,haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported asquantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH)


0003MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT,haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported asquantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH)


0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithmreported as a risk score Requires Prior Authorization 01/01/13 None

0005U Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine,algorithm reported as risk score Requires Prior Authorization 05/01/17 None

0006M Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue,with alpha-fetoprotein level, algorithm reported as a risk classifier Requires Prior Authorization 01/01/15 None

0007M Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizingwhole peripheral blood, algorithm reported as a nomogram of tumor disease index Requires Prior Authorization 01/01/15 None

0011M Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR testutilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk Requires Prior Authorization 01/01/18 None

0012MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK,HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for havingurothelial carcinoma


0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, wholeblood, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None

0013MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK,HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for havingrecurrent urothelial carcinoma


0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing,DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None

0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome nextgenerationsequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s) Requires Prior Authorization 08/01/17 None

0018U Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate,algorithm reported as a positive or negative result for moderate to high risk of malignancy Requires Prior Authorization 10/01/17 None

0019U Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue orfresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents Requires Prior Authorization 10/01/17 None

0022UTargeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes,interrogation for sequence variants and rearrangements, reported as presence/absence of variants andassociated therapy(ies) to consider


Page 7 of 11


0026UOncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroidnodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or"Negative, low probability of malignancy")


0029U Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2,CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) Requires Prior Authorization 01/01/18 None

0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1,rs12777823) Requires Prior Authorization 01/01/18 None

0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, commonvariants (ie, *1F, *1K, *6, *7) Requires Prior Authorization 01/01/18 None

0032U COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant Requires Prior Authorization 01/01/18 None

0033UHTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citaloprammetabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G])


0034U TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), geneanalysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15*3, *4, *5) Requires Prior Authorization 01/01/18 None

0036U Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen,sequence analyses Requires Prior Authorization 04/01/18 None

0037UTargeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation forsequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumormutational burden


0045UOncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by realtime RT-PCR of 12 genes (7content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrencescore


0047U Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score Requires Prior Authorization 07/01/18 None

0048UOncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associatedgenes, including interrogation for somatic mutations and microsatellite instability, matched with normalspecimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)


0050U Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes,interrogation for sequence variants, copy number variants or rearrangements Requires Prior Authorization 07/01/18 None

0053U Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsyspecimen, algorithm reported as probability of higher tumor grade Requires Prior Authorization 07/01/18 None

0055U Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotidepolymorphism targets and two control targets), plasma Requires Prior Authorization 07/01/18 None

0056U Hematology (acute myelogenous leukemia), DNA, whole genome nextgeneration sequencing to detect generearrangement(s), blood or bone marrow, report of specific gene rearrangement(s) Requires Prior Authorization 07/01/18 None

0060U Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA inmaternal blood Requires Prior Authorization 07/01/18 None

0067UOncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [MMP-1], carcinoembryonic antigen-related cell adhesion molecule 6 [CEACAM6], hyaluronoglucosaminidase[HYAL1], highly expressed in cancer protein [HEC1]), formalin-fixed paraffin-embedded precancerous breasttissue, algorithm reported as carcinoma risk score


0069U Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin fixed paraffin-embeddedtissue, algorithm reported as an expression score Requires Prior Authorization 10/01/18 None

0070UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, commonand select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35,*36, *41, *57, *61, *63, *68, *83, *xN)


0071U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full genesequence (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None

0072U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None

0073U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/18 None

Page 8 of 11


0074UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition tocode for primary procedure)


0075UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, 5’ gene duplication/multiplication) (List separately in addition to code for primaryprocedure)


0076UCYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targetedsequence analysis (ie, 3’ gene duplication/ multiplication) (List separately in addition to code for primaryprocedure)


0078UPain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH,DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab orother germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder


0079U Comparative DNA analysis using multiple selected single-nucleotide polymorphisms (SNPs), urine and buccalDNA, for specimen identity verification Requires Prior Authorization 10/01/18 None

0081UOncology (uveal melanoma), mRNA, gene-expression profiling by real-time RT-PCR of 15 genes (12 content and3 housekeeping genes), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithmreported as risk of metastasis


0084U Red blood cell antigen typing, DNA, genotyping of 10 blood groups with phenotype prediction of 37 red blood cellantigens Requires Prior Authorization 07/01/19 None

0087U Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsytissue, allograft rejection and injury algorithm reported as a probability score Requires Prior Authorization 07/01/19 None

0088U Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizingtransplant biopsy tissue, algorithm reported as a probability score for rejection Requires Prior Authorization 07/01/19 None

0089U Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collectionusing adhesive patch(es) Requires Prior Authorization 07/01/19 None

0090UOncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie,benign, indeterminate, malignant)


0094U Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis Requires Prior Authorization 07/01/19 None

0101UHereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger,MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (15genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only])


0102UHereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arrayCGH, with mRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencingand deletion/duplication])


0103UHereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequenceanalysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolvevariants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM[deletion/duplication only])


0104UHereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditarycolorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arrayCGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes sequencingand deletion/duplication], EPCAM and GREM1 [deletion/duplication only])

Requires Prior Authorization 07/01/19 10/01/19

0111U Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) geneanalysis utilizing formalin-fixed paraffin-embedded tissue Requires Prior Authorization 10/01/19 None

0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostaticmassage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score Requires Prior Authorization 10/01/19 None

0114U Gastroenterology (Barrett’s esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithmreported as likelihood for Barrett’s esophagus Requires Prior Authorization 10/01/19 None

0118U Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generationsequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA Requires Prior Authorization 10/01/19 None

0120UOncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reportedas likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) withcell of origin subtyping in the latter


Page 9 of 11


0129UHereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2,CDH1, CHEK2, PALB2, PTEN, and TP53)


0130UHereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome,familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2,MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure)


0131UHereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code forprimary procedure)


0132UHereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditaryendometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code forprimary procedure)


0133U Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (Listseparately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None

0134UHereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditarycolorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code forprimary procedure)


0135UHereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer,hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition tocode for primary procedure)


0136U ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately inaddition to code for primary procedure) Requires Prior Authorization 10/01/19 None

0137U PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None

0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast andovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) Requires Prior Authorization 10/01/19 None

0153UOncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizingformalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s)with information on immune cell involvement


0156U Copy number (eg, intellectual disability, dysmorphology), sequence analysis Requires Prior Authorization 01/01/20 None

0157U APC (APC regulator of WNT signaling pathway) (eg, familial adenomatosis polyposis [FAP]) mRNA sequenceanalysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

0158U MLH1 (mutL homolog 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequenceanalysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

0159U MSH2 (mutS homolog 2) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

0160U MSH6 (mutS homolog 6) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (Listseparately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

0161U PMS2 (PMS1 homolog 2, mismatch repair system component) (eg, hereditary non-polyposis colorectal cancer,Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

0162U Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6,PMS2) (List separately in addition to code for primary procedure) Requires Prior Authorization 01/01/20 None

G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) Requires Prior Authorization 08/03/09 NoneS3800 Genetic testing for amyotrophic lateral sclerosis (als) Requires Prior Authorization 07/01/07 None

S3840 Dna analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasiatype 2 Requires Prior Authorization 07/01/03 None

S3841 Genetic testing for retinoblastoma Requires Prior Authorization 07/01/03 NoneS3842 Genetic testing for von hippel-lindau disease Requires Prior Authorization 07/01/03 NoneS3844 Dna analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness Requires Prior Authorization 07/01/03 NoneS3845 Genetic testing for alpha-thalassemia Requires Prior Authorization 07/01/03 NoneS3846 Genetic testing for hemoglobin e beta-thalassemia Requires Prior Authorization 07/01/03 NoneS3850 Genetic testing for sickle cell anemia Requires Prior Authorization 07/01/03 None

Page 10 of 11

Procedure Code Full Description How Code is Managed Effective Date Termination DateS3852 Dna analysis for apoe epsilon 4 allele for susceptibility to alzheimer's disease Requires Prior Authorization 07/01/03 NoneS3854 Gene expression profiling panel for use in the management of breast cancer treatment Requires Prior Authorization 01/01/06 None

S3861 Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (scn5a) and variants for suspectedbrugada syndrome Requires Prior Authorization 10/01/08 None

S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy Requires Prior Authorization 04/01/09 None

S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (hcm) in an individual with aknown hcm mutation in the family Requires Prior Authorization 04/01/09 None

S3870 Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorderand/or intellectual disability Requires Prior Authorization 04/01/09 None

Footer 1 CPT® copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of theAmerican Medical Association.

Footer 2 All procedure codes (81105-81599) included in a multiple procedure code panel are subject to medical necessityreview if any code requires prior authorization.

Page 11 of 11

Network Health (NWH-WI Medicare)

Primary Alt Descriptions HCPCS Codes Network Health (NWH-WIMedicare) Administration Technique Drug Class

5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary

Ado-Trastuzumab Emtansine Kadcyla J9354 Y INJECTABLE Primary

Aldesleukin Proleukin, Interleukin-2 J9015 Y INJECTABLE Primary

Arsenic Trioxide Trisenox J9017 Y INJECTABLE Primary

Asparaginase Erwinaze J9019 Y INJECTABLE Primary

Atezolizumab Tecentriq J9022 Y INJECTABLE Primary

Avelumab Bavencio J9023 Y INJECTABLE Primary

Azacitidine Vidaza J9025 Y INJECTABLE Primary

BCG TheraCys, Tice J9031 Y INJECTABLE Primary

Belinostat Beleodaq J9032 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) C9399 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary

Bendamustine Treanda J9033 Y INJECTABLE Primary

Bendamustine HCL Belrapzo C9042 Y INJECTABLE Primary

Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary

Bevacizumab Avastin J9035 Y INJECTABLE Primary

Bevacizumab-awwb (not currentlyavailable on the market)

Mvasi Q5107 Y INJECTABLE Primary

Bleomycin Blenoxane J9040 Y INJECTABLE Primary

Blinatumomab Blincyto J9039 Y INJECTABLE Primary

Bortezomib Velcade J9041 Y INJECTABLE Primary

Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary

Brentuximab Vedotin Adcetris J9042 Y INJECTABLE Primary

Cabazitaxel Jevtana J9043 Y INJECTABLE Primary

Calaspargase pegol-mknl Asparlas J3490 Y INJECTABLE Primary


Carboplatin Paraplatin J9045 Y INJECTABLE Primary

Carfilzomib Kyprolis J9047 Y INJECTABLE Primary

Carmustine BiCNU, BCNU J9050 Y INJECTABLE Primary

Cemiplimab-rwlc Libtayo C9399 Y INJECTABLE Primary

Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary


Cetuximab Erbitux J9055 Y INJECTABLE Primary

Cisplatin Platinol J9060 Y INJECTABLE Primary

Cladribine Leustatin J9065 Y INJECTABLE Primary

Page 1 of 6


Clofarabine Clolar J9027 Y INJECTABLE Primary

Copanlisib Aliqopa J9057 Y INJECTABLE Primary

Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Y INJECTABLE Primary

Cytarabine Ara-C J9100 Y INJECTABLE Primary

Cytarabine-Liposome DepoCyt J9098 Y INJECTABLE Primary

Dacarbazine DTIC-Dome J9130 Y INJECTABLE Primary

Dactinomycin Cosmegen, Actinomycin J9120 Y INJECTABLE Primary

Daratumumab Darzalex J9145 Y INJECTABLE Primary

Daunorubicin Cerubidine J9150 Y INJECTABLE Primary

Decitabine Dacogen J0894 Y INJECTABLE Primary

Degarelix Firmagon J9155 Y INJECTABLE Primary

Dinutuximab Unituxin C9399 Y INJECTABLE Primary

Dinutuximab Unituxin J9999 Y INJECTABLE Primary

Docetaxel Taxotere J9171 Y INJECTABLE Primary

Doxorubicin HCL Adriamycin J9000 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Lipodox Q2049 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Doxil Q2050 Y INJECTABLE Primary

Durvalumab Imfinzi J9173 Y INJECTABLE Primary

Elotuzumab Empliciti J9176 Y INJECTABLE Primary

Epirubicin Ellence J9178 Y INJECTABLE Primary

Eribulin mesylate Halaven J9179 Y INJECTABLE Primary

Etoposide - inj Toposar, VePesid, Etopophos J9181 Y INJECTABLE Primary

Floxuridine FUDR J9200 Y INJECTABLE Primary

Fludarabine Phosphate Fludara, Oforta J9185 Y INJECTABLE Primary

Fulvestrant Faslodex J9395 Y INJECTABLE Primary

Gemcitabine Gemzar J9201 Y INJECTABLE Primary

Gemcitabine HCL - NACL Infugem J3490 Y INJECTABLE Primary


Gemtuzumab Ozogamicin Mylotarg J9203 Y INJECTABLE Primary

Goserelin acetate implant Zoladex J9202 Y INJECTABLE Primary

Histrelin Implant Vantas J9225 Y INJECTABLE Primary

Idarubicin HCL - inj Idamycin J9211 Y INJECTABLE Primary

Ifosfamide Ifex, Mitoxana J9208 Y INJECTABLE Primary

Inotuzumab Ozogamicin Besponsa J9229 Y INJECTABLE Primary

Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary

Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary

Ipilumumab Yervoy J9228 Y INJECTABLE Primary

Page 2 of 6


Irinotecan Camptosar J9206 Y INJECTABLE Primary

Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary

Ixabepilone Ixempra J9207 Y INJECTABLE Primary

Lanreotide Somatuline Depot J1930 Y INJECTABLE Primary

Leucovorin - inj Leucovorin J0640 Y INJECTABLE Primary

Leuprolide Acetate Eligard, Lupron Depot, Lupron,Leuprolide Acetate

J1950 Y INJECTABLE Primary





Levoleucovorin Fusilev J0641 Y INJECTABLE Primary

Levoleucovorin Khapzory J3490 Y INJECTABLE Primary

Levoleucovorin Khapzory C9399 Y INJECTABLE Primary


Liposome-encapsulatedcombination of Daunorubicin andCytarabine

Vyxeos J9153 Y INJECTABLE Primary

Mechlorethamine HCL Mustragen J9230 Y INJECTABLE Primary

Melphalan HCL - inj Alkeran J9245 Y INJECTABLE Primary

Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Y INJECTABLE Primary

Methotrexate Sodium (J9260:50mg)

Folex, Methotrexate J9260 Y INJECTABLE Primary

Mitomycin Mutamycin J9280 Y INJECTABLE Primary

Mitoxantrone HCL Novantrone J9293 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti J9999 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti C9045 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo J9999 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo C9038 Y INJECTABLE Primary

Necitumumab Portrazza J9295 Y INJECTABLE Primary

Nelarabine Arranon J9261 Y INJECTABLE Primary

Nivolumab Opdivo J9299 Y INJECTABLE Primary

Obinutuzumab Gazyva J9301 Y INJECTABLE Primary

Octreotide depot Sandostatin J2353 Y INJECTABLE Primary

Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary

Ofatumumab Arzerra J9302 Y INJECTABLE Primary

Olaratumab Lartruvo J9285 Y INJECTABLE Primary

Omacetaxine Synribo J9262 Y INJECTABLE Primary

Oxaliplatin Eloxatin J9263 Y INJECTABLE Primary

Paclitaxel Nov-Onxol, Taxol J9267 Y INJECTABLE Primary

Paclitaxel (albumin-bound) Abraxane J9264 Y INJECTABLE Primary

Page 3 of 6


Panitumumab Vectibix J9303 Y INJECTABLE Primary

Pegaspargase Oncaspar J9266 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys S0145 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron J3590 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron S0148 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron C9399 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron J9999 Y INJECTABLE Primary

Pembrolizumab Keytruda J9271 Y INJECTABLE Primary

Pemetrexed Alimta J9305 Y INJECTABLE Primary

Pentostatin Nipent J9268 Y INJECTABLE Primary

Pertuzumab Perjeta J9306 Y INJECTABLE Primary

Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary

Pralatrexate Folotyn J9307 Y INJECTABLE Primary

Ramucirumab Cyramza J9308 Y INJECTABLE Primary

Rituximab Rituxan J9312 Y INJECTABLE Primary

Rituximab-abbs Truxima C9399 Y INJECTABLE Primary

Rituximab-abbs Truxima J3490 Y INJECTABLE Primary



Rituximab and HyaluronidaseHuman

Rituxan Hycela J9311 Y INJECTABLE Primary

Romidepsin Istodax J9315 Y INJECTABLE Primary

Siltuximab Sylvant J2860 Y INJECTABLE Primary

Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary

Streptozocin Zanosar J9320 Y INJECTABLE Primary

Tagraxofusp-erzs (not available tomarket yet)

Elzonris C9399 Y INJECTABLE Primary


Elzonris J9999 Y INJECTABLE Primary

Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary

Temozolomide - inj Temodar J9328 Y INJECTABLE Primary

Temsirolimus Torisel J9330 Y INJECTABLE Primary

Teniposide Vumon Q2017 Y INJECTABLE Primary

Thiotepa Thioplex J9340 Y INJECTABLE Primary

Tocilizumab Actemra J3262 Y INJECTABLE Primary

Topotecan - inj Hycamtin J9351 Y INJECTABLE Primary

Trabectedin Yondelis J9352 Y INJECTABLE Primary

Trastuzumab Herceptin J9355 Y INJECTABLE Primary

Page 4 of 6


Trastuzumab-dkst (Not currently onthe Market)

Ogiviri J3490 Y INJECTABLE Primary





Trastuzumab-dttb (Not currently onthe Market)

Ontruzant J3490 Y INJECTABLE Primary



Trastuzumab-pkrb Herzuma J3490 Y INJECTABLE Primary


Trastuzumab-qyyp Trazimera J3490 Y INJECTABLE Primary


Trastuzumab and hyaluronidase-oysk

Herceptin Hylecta J3490 Y INJECTABLE Primary



Triptorelin Pamoate Trelstar J3315 Y INJECTABLE Primary

Valrubicin Valstar J9357 Y INJECTABLE Primary

Vinblastine Sulfate Velban J9360 Y INJECTABLE Primary

Vincristine Sulfate Oncovin, Vincasar PFS J9370 Y INJECTABLE Primary

Vincristine Sulfate Liposome Marqibo J9371 Y INJECTABLE Primary

Vinorelbine Tartrate Navelbine J9390 Y INJECTABLE Primary

Zivafibercept Zaltrap J9400 Y INJECTABLE Primary

Capecitabine - oral Xeloda (150 mg) J8520 Y - Medicare Part B only ORAL Primary

Etoposide - oral Toposar J8560 Y - Medicare Part B only ORAL Primary

Temozolomide - oral Temodar J8700 Y - Medicare Part B only ORAL Primary

Topotecan - oral Hycamtin J8705 Y - Medicare Part B only ORAL Primary

Aprepitant Cinvanti J0185 Y INJECTABLE Supportive/Antiemetic

Darbepoetin alfa Aranesp J0881 Y INJECTABLE Supportive

Denosumab Xgeva, Prolia J0897 Y INJECTABLE Supportive

Epoetin alfa Epogen, Procrit J0885 Y INJECTABLE Supportive

Epoetin alfa-epbx Retacrit Q5106 Y INJECTABLE Supportive

Filgrastim Neupogen J1442 Y INJECTABLE Supportive

Filgrastim-aafi Nivestym Q5110 Y INJECTABLE Supportive

Filgrastim-sndz Zarxio Q5101 Y INJECTABLE Supportive

Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic

Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic

Ibandronate sodium (manage onlyfor NWH WI Medicare)

Boniva J1740 Y INJECTABLE Supportive

Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive

Page 5 of 6


Fosnetupitant/Palonosetron Akynzeo J1454 Y INJECTABLE Supportive/Antiemetic

Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic

Pamidronate Disodium Aredia J2430 Y INJECTABLE Supportive

Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive

Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive

Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive

Sargramostim Leukine J2820 Y INJECTABLE Supportive

Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive

Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive

Page 6 of 6

Network Health (NWH-WI Commercial)

Primary Alt Descriptions HCPCS Codes Network Health (NWH-WICommercia) Administration Technique Drug Class

5-Fluorouracil 5FU, Adrucil J9190 Y INJECTABLE Primary

Ado-Trastuzumab Emtansine Kadcyla J9354 Y INJECTABLE Primary

Aldesleukin Proleukin, Interleukin-2 J9015 Y INJECTABLE Primary

Arsenic Trioxide Trisenox J9017 Y INJECTABLE Primary

Asparaginase Erwinaze J9019 Y INJECTABLE Primary

Atezolizumab Tecentriq J9022 Y INJECTABLE Primary

Avelumab Bavencio J9023 Y INJECTABLE Primary

Azacitidine Vidaza J9025 Y INJECTABLE Primary

BCG TheraCys, Tice J9031 Y INJECTABLE Primary

Belinostat Beleodaq J9032 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) C9399 Y INJECTABLE Primary

Bendamustine Bendamustine (Not otherwise specified) J9999 Y INJECTABLE Primary

Bendamustine Treanda J9033 Y INJECTABLE Primary

Bendamustine HCL Belrapzo C9042 Y INJECTABLE Primary

Bendamustine HCL Bendeka J9034 Y INJECTABLE Primary

Bevacizumab Avastin J9035 Y INJECTABLE Primary

Bevacizumab-awwb (not currentlyavailable on the market)

Mvasi Q5107 Y INJECTABLE Primary

Bleomycin Blenoxane J9040 Y INJECTABLE Primary

Blinatumomab Blincyto J9039 Y INJECTABLE Primary

Bortezomib Velcade J9041 Y INJECTABLE Primary

Bortezomib Bortezomib (not otherwise specified) J9044 Y INJECTABLE Primary

Brentuximab Vedotin Adcetris J9042 Y INJECTABLE Primary

Cabazitaxel Jevtana J9043 Y INJECTABLE Primary



Carboplatin Paraplatin J9045 Y INJECTABLE Primary

Carfilzomib Kyprolis J9047 Y INJECTABLE Primary

Carmustine BiCNU, BCNU J9050 Y INJECTABLE Primary


Cemiplimab-rwlc Libtayo J9999 Y INJECTABLE Primary


Cetuximab Erbitux J9055 Y INJECTABLE Primary

Cisplatin Platinol J9060 Y INJECTABLE Primary

Cladribine Leustatin J9065 Y INJECTABLE Primary

Page 1 of 8


Clofarabine Clolar J9027 Y INJECTABLE Primary

Copanlisib Aliqopa J9057 Y INJECTABLE Primary

Cyclophosphamide - inj Cytoxan, Endoxan-Asta J9070 Y INJECTABLE Primary

Cytarabine Ara-C J9100 Y INJECTABLE Primary

Cytarabine-Liposome DepoCyt J9098 Y INJECTABLE Primary

Dacarbazine DTIC-Dome J9130 Y INJECTABLE Primary

Dactinomycin Cosmegen, Actinomycin J9120 Y INJECTABLE Primary

Daratumumab Darzalex J9145 Y INJECTABLE Primary

Daunorubicin Cerubidine J9150 Y INJECTABLE Primary

Decitabine Dacogen J0894 Y INJECTABLE Primary

Degarelix Firmagon J9155 Y INJECTABLE Primary

Dinutuximab Unituxin C9399 Y INJECTABLE Primary

Dinutuximab Unituxin J9999 Y INJECTABLE Primary

Docetaxel Taxotere J9171 Y INJECTABLE Primary

Doxorubicin HCL Adriamycin J9000 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Lipodox Q2049 Y INJECTABLE Primary

Doxorubicin HCL (liposomal) Doxil Q2050 Y INJECTABLE Primary

Durvalumab Imfinzi J9173 Y INJECTABLE Primary

Elotuzumab Empliciti J9176 Y INJECTABLE Primary

Epirubicin Ellence J9178 Y INJECTABLE Primary

Eribulin mesylate Halaven J9179 Y INJECTABLE Primary

Etoposide - inj Toposar, VePesid, Etopophos J9181 Y INJECTABLE Primary

Floxuridine FUDR J9200 Y INJECTABLE Primary

Fludarabine Phosphate Fludara, Oforta J9185 Y INJECTABLE Primary

Fulvestrant Faslodex J9395 Y INJECTABLE Primary

Gemcitabine Gemzar J9201 Y INJECTABLE Primary



Gemtuzumab Ozogamicin Mylotarg J9203 Y INJECTABLE Primary

Goserelin acetate implant Zoladex J9202 Y INJECTABLE Primary

Histrelin Implant Vantas J9225 Y INJECTABLE Primary

Idarubicin HCL - inj Idamycin J9211 Y INJECTABLE Primary

Ifosfamide Ifex, Mitoxana J9208 Y INJECTABLE Primary

Inotuzumab Ozogamicin Besponsa J9229 Y INJECTABLE Primary

Interferon, alfa-2b, recombinant Intron A J9214 Y INJECTABLE Primary

Interferon, gamma-1b Actimmune J9216 Y INJECTABLE Primary

Ipilumumab Yervoy J9228 Y INJECTABLE Primary

Page 2 of 8


Irinotecan Camptosar J9206 Y INJECTABLE Primary

Irinotecan Liposome Onivyde J9205 Y INJECTABLE Primary

Ixabepilone Ixempra J9207 Y INJECTABLE Primary

Lanreotide Somatuline Depot J1930 Y INJECTABLE Primary

Leucovorin - inj Leucovorin J0640 Y INJECTABLE Primary







Levoleucovorin Fusilev J0641 Y INJECTABLE Primary

Levoleucovorin Khapzory J3490 Y INJECTABLE Primary



Liposome-encapsulatedcombination of Daunorubicin andCytarabine

Vyxeos J9153 Y INJECTABLE Primary

Mechlorethamine HCL Mustragen J9230 Y INJECTABLE Primary

Melphalan HCL - inj Alkeran J9245 Y INJECTABLE Primary

Methotrexate Sodium (J9250: 5mg) Folex, Methotrexate J9250 Y INJECTABLE Primary

Methotrexate Sodium (J9260:50mg)

Folex, Methotrexate J9260 Y INJECTABLE Primary

Mitomycin Mutamycin J9280 Y INJECTABLE Primary

Mitoxantrone HCL Novantrone J9293 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti J9999 Y INJECTABLE Primary

Moxetumomab pasudotox-tdfk Lumoxiti C9045 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo J9999 Y INJECTABLE Primary

Mogamulizumab-kpkc Poteligeo C9038 Y INJECTABLE Primary

Necitumumab Portrazza J9295 Y INJECTABLE Primary

Nelarabine Arranon J9261 Y INJECTABLE Primary

Nivolumab Opdivo J9299 Y INJECTABLE Primary

Obinutuzumab Gazyva J9301 Y INJECTABLE Primary

Octreotide depot Sandostatin J2353 Y INJECTABLE Primary

Octreotide non-depot Sandostatin J2354 Y INJECTABLE Primary

Ofatumumab Arzerra J9302 Y INJECTABLE Primary

Olaratumab Lartruvo J9285 Y INJECTABLE Primary

Omacetaxine Synribo J9262 Y INJECTABLE Primary

Oxaliplatin Eloxatin J9263 Y INJECTABLE Primary

Paclitaxel Nov-Onxol, Taxol J9267 Y INJECTABLE Primary

Paclitaxel (albumin-bound) Abraxane J9264 Y INJECTABLE Primary

Page 3 of 8


Panitumumab Vectibix J9303 Y INJECTABLE Primary

Pegaspargase Oncaspar J9266 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys J3590 Y INJECTABLE Primary

Peginterferon, alfa-2a Pegasys S0145 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron J3590 Y INJECTABLE Primary

Peginterferon, alfa-2b PegIntron S0148 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron C9399 Y INJECTABLE Primary

Peginterferon, alfa-2b Sylatron J9999 Y INJECTABLE Primary

Pembrolizumab Keytruda J9271 Y INJECTABLE Primary

Pemetrexed Alimta J9305 Y INJECTABLE Primary

Pentostatin Nipent J9268 Y INJECTABLE Primary

Pertuzumab Perjeta J9306 Y INJECTABLE Primary

Porfimer Sodium Photofrin J9600 Y INJECTABLE Primary

Pralatrexate Folotyn J9307 Y INJECTABLE Primary

Ramucirumab Cyramza J9308 Y INJECTABLE Primary

Rituximab Rituxan J9312 Y INJECTABLE Primary

Rituximab-abbs Truxima C9399 Y INJECTABLE Primary




Rituximab and HyaluronidaseHuman

Rituxan Hycela J9311 Y INJECTABLE Primary

Romidepsin Istodax J9315 Y INJECTABLE Primary

Siltuximab Sylvant J2860 Y INJECTABLE Primary

Sipuleucel-T Provenge Q2043 Y INJECTABLE Primary

Streptozocin Zanosar J9320 Y INJECTABLE Primary


Elzonris C9399 Y INJECTABLE Primary


Elzonris J9999 Y INJECTABLE Primary

Talimogene Laherparepvec Imlygic J9325 Y INJECTABLE Primary

Temozolomide - inj Temodar J9328 Y INJECTABLE Primary

Temsirolimus Torisel J9330 Y INJECTABLE Primary

Teniposide Vumon Q2017 Y INJECTABLE Primary

Thiotepa Thioplex J9340 Y INJECTABLE Primary

Tocilizumab Actemra J3262 Y INJECTABLE Primary

Topotecan - inj Hycamtin J9351 Y INJECTABLE Primary

Trabectedin Yondelis J9352 Y INJECTABLE Primary

Trastuzumab Herceptin J9355 Y INJECTABLE Primary

Page 4 of 8




















Triptorelin Pamoate Trelstar J3315 Y INJECTABLE Primary

Valrubicin Valstar J9357 Y INJECTABLE Primary

Vinblastine Sulfate Velban J9360 Y INJECTABLE Primary

Vincristine Sulfate Oncovin, Vincasar PFS J9370 Y INJECTABLE Primary

Vincristine Sulfate Liposome Marqibo J9371 Y INJECTABLE Primary

Vinorelbine Tartrate Navelbine J9390 Y INJECTABLE Primary

Zivafibercept Zaltrap J9400 Y INJECTABLE Primary

Abemaciclib - oral Verzenio C9399 Y ORAL Primary

Abemaciclib - oral Verzenio J8999 Y ORAL Primary

Abiraterone Acetate - oral Zytiga (not interchangeable with Yonsa) J8999 Y ORAL Primary

Abiraterone Acetate - oral (Notcurrently on the market)

Yonsa (not interchangeable with Zytiga) J8999 Y ORAL Primary

Acalabrutinib Calquence C9399 Y ORAL Primary

Acalabrutinib Calquence J8999 Y ORAL Primary

Afatinib - oral Gilotrif J8999 Y ORAL Primary

Alectinib - oral Alecensa J8999 Y ORAL Primary

All-trans Retinoic Acid - oral Vesanoid, ATRA, Tretinoin J8999 Y ORAL Primary

Altretamine - oral Hexalen J8999 Y ORAL Primary

Apalutamide - oral Erleada J8999 Y ORAL Primary

Axitinib - oral Inlyta J8999 Y ORAL Primary

Bexarotene - oral Targretin J8999 Y ORAL Primary

Binimetinib - oral Mektovi J8999 Y ORAL Primary

Bosutinib - oral Bosulif J8999 Y ORAL Primary

Brigatinib - oral Alunbrig J8999 Y ORAL Primary

Page 5 of 8


Cabozantinib - oral Cabometyx J8999 Y ORAL Primary

Cabozantinib - oral Cometriq J8999 Y ORAL Primary

Capecitabine - oral Xeloda (150 mg) J8520 Y ORAL Primary

Capecitabine - oral Xeloda (500 mg) J8521 Y ORAL Primary

Ceritinib - oral Zykadia J8999 Y ORAL Primary

Chlorambucil - oral Leukeran J8999 Y ORAL Primary

Chlorambucil - oral Leukeran S0172 Y ORAL Primary

Cobimetinib - oral Cotellic J8999 Y ORAL Primary

Crizotinib - oral Xalkori J8999 Y ORAL Primary

Dabrafenib - oral Tafinlar J8999 Y ORAL Primary

Dacomitinib - oral Vizimpro J8999 Y ORAL Primary

Dasatinib - oral Sprycel J8999 Y ORAL Primary

Duvelisib - oral Copiktra J8999 Y ORAL Primary

Enasidenib - oral IDHIFA J8999 Y ORAL Primary

Encorafenib - oral Braftovi J8999 Y ORAL Primary

Enzalutamide - oral Xtandi J8999 Y ORAL Primary

Erdafitinib Balversa J8999 Y ORAL Primary

Erlotinib - oral Tarceva J8999 Y ORAL Primary

Estramustine - oral Emcyt J8999 Y ORAL Primary

Etoposide - oral Toposar J8560 Y ORAL Primary

Everolimus - oral Afinitor J8999 Y ORAL Primary

Exemestane - oral Aromasin J8999 Y ORAL Primary

Exemestane - oral Aromasin S0156 Y ORAL Primary

Fluoxymesterone - oral Androxy J8499 Y ORAL Primary

Gefitinib - oral Iressa J8565 Y ORAL Primary

Gilteritinib - oral Xospata J8999 Y ORAL Primary

Glasdegib - oral Daurismo J8999 Y ORAL Primary

Ibrutinib - oral Imbruvica J8999 Y ORAL Primary

Idarubicin - oral Idamycin J8999 Y ORAL Primary

Idelalisib - oral Zydelig J8999 Y ORAL Primary

Imatinib - oral Gleevec J8999 Y ORAL Primary

Imatinib - oral Gleevec S0088 Y ORAL Primary

Ivosidenib - oral Tibsovo J8999 Y ORAL Primary

Ixazomib - oral Ninlaro J8999 Y ORAL Primary

Lapatinib - oral Tykerb J8999 Y ORAL Primary

Larotrectinib - oral Vitrakvi J8999 Y ORAL Primary

Lenalidomide - oral Revlimid J8999 Y ORAL Primary

Page 6 of 8


Lenvatinib - oral Lenvima J8999 Y ORAL Primary

Leucovorin - oral , , , J8999 Y ORAL Primary

Lomustine - oral Gleostine, CeeNu, CCNU S0178 Y ORAL Primary

Lorlatinib - oral Lorbrena C9399 Y ORAL Primary

Lorlatinib - oral Lorbrena J8999 Y ORAL Primary

Midostaurin - oral Rydapt J8999 Y ORAL Primary

Mitotane - oral Lysodren J8999 Y ORAL Primary

Neratinib - oral Nerlynx J8999 Y ORAL Primary

Nilotinib - oral Tasigna J8999 Y ORAL Primary

Niraparib - oral Zejula J8999 Y ORAL Primary

Olaparib - oral Lynparza J8999 Y ORAL Primary

Osimertinib - oral Tagrisso J8999 Y ORAL Primary

Palbociclib - oral Ibrance J8999 Y ORAL Primary

Panobinostat - oral Farydak J8999 Y ORAL Primary

Pazopanib - oral Votrient J8999 Y ORAL Primary

Pomalidomide - oral Pomalyst J8999 Y ORAL Primary

Ponatinib - oral Iclusig J8999 Y ORAL Primary

Procarbazine - oral Matulane J8999 Y ORAL Primary

Procarbazine - oral Matulane S0182 Y ORAL Primary

Regorafenib - oral Stivarga J8999 Y ORAL Primary

Ribociclib - oral Kisqali J8999 Y ORAL Primary

Rucaparib - oral Rubraca J8999 Y ORAL Primary

Ruxolitinib - oral Jakafi J8999 Y ORAL Primary

Sonidegib - oral Odomzo J8999 Y ORAL Primary

Sorafenib Tosylate - oral Nexavar J8999 Y ORAL Primary

Sunitinib - oral Sutent J8999 Y ORAL Primary

Talazoparib - oral Talzenna J8999 Y ORAL Primary

Temozolomide - oral Temodar J8700 Y ORAL Primary

Thalidomide - oral Thalomid J8999 Y ORAL Primary

Topotecan - oral Hycamtin J8705 Y ORAL Primary

Trametinib - oral Mekinist J8999 Y ORAL Primary

Trifluridine/Tipiracil - oral Lonsurf J8999 Y ORAL Primary

Vandetanib - oral Caprelsa J8999 Y ORAL Primary

Vemurafenib - oral Zelboraf J8999 Y ORAL Primary

Venetoclax - oral Venclexta J8999 Y ORAL Primary

Vismodegib - oral Erivedge J8999 Y ORAL Primary

Vorinostat - oral Zolinza J8999 Y ORAL Primary

Page 7 of 8


5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex C9399 Y TOPICAL Primary

5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex J3490 Y TOPICAL Primary

5-Fluorouracil - topical 5FU Cream, Efudex, Carac, Fluoroplex J9999 Y TOPICAL Primary

Bexarotene - topical Targretin gel C9399 Y TOPICAL Primary

Bexarotene - topical Targretin gel J3490 Y TOPICAL Primary

Mechlorethamine - topical Valchlor J9999 Y TOPICAL Primary

Aprepitant Cinvanti J0185 Y INJECTABLE Supportive/Antiemetic

Darbepoetin alfa Aranesp J0881 Y INJECTABLE Supportive

Denosumab Xgeva, Prolia J0897 Y INJECTABLE Supportive

Epoetin alfa Epogen, Procrit J0885 Y INJECTABLE Supportive

Epoetin alfa-epbx Retacrit Q5106 Y INJECTABLE Supportive

Filgrastim Neupogen J1442 Y INJECTABLE Supportive

Filgrastim-aafi Nivestym Q5110 Y INJECTABLE Supportive

Filgrastim-sndz Zarxio Q5101 Y INJECTABLE Supportive

Fosaprepitant Emend J1453 Y INJECTABLE Supportive/Antiemetic

Granisetron Sustol J1627 Y INJECTABLE Supportive/Antiemetic

Lanreotide Somatuline Depot J1930 Y INJECTABLE Supportive

Fosnetupitant/Palonosetron Akynzeo J1454 Y INJECTABLE Supportive/Antiemetic

Palonosetron Aloxi J2469 Y INJECTABLE Supportive/Antiemetic

Pamidronate Disodium Aredia J2430 Y INJECTABLE Supportive

Pegfilgrastim Neulasta J2505 Y INJECTABLE Supportive

Pegfilgrastim-cbqv Udenyca Q5111 Y INJECTABLE Supportive

Pegfilgrastim-jmdb Fulphila Q5108 Y INJECTABLE Supportive

Sargramostim Leukine J2820 Y INJECTABLE Supportive

Tbo-filgrastim Granix J1447 Y INJECTABLE Supportive

Zoledronic Acid Zometa J3489 Y INJECTABLE Supportive

Aprepitant - oral Emend J8501 Y ORAL Supportive/Antiemetic

Netupitant/Palonosetron - oral Akynzeo J8655 Y ORAL Supportive/Antiemetic

Rolapitant - oral Varubi J8670 Y ORAL Supportive/Antiemetic

Telotristat ethyl - oral Xermelo J8999 Y ORAL Supportive

Granisetron - transdermal Sancuso J3490 Y TRANSDERMAL Supportive/Antiemetic

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comprehensive code list · 2019-12-18 · v1.2019 effective: 1/1/2019 category cpt® code. cpt ®...

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