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UnitedHealthcare Community Plan

STAR Kids Prior Authorization List

Category Code Description Bariatric Surgery 43644 LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM Bariatric Surgery 43645 LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ Bariatric Surgery 43647 LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM Bariatric Surgery 43648 LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM Bariatric Surgery 43659 UNLISTED LAPAROSCOPIC PROCEDURE STOMACH Bariatric Surgery 43770 LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE Bariatric Surgery 43771 LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE Bariatric Surgery 43772 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE Bariatric Surgery 43773 LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE Bariatric Surgery 43774 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE &PORT Bariatric Surgery 43775 LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY Bariatric Surgery 43842 GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY Bariatric Surgery 43843 GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP Bariatric Surgery 43845 GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM Bariatric Surgery 43846 GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< Bariatric Surgery 43847 GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ Bariatric Surgery 43848 REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE Bariatric Surgery 43860 REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY Bariatric Surgery 43865 REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY Bariatric Surgery 43881 IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN Bariatric Surgery 43882 REVISION/RMVL GASTRIC NSTIM ELTRDE ANTRUM OPEN Bariatric Surgery 43886 GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY Bariatric Surgery 43887 GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY Bariatric Surgery 43888 GSTR RSTCV OPN RMVL&RPLCMT SUBQ PORT Bariatric Surgery 64590 INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR Bariatric Surgery 95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG

UnitedHealthcare Community Plan STAR Kids Prior Authorization List

Bariatric Surgery 95981 ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG Bariatric Surgery 95982 ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG

Bariatric Surgery 0312T

Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming

Bariatric Surgery 0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator

Bariatric Surgery 0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator

Bariatric Surgery 0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator Bariatric Surgery 0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator

Bariatric Surgery 0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed

Bone Growth Stimulator 20974 ELECTRICAL STIMULATION BONE HEALING NONINVASIVE Bone Growth Stimulator 20975 ELECTRICAL STIMULATION BONE HEALING INVASIVE Bone Growth Stimulator 20979 LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE Bone Growth Stimulator E0747 OSTOGNS STIM ELEC NONINVASV OTH THAN SP APPLIC Bone Growth Stimulator E0748 OSTOGNS STIMULATOR ELEC NONINVASV SPINAL APPLIC Bone Growth Stimulator E0749 OSTEOGENESIS STIMULATOR ELEC SURGICALLY IMPL Bone Growth Stimulator E0760 Effective 12/7/15 for all others BRCA Genetic Testing 81162 BRCA1&BRCA2 FULL SEQ ANALYS/FULL DUP/DEL ANALYS BRCA Genetic Testing 81211 BRCA1&BRCA2 FULL SEQ ANALYS/COMM DUP/DEL BRCA1 BRCA Genetic Testing 81212 BRCA1&BRCA2 ANAL 185DELAG5385INSC/6174DELT BRCA Genetic Testing 81213 BRCA1&BRCA2 ANAL UNCOMMON DUP/DEL VARIANTS BRCA Genetic Testing 81214 BRCA1 FULL SEQ ANAL&COMMON DUP/DEL VARIANTS BRCA Genetic Testing 81215 BRCA1 GENE ANALYSIS KNOWN FAMILIAL VARIANT BRCA Genetic Testing 81216 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS BRCA Genetic Testing 81217 BRCA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT BRCA Genetic Testing 81432 HEREDITARY BRST CA-RELATED GEN SEQ ANALYS 14 GEN BRCA Genetic Testing 81433 HEREDITARY BRST CA-RELATED DUP/DEL ANALYSIS Breast Reconstruction (Non-Mastectomy) 19316 MASTOPEXY Breast Reconstruction 19318 REDUCTION MAMMAPLASTY


(Non-Mastectomy) Breast Reconstruction (Non-Mastectomy) 19324 MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT Breast Reconstruction (Non-Mastectomy) 19325 MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT Breast Reconstruction (Non-Mastectomy) 19328 REMOVAL INTACT MAMMARY IMPLANT Breast Reconstruction (Non-Mastectomy) 19330 REMOVAL MAMMARY IMPLANT MATERIAL Breast Reconstruction (Non-Mastectomy) 19340 IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ Breast Reconstruction (Non-Mastectomy) 19342 DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ Breast Reconstruction (Non-Mastectomy) 19350 NIPPLE/AREOLA RECONSTRUCTION Breast Reconstruction (Non-Mastectomy) 19357 BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ Breast Reconstruction (Non-Mastectomy) 19361 BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL Breast Reconstruction (Non-Mastectomy) 19364 BREAST RECONSTRUCTION FREE FLAP Breast Reconstruction (Non-Mastectomy) 19366 BREAST RECONSTRUCTION OTHER TECHNIQUE Breast Reconstruction (Non-Mastectomy) 19367 BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE Breast Reconstruction (Non-Mastectomy) 19368 BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST Breast Reconstruction (Non-Mastectomy) 19369 BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE Breast Reconstruction (Non-Mastectomy) 19370 OPEN PERIPROSTHETIC CAPSULOTOMY BREAST Breast Reconstruction (Non-Mastectomy) 19371 PERIPROSTHETIC CAPSULECTOMY BREAST Breast Reconstruction (Non-Mastectomy) 19380 REVISION RECONSTRUCTED BREAST


Breast Reconstruction (Non-Mastectomy) 19396 PREPARATION MOULAGE CUSTOM BREAST IMPLANT Breast Reconstruction (Non-Mastectomy) L8600 IMPLANTABLE BREAST PROSTHESIS SILICONE OR EQUAL Cardiology 33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial

Cardiology 33207 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular

Cardiology 33208 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

Cardiology 33212 Insertion of pacemaker pulse generator only; with existing single lead Cardiology 33213 Insertion of pacemaker pulse generator only; with existing dual leads

Cardiology 33214

Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new generator)

Cardiology 33221 Insertion of pacemaker pulse generator only; with existing multiple leads

Cardiology 33224

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, w/ attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)

Cardiology 33225

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)

Cardiology 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system

Cardiology 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system

Cardiology 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system

Cardiology 33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads Cardiology 33231 Insertion of implantable defibrillator pulse generator only; with existing multiple leads Cardiology 33240 Insertion of implantable defibrillator pulse generator only; with existing single lead

Cardiology 33249 Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

Cardiology 33262 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system


Cardiology 33263 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system

Cardiology 33264 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system

Cardiology 93303 Transthoracic echocardiography for congenital cardiac anomalies Cardiology 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study

Cardiology 93306

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

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

Cardiology 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

Cardiology 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

Cardiology 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

Cardiology 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

Cardiology 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

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

Cardiology 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

Cardiology 93456

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


Cardiology 93457

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

Cardiology 93458

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

Cardiology 93459

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

Cardiology 93460

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

Cardiology 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

Circumcision 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block

Circumcision 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)

Circumcision 54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age Circumcision 54162 Lysis or excision of penile post-circumcision adhesions Cochlear Implants and Other Auditory Implants 69710 IMPLTJ/RPLCMT EMGNT BONE CNDJ DEV TEMPORAL BONE Cochlear Implants and Other Auditory Implants 69714 IMPLTJ OSSEOINTEGRATED TEMPORAL BONE W/MASTOID Cochlear Implants and Other Auditory Implants 69715 IMPLJ OSSEOINTEGRATED TEMPORAL BONE W/O MASTOID Cochlear Implants and Other Auditory Implants 69717 RPLMCT OSSEOINTEGRATE IMPLNT W/O MASTOIDECTOMY Cochlear Implants and 69718 RPLMCT OSSEOINTEGRATE IMPLNT W/MASTOIDECTOMY


Other Auditory Implants Cochlear Implants and Other Auditory Implants 69930 COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY Cochlear Implants and Other Auditory Implants L8614 COCHLEAR DEVICE INCLUDES ALL INT&EXT COMPONENTS Cochlear Implants and Other Auditory Implants L8615 HEADSET/HEADPIECE COCHLEAR IMPLANT DEVICE REPL Cochlear Implants and Other Auditory Implants L8616 MICROPHONE COCHLEAR IMPLANT DEVICE REPLACEMENT Cochlear Implants and Other Auditory Implants L8617 TRANSMITTING COIL COCHLEAR IMPLANT DEVICE REPL Cochlear Implants and Other Auditory Implants L8618 TRANSMITTER CABLE COCHLEAR IMPLANT DEVICE REPL Cochlear Implants and Other Auditory Implants L8619 COCHLEAR IMPL EXT SPEECH PROCESSR/CONTROLLR REPL Cochlear Implants and Other Auditory Implants L8621 ZINC AIR BATTERY COCHLEAR IMPLANT DEVC REPL EA Cochlear Implants and Other Auditory Implants L8622 ALKALIN BATTRY COCHLEAR IMPL DEVC ANY SZ REPL EA Cochlear Implants and Other Auditory Implants L8623 LITHIUM ION BATTERY OTH THAN EAR LEVEL REPL EA Cochlear Implants and Other Auditory Implants L8624 LITHIUM ION BATTERY EAR LEVEL REPL EA Cochlear Implants and Other Auditory Implants L8627 COCHLEAR IMPL EXT SPEECH PROCESSR COMPONENT REPL Cochlear Implants and Other Auditory Implants L8628 COCHLEAR IMPLANT EXT CONTROLLER COMPONENT REPL Cochlear Implants and Other Auditory Implants L8690 AUDITORY OSSEOINTEGRATED DEVC INT/EXT COMPONENTS Cochlear Implants and Other Auditory Implants L8691 AUDITORY OSSEOINTEGRATD DEVC EXT SOUND PROC REPL Cochlear Implants and Other Auditory Implants L8692 AUDITORY OSSEOINTEGRATED DEV EXT SOUND BODY WORN Cochlear Implants and Other Auditory Implants L8693 AUD OSSEOINTEGRATED DEVC ABUT LENGTH REPL ONLY


Cosmetic & Reconstructive 11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ Cosmetic & Reconstructive 11971 REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS Cosmetic & Reconstructive 15820 BLEPHAROPLASTY LOWER EYELID Cosmetic & Reconstructive 15821 BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD Cosmetic & Reconstructive 15822 BLEPHAROPLASTY UPPER EYELID Cosmetic & Reconstructive 15823 BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN Cosmetic & Reconstructive 15830 EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY Cosmetic & Reconstructive 15847 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN Cosmetic & Reconstructive 15877 SUCTION ASSISTED LIPECTOMY TRUNK Cosmetic & Reconstructive 17106 DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM Cosmetic & Reconstructive 17107 DSTRJ CUTANEOUS VASCULAR LESIONS 10.0-50.0 SQ CM Cosmetic & Reconstructive 17108 DSTRJ CUTANEOUS VASCULAR LESIONS Greater than50.0 SQ CM Cosmetic & Reconstructive 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue Cosmetic & Reconstructive 21137 REDUCTION FOREHEAD CONTOURING ONLY Cosmetic & Reconstructive 21138 RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT Cosmetic & Reconstructive 21139 RDCTJ FHD CNTRG&SETBACK ANT FRONTAL SINUS WALL Cosmetic & Reconstructive 21172 RCNSTJ SUPERIOR-LATERAL ORBITAL RIM&LOWER FHD Cosmetic & Reconstructive 21175 RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS&LWR FHD Cosmetic & Reconstructive 21179 RCNSTJ FOREHEAD&/SUPRAORB RIMS W/ALGRF/PROSTC Cosmetic & Reconstructive 21180 RCNSTJ FOREHEAD&/SUPRAORBITAL RIMS W/AUTOGRAFT Cosmetic & Reconstructive 21181 RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC Cosmetic & Reconstructive 21182 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF <40SQCM Cosmetic & Reconstructive 21183 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 GRF Greater than40 <80SQCM Cosmetic & Reconstructive 21184 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRFGreater than80SQ CM Cosmetic & Reconstructive 21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR Cosmetic & Reconstructive 21235 GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR Cosmetic & Reconstructive 21256 RECONSTRUCTION ORBIT W/OSTEOTOMIES&BONE GRAFTS Cosmetic & Reconstructive 21260 PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL Cosmetic & Reconstructive 21261 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA&XTRC Cosmetic & Reconstructive 21263 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD Cosmetic & Reconstructive 21267 ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL Cosmetic & Reconstructive 21268 ORBITAL REPOSITIONING W/BONE GRAFTS ICRA&XTRC


Cosmetic & Reconstructive 21275 SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ Cosmetic & Reconstructive 21280 MEDIAL CANTHOPEXY SEPARATE PROCEDURE Cosmetic & Reconstructive 21282 LATERAL CANTHOPEXY Cosmetic & Reconstructive 21295 REDUCTION MASSETER MUSCLE&BONE EXTRAORAL Cosmetic & Reconstructive 21740 REPAIR PECTUS EXCAVATUM/CARINATUM OPEN Cosmetic & Reconstructive 21742 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC Cosmetic & Reconstructive 21743 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC Cosmetic & Reconstructive 28344 RECONSTRUCTION TOE POLYDACTYLY Cosmetic & Reconstructive 30540 REPAIR CHOANAL ATRESIA INTRANASAL Cosmetic & Reconstructive 30545 REPAIR CHOANAL ATRESIA TRANSPALATINE Cosmetic & Reconstructive 30560 LYSIS INTRANASAL SYNECHIA Cosmetic & Reconstructive 30620 SEPTAL/OTHER INTRANASAL DERMATOPLASTY Cosmetic & Reconstructive 67900 REPAIR BROW PTOSIS Cosmetic & Reconstructive 67901 RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL Cosmetic & Reconstructive 67902 RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING Cosmetic & Reconstructive 67903 RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL Cosmetic & Reconstructive 67904 RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL Cosmetic & Reconstructive 67906 RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING Cosmetic & Reconstructive 67908 RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ Cosmetic & Reconstructive 67909 REDUCTION OVERCORRECTION PTOSIS Cosmetic & Reconstructive 67911 CORRECTION LID RETRACTION Cosmetic & Reconstructive 67912 CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD Cosmetic & Reconstructive 67914 REPAIR ECTROPION SUTURE Cosmetic & Reconstructive 67915 REPAIR ECTROPION THERMOCAUTERIZATION Cosmetic & Reconstructive 67916 REPAIR ECTROPION EXCISION TARSAL WEDGE Cosmetic & Reconstructive 67917 REPAIR ECTROPION EXTENSIVE Cosmetic & Reconstructive 67921 REPAIR ENTROPION SUTURE Cosmetic & Reconstructive 67922 REPAIR ENTROPION THERMOCAUTERIZATION Cosmetic & Reconstructive 67923 REPAIR ENTROPION EXCISION TARSAL WEDGE Cosmetic & Reconstructive 67924 REPAIR ENTROPION EXTENSIVE Cosmetic & Reconstructive 67950 CANTHOPLASTY Cosmetic & Reconstructive 67961 EXCISION & REPAIR EYELID Greater than ONE-FOURTH LID MARGIN


Cosmetic & Reconstructive 67966 EXCISION & REPAIR EYELID ONE-FOURTH LID MARGIN/Greater than Cosmetic & Reconstructive Q2026 INJECTION RADIESSE 0.1ML DME Greater than $500 A9275 HOME GLUCOSE DISPBL MONITOR INCLUDES TEST STRIPS DME Greater than $500 A9279 MONITOR FEATURE/DEVC STAND-ALONE/INTEGRATED NOC DME Greater than $500 A9280 ALERT OR ALARM DEVICE NOT OTHERWISE CLASSIFIED DME Greater than $500 A9900 DME SUP/ACCESS/SRV-COMPON/OTH HCPCS DME Greater than $500 A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY NOS DME Greater than $500 E0193 POWERED AIR FLOTATION BED DME Greater than $500 E0194 AIR FLUIDIZED BED DME Greater than $500 E0265 HOSP BED TOT ELEC W/ANY TYPE SIDE RAIL W/MATTRSS DME Greater than $500 E0266 HOS BED TOT ELEC ANY TYPE SIDE RAIL W/O MATTRSS DME Greater than $500 E0270 HOSP BED INSTITUTIONAL TYPE: W/MATTRSS DME Greater than $500 E0274 OVER-BED TABLE DME Greater than $500 E0277 POWERED PRESSURE-REDUCING AIR MATTRESS DME Greater than $500 E0296 HOSPITAL BED TOTAL ELEC W/O SIDE RAILS W/MATTRSS DME Greater than $500 E0297 HOSP BED TOTAL ELEC W/O SIDE RAILS W/O MATTRSS DME Greater than $500 E0300 PEDIATRIC CRIB HOSPITAL GRADE FULLY ENCLOSED DME Greater than $500 E0302 HOS BED XTRA HEVY DUTY WT CAPGreater than600 PDS W/O MTTRSS DME Greater than $500 E0304 HOS BED EXTRA HEAVY DUTY WT CAPGreater than600 PDS MATTRSS DME Greater than $500 E0328 HOSPITAL BED PEDIATRIC MANUAL INCLUDES MATTRESS DME Greater than $500 E0329 HOSPITAL BED PEDIATRIC ELECTRIC INCLUDE MATTRESS DME Greater than $500 E0445 OXIMETER DEVICE MSR BLD O2 LEVLS NON-INVASV DME Greater than $500 E0457 CHEST SHELL DME Greater than $500 E0460 NEG PRESSURE VENTILATOR; PORTABLE/STATIONARY DME Greater than $500 E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) DME Greater than $500 E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)

DME Greater than $500 E0470

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

DME Greater than $500 E0471 RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACK-UP DME Greater than $500 E0472 RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACKUP DME Greater than $500 E0483 HI FREQ CHST WALL OSCILLAT AIR-PULSE GEN SYS EA


DME Greater than $500 E0485 ORL DEVC/APPL RDUC UP ARWAY COLLAPSIBILITY PRFAB DME Greater than $500 E0486 ORL DEVC/APPL RDUC UP AIRWAY COLLAPSIBILITY CSTM DME Greater than $500 E0601 CONTINUOUS AIRWAY PRESSURE DEVICE DME Greater than $500 E0620 SKIN PIERCING DEVICE CLCT CAPILLARY BLD LASER EA DME Greater than $500 E0636 MX PSTN PT SUPP SYS INTGR LIFT PT ACSSIBLE CNTRL DME Greater than $500 E0637 COMB SIT STAND FRAME/TABLE SYS SEATLIFT FEATURE DME Greater than $500 E0638 STANDING FRAME/TABLE SYS ONE POSITION ANY SZ DME Greater than $500 E0641 STANDING FRAME/TABLE SYS MULTI-POSITION ANY SZ DME Greater than $500 E0642 STANDING FRAME/TABLE SYS MOBILE DYNAMIC ANY SZ DME Greater than $500 E0650 PNEUMATIC COMPRESSOR NONSEGMENTAL HOME MODEL DME Greater than $500 E0651 PNEUMAT COMPRS SEG HOM MDL NO CALBRTD GRDNT PRSS DME Greater than $500 E0652 PNEUMAT COMPRS SEG HOM MDL W/CALBRTD GRADNT PRSS DME Greater than $500 E0656 SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS TRUNK DME Greater than $500 E0666 NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEG DME Greater than $500 E0667 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL LEG DME Greater than $500 E0668 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL ARM DME Greater than $500 E0669 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEG DME Greater than $500 E0670 SEG PNEUMATIC APPLI HALF ARM DME Greater than $500 E0671 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL LEG DME Greater than $500 E0672 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL ARM DME Greater than $500 E0673 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC HALF LEG DME Greater than $500 E0675 PNEUMAT COMPRS DEVC HI PRSS RAPID INFLATION/DEFL DME Greater than $500 E0691 UV LIGHT TX SYS BULB/LAMP TIMER; TX 2 SQ FT/LESS DME Greater than $500 E0692 UV LT TX SYS PANL W/BULB/LAMP TIMER 4 FT PANEL DME Greater than $500 E0693 UV LT TX SYS PANL W/BULBS/LAMPS TIMER 6 FT PANEL DME Greater than $500 E0694 UV MX DIR LT TX SYS 6 FT CABINET W/BULB/LAMP TMR DME Greater than $500 E0700 SAFETY EQUIPMENT DEVICE OR ACCESSORY ANY TYPE DME Greater than $500 E0710 RESTRAINT ANY TYPE DME Greater than $500 E0745 NEUROMUSCULAR STIMULATOR ELECTRONIC SHOCK UNIT DME Greater than $500 E0762 TRANSCUT ELEC JOINT STIM DEVC SYS INCL ALL ACCSS DME Greater than $500 E0764 FUNC NEUROMUSC STIM MUSC AMBUL CMPT CNTRL SC INJ DME Greater than $500 E0782 INFUSION PUMP IMPLANTABLE NON-PROGRAMMABLE


DME Greater than $500 E0783 INFUSION PUMP SYSTEM IMPLANTABLE PROGRAMMABLE DME Greater than $500 E0784 EXTERNAL AMBULATORY INFUSION PUMP INSULIN DME Greater than $500 E0786 IMPLANTABLE PROGRAMMABLE INFUSION PUMP REPL DME Greater than $500 E0947 FRACTURE FRAME ATTCH COMPLEX PELVIC TRACTION DME Greater than $500 E0948 FRACTURE FRAME ATTCH COMPLEX CERVICAL TRACTION DME Greater than $500 E0984 MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC DME Greater than $500 E0986 MNL WHLCHAIR ACSS PUSH ACTIVATED POWER ASSIST EA DME Greater than $500 E1002 WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLY DME Greater than $500 E1003 WC ACSS PWR SEAT SYS RECLINE W/O SHEAR RDUC DME Greater than $500 E1004 WC ACSS PWR SEAT SYS RECLINE W/MECH SHEAR RDUC DME Greater than $500 E1005 WC ACSS PWR SEAT SYS RECLINE W/PWR SHEAR RDUC DME Greater than $500 E1006 WC ACSS PWR SEAT SYS TILT&RECLINE NO SHEAR RDUC DME Greater than $500 E1007 WC ACSS PWR SEAT TILT&RECLINE MECH SHEAR RDUC DME Greater than $500 E1008 WC ACSS PWR SEAT TILT&RECLINE W/PWR SHEAR RDUC DME Greater than $500 E1009 WC ACCSS ADD PWR SEAT MECH LINKD LEG ELEV SYS EA DME Greater than $500 E1010 WC ACCSS ADD PWR SEAT SYS PWR LEG ELEV SYS PAIR DME Greater than $500 E1011 MOD PEDIATRIC SIZE WC WIDTH ADJUSTMENT PACKAGE DME Greater than $500 E1018 HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY PWR WC EA DME Greater than $500 E1030 WHEELCHAIR ACCESSORY VENTILATOR TRAY GIMBALED DME Greater than $500 E1035 MULTI-PSTN PT TRNSF SYS W/SEAT PT WT </= 300 LBS DME Greater than $500 E1036 MULTI-PSTN PT TRNSF SYS EXTRA WIDE PT Greater than300 LBS DME Greater than $500 E1085 HEMI-WHLCHAIR; FIX FULL ARMS DTACHBLE FOOTRESTS DME Greater than $500 E1086 HEMI-WHLCHAIR; DTACHBLE ARMS DESK/FULL FOOTRESTS DME Greater than $500 E1089 HI-STRGTH LGHTWT WHLCHAIR; FIX ARM DTACH FOOTRST DME Greater than $500 E1090 HI-STRGTH LGHTWT WHLCHAIR; DTACHBL ARMS FOOTREST DME Greater than $500 E1130 STD WHLCHAIR; FIX FULL-LEN ARMS DTACHBL FOOTRSTS DME Greater than $500 E1140 WHLCHAIR; DTACHBLE ARMS DTACHBLE FOOTRESTS DME Greater than $500 E1161 MANUAL ADULT SIZE WHEELCHAIR INCLUDES TILT SPACE DME Greater than $500 E1220 WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED DME Greater than $500 E1226 WHLCHAIR ACCESS MANUAL FULL RECLINING BACK EACH DME Greater than $500 E1229 WHEELCHAIR PEDIATRIC SIZE NOS DME Greater than $500 E1230 PWR OPERATED VEH SPEC BRAND NAME & MODEL NUMBER


DME Greater than $500 E1231 WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/SEAT SYS DME Greater than $500 E1232 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/SEAT SYS DME Greater than $500 E1233 WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/O SEAT DME Greater than $500 E1234 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/O SEAT DME Greater than $500 E1235 WHLCHAIR PED SIZE RIGD ADJUSTBL W/SEATING SYSTEM DME Greater than $500 E1236 WHLCHAIR PED SIZE FOLD ADJUSTBL W/SEATING SYSTEM DME Greater than $500 E1237 WHLCHAIR PED SZ RIGD ADJUSTBL W/O SEATING SYSTEM DME Greater than $500 E1238 WHLCHAIR PED SZ FOLD ADJUSTBL W/O SEATING SYSTEM DME Greater than $500 E1239 POWER WHEELCHAIR PEDIATRIC SIZE NOS DME Greater than $500 E1250 LGHTWT WHLCHAIR; FIX FULL ARMS DTACHBL FOOTRESTS DME Greater than $500 E1260 LGHTWT WHLCHAIR; DTACHBL ARMS DTACHBL FOOTRESTS DME Greater than $500 E1285 HEVY-DUTY WHLCHAIR; FIX ARMS DTACHBLE FOOTRESTS DME Greater than $500 E1290 HEVY-DUTY WC DTCHBL ARMS SWNG AWAY DTCHBL FTRST DME Greater than $500 E1300 WHIRLPOOL PORTABLE DME Greater than $500 E1310 WHIRLPOOL NONPORTABLE DME Greater than $500 E1399 DURABLE MEDICAL EQUIPMENT MISCELLANEOUS DME Greater than $500 E1825 DYN ADJUSTBL FNGR EXT/FLX DEVC W/SFT INTRFCE MAT DME Greater than $500 E1830 DYN ADJUSTBL TOE EXT/FLX DEVC W/SFT INTRFCE MATL DME Greater than $500 E1840 SOFT INTERFACE MATERIAL DME Greater than $500 E2100 BLD GLU MONITOR W/INTEGRATED VOICE SYNTHESIZER DME Greater than $500 E2204 MANUAL WC ACSS NONSTD SEAT FRME DEPTH 22-25 IN DME Greater than $500 E2227 MANUAL WC ACCESS GEAR REDUCTION DRIVE WHEEL EACH DME Greater than $500 E2228 MNL WC ACCESS WHEEL BRAKING SYS&LOCK COMPLETE EA DME Greater than $500 E2230 MANUAL WHEELCHAIR ACCESSORY MANUAL STANDING SYS DME Greater than $500 E2300 POWER WHEELCHAIR ACCESS POWER SEAT ELEV SYSTEM DME Greater than $500 E2301 POWER WHEELCHAIR ACCESSORY POWER STANDING SYSTEM DME Greater than $500 E2310 PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&ONE PWR DME Greater than $500 E2311 PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&TWO/MORE DME Greater than $500 E2312 POWER WC ACCESS HAND OR CHIN CONTROL INTERFACE DME Greater than $500 E2321 PWR WC ACSS HND CNTRL REMOT JOYSTCK NO PRPRTNL DME Greater than $500 E2322 PWR WC ACSS HND CNTRL MX MECH SWTCH NO PRPRTNL DME Greater than $500 E2325 PWR WC ACSS SIP&PUFF INTERFCE NONPROPRTNAL


DME Greater than $500 E2327 PWR WC ACSS HEAD CNTRL INTERFCE MECH PROPRTNAL DME Greater than $500 E2328 PWR WC ACSS HEAD CNTRL/EXT CNTRL ELEC PRPRTNL DME Greater than $500 E2329 PWR WC ACSS HEAD CNTRL CNTC SWTCH MECH NOPRPRTNL DME Greater than $500 E2330 PWR WC ACCSS HEAD PROX SWITCH MECH NONPRPRTNL DME Greater than $500 E2331 PWR WC ACSS ATTENDANT CONTROL PROPROTIONAL DME Greater than $500 E2343 PWR WC ACSS NONSTD SEAT FRME DEPTH 22-25 IN DME Greater than $500 E2351 PWR WC ACSS ELEC INTERFCE OPERATE SPCH GEN DEVC DME Greater than $500 E2370 PWR WC CMPNT MOTR&GEAR BOX COMB REPLCMT ONLY DME Greater than $500 E2373 PWR WC MINI-PROPORTIONAL COMPACT REMOTE JOYSTICK DME Greater than $500 E2375 PWR WC NONEXPNDABLE CONTROLLER REPLACEMENT ONLY DME Greater than $500 E2376 PWR WC EXPANDABLE CONTROLLER REPLACEMENT ONLY DME Greater than $500 E2510 SPCH GEN DEVC SYNTHESIZD MX METH MESS&DEVC ACCSS DME Greater than $500 E2511 SPEECH GEN SOFTWARE PROG PC/PERS DIGITAL ASSIST DME Greater than $500 E2512 ACCESS SPEECH GENERATING DEVICE MOUNTING SYSTEM DME Greater than $500 E2599 ACCESSORY FOR SPEECH GENERATING DEVICE NOC DME Greater than $500 E2614 PSTN WC BACK CUSHN POST WIDTH 22 IN/Greater than ANY HEIGHT DME Greater than $500 E2616 PSTN WC BACK CUSHN POSTLAT WIDTH 22 IN/Greater than ANY HT DME Greater than $500 E2620 PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH <22 IN DME Greater than $500 E2621 PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH 22 IN/Greater than DME Greater than $500 E2626 WC ACCESS SHLDR ELB MOBIL ARM SUPP WC ADJUSTBLE DME Greater than $500 E2627 WC ACCESS SHLDR ELB M ARM SUPP ADJUSTBL RANCHO DME Greater than $500 E2628 WC ACCESS SHLDR ELB MOBIL ARM SUPP WC RECLINING DME Greater than $500 E2629 WC ACCESS SHLDR ELB M ARM SUPP FRICTION ARM SUPP DME Greater than $500 E2630 WC ACCESS SHLDR ELB MOBIL MONOSUSP ARM HAND SUPP DME Greater than $500 E8000 GAIT TRAINER PED SZ POST SUPP W/ALL ACSS&CMPNTS DME Greater than $500 E8001 GAIT TRAINER PED SZ UPRT SUPP W/ALL ACSS&CMPNTS DME Greater than $500 E8002 GAIT TRAINER PED SZ ANT SUPP W/ALL ACSS&CMPNTS DME Greater than $500 K0005 ULTRALIGHTWEIGHT WHEELCHAIR DME Greater than $500 K0007 EXTRA HEAVY-DUTY WHEELCHAIR DME Greater than $500 K0008 Cstm manual wheelchair/base DME Greater than $500 K0011 STD-WT FRME MOTRIZD/PWR WHLCHAIR W/PROG CNTRL DME Greater than $500 K0013 Custom power whlchr base


DME Greater than $500 K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE DME Greater than $500 K0108 OTHER ACCESSORIES (MISCELLANEOUS) DME Greater than $500 K0606 AUTO EXT DEFIB W/INTGR ECG ANALY GARMENT TYPE DME Greater than $500 K0609 REPL ELEC W/AUTO EXT DEFIB GARMNT TYPE ONLY EA DME Greater than $500 K0730 CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM DME Greater than $500 K0800 PWR OP VEH GRP 1 STD PT WT CAP TO & INCL 300 LBS DME Greater than $500 K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds DME Greater than $500 K0802 PWR OP VEH GRP 1 VERY HEAVY DUTY PT 451-600 LBS DME Greater than $500 K0806 PWR OP VEH GRP 2 STD PT WT CAP TO & INCL 300 LBS DME Greater than $500 K0807 PWR OP VEH GRP 2 HEAVY DUTY PT 301 TO 450 LBS DME Greater than $500 K0808 PWR OP VEH GRP 2 VERY HEAVY DUTY PT 451-600 LBS DME Greater than $500 K0812 POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIED DME Greater than $500 K0821 PWR WC GRP 2 STD PORT CAPT CHAIR PT TO &=300 LBS DME Greater than $500 K0822 PWR WC GRP 2 STD SLING SEAT PT TO &=300 LBS DME Greater than $500 K0823 PWR WC GRP 2 STD CAPTAINS CHAIR PT TO &=300 LBS DME Greater than $500 K0824 PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBS DME Greater than $500 K0825 PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBS DME Greater than $500 K0826 PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LB DME Greater than $500 K0827 PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBS DME Greater than $500 K0828 PWR WC GRP 2 XTRA HVY DUTY SLING SEAT PT 601LB/Greater than DME Greater than $500 K0829 PWR WC GRP 2 XTRA HVY DUTY CHAIR PT 601 LBS/Greater than DME Greater than $500 K0830 PWR WC GRP 2 STD SEAT ELEV SLING PT TO &=300 LBS DME Greater than $500 K0831 PWR WC GRP 2 STD SEAT ELEV CAP CHR PT TO 300 LB DME Greater than $500 K0836 PWR WC GRP 2 STD 1 PWR CAPT CHAIR PT TO 300 LBS DME Greater than $500 K0837 PWR WC GRP 2 HVY 1 PWR SLING SEAT PT 301-450 LBS DME Greater than $500 K0838 PWR WC GRP 2 HVY 1 PWR CAPT CHAIR PT 301-450 LBS DME Greater than $500 K0839 PWR WC GRP 2 VRY HVY 1 PWR SLING PT 451-600 LBS DME Greater than $500 K0840 PWR WC GRP 2 XTRA HVY 1 PWR SLING PT 601 LBS/Greater than DME Greater than $500 K0841 PWR WC GRP 2 MX PWR SLING SEAT PT TO &=300 LBS DME Greater than $500 K0842 PWR WC GRP 2 STD MX PWR CAPT CHR PT TO &=300 LBS DME Greater than $500 K0843 PWR WC GRP 2 HVY MX PWR SLNG SEAT PT 301-450 LBS DME Greater than $500 K0848 PWR WC GRP 3 STD SLING SEAT PT TO & = 300 LBS


DME Greater than $500 K0849 PWR WC GRP 3 STD CAPTAIN CHAIR PT TO & = 300 LBS DME Greater than $500 K0850 PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBS DME Greater than $500 K0851 PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 301-450 LBS DME Greater than $500 K0852 PWR WC GRP 3 V HVY DUTY SLING SEAT PT 451-600 LB DME Greater than $500 K0853 PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 451-600 LBS DME Greater than $500 K0854 PWR WC GRP 3 XTRA HVY DTY SLNG SEAT PT 601 LBS/Greater than DME Greater than $500 K0855 PWR WC GRP 3X HVY DTY CHR PT WT CAP 601 LB/Greater than DME Greater than $500 K0856 PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO &=300 LB DME Greater than $500 K0857 PWR WC GRP 3 STD 1 PWR CAPT CHAIR PT TO &=300 LB DME Greater than $500 K0858 PWR WC GRP 3 HD 1 PWR SLING SEAT PT 301-450 LBS DME Greater than $500 K0859 PWR WC GRP 3 HD 1 PWR CAPT CHAIR PT 301-450 LBS DME Greater than $500 K0860 PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LB DME Greater than $500 K0861 PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO &=300 LB DME Greater than $500 K0862 PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBS DME Greater than $500 K0863 PWR WC GRP 3 V HD MX PWR SLNG SEAT PT 451-600 LB DME Greater than $500 K0864 PWR WC GRP 3 XTR HD MX PWR SLNG SEAT PT 601 LB/Greater than DME Greater than $500 K0868 PWR WC GRP 4 STD SLING SEAT PT TO & = 300 LBS DME Greater than $500 K0869 PWR WC GRP 4 STD CAPTAIN CHAIR PT TO & = 300 LBS DME Greater than $500 K0870 PWR WC GRP 4 HVY DUTY SLING SEAT PT 301-450 LBS DME Greater than $500 K0871 PWR WC GRP 4 V HVY DUTY SLING SEAT PT 451-600 LB DME Greater than $500 K0877 PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO &=300 LB DME Greater than $500 K0878 PWR WC GRP 4 STD 1 PWR CAPT CHAIR PT TO &=300 LB DME Greater than $500 K0879 PWR WC GRP 4 HD 1 PWR SLING SEAT PT 301-450 LBS DME Greater than $500 K0880 PWR WC GRP 4 V HD 1 PWR SLING SEAT PT 451-600 LB DME Greater than $500 K0884 PWR WC GRP 4 STD MX PWR SLNG SEAT PT TO &=300 LB DME Greater than $500 K0885 PWR WC GRP 4 STD MX PWR CAPT CHR PT TO &=300 LBS DME Greater than $500 K0886 PWR WC GRP 4 HD MX PWR SLING SEAT PT 301-450 LBS DME Greater than $500 K0890 PWR WC GRP 5 PED 1 PWR SLING SEAT PT TO &=125 LB DME Greater than $500 K0891 PWR WC GRP 5 PED MX PWR SLNG SEAT PT TO &=125 LB DME Greater than $500 K0898 POWER WHEELCHAIR NOT OTHERWISE CLASSIFIED DME Greater than $500 K0899 PWR MOBILTY DVC NOT CODED DME PDAC/NOT MEET CRIT DME Greater than $500 Q0479 POWER MODULE ELECTRIC/PNEUMATIC VAD REPLACE ONLY


DME Greater than $500 Q0480 DRIVER FOR USE WITH PNEUMATIC VAD REPL ONLY DME Greater than $500 Q0481 MICROPROCESSOR CNTRL UNIT FOR ELEC VAD REPL ONLY DME Greater than $500 Q0482 MICROPROCESSOR CU FOR ELEC/PNEUMAT VAD REPL ONL DME Greater than $500 Q0483 MONITOR/DISPLAY MODULE FOR ELEC VAD REPL ONLY DME Greater than $500 Q0484 MONITOR FOR ELEC OR ELEC/PNEUMAT VAD REPL ONLY DME Greater than $500 Q0488 POWER PACK BASE FOR USE W/ELEC VAD REPL ONLY DME Greater than $500 Q0489 POWER PACK BASE FOR ELEC/PNEUMAT VAD REPL ONLY DME Greater than $500 Q0490 EMERGENCY POWER SOURCE FOR ELEC VAD REPL ONLY DME Greater than $500 Q0491 EMERG POWER SRC FOR ELEC/PNEUMAT VAD REPL ONLY DME Greater than $500 Q0495 BATT CHRGR ELEC OR ELEC/PNEUMAT VAD REPL ONLY DME Greater than $500 Q0496 BATTERY NOT LITHIUM-ION ELEC/PNEUMAT VAD REPL DME Greater than $500 Q0502 MOBILITY CART FOR PNEUMATIC VAD REPL ONLY DME Greater than $500 Q0503 BATTERY FOR PNEUMATIC VAD REPLACEMENT ONLY EACH DME Greater than $500 Q0504 POWER ADAPTER FOR PNEUMAT VAD REPL ONLY VEH TYPE DME Greater than $500 Q0506 BATTERY LITHIUM-ION ELEC/PNEUMATIC VAD REPL DME Greater than $500 T1999 MISC TX ITEMS & SPL RETAIL PURCHASE NOC DME Greater than $500 T5999 SUPPLY NOT OTHERWISE SPECIFIED DME Greater than $500 V2786 SPECIALTY OCCUPATIONAL MULTIFOCAL LENS PER LENS DME Greater than $500 V5268 Assistive listening device, telephone amplifier, any type DME Greater than $500 V5269 Assistive listening device, alerting, any type DME Greater than $500 V5270 Assistive listening device, television amplifier, any type DME Greater than $500 V5271 Assistive listening device, television caption decoder DME Greater than $500 V5272 Assistive listening device, tdd DME Greater than $500 V5274 Assistive listening device, not otherwise specified

DME Greater than $500 V5281 Assistive listening device, personal fm/dm system, monaural, (1 receiver, transmitter, microphone), any type

DME Greater than $500 V5282 Assistive listening device, personal fm/dm system, binaural, (2 receivers, transmitter, microphone), any type

DME Greater than $500 V5283 Assistive listening device, personal fm/dm neck, loop induction receiver DME Greater than $500 V5284 Assistive listening device, personal fm/dm, ear level receiver DME Greater than $500 V5285 Assistive listening device, personal fm/dm, direct audio input receiver DME Greater than $500 V5286 Assistive listening device, personal blue tooth fm/dm receiver


DME Greater than $500 V5287 Assistive listening device, personal fm/dm receiver, not otherwise specified DME Greater than $500 V5288 Assistive listening device, personal fm/dm transmitter assistive listening device DME Greater than $500 V5289 Assistive listening device, personal fm/dm adapter/boot coupling device for receiver, any type DME Greater than $500 V5290 Assistive listening device, transmitter microphone, any type Enteral Services B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE FED PER DAY Enteral Services B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY Enteral Services B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED PER DAY Enteral Services B4100 FOOD THICKENER ADMINISTERED ORALLY PER OUNCE Enteral Services B4102 ENTRAL FORMULA ADLT REPL FLS&LYTES 500 ML = 1 U Enteral Services B4103 ENTRAL FORMULA PED REPL FLS&LYTES 500 ML = 1 U Enteral Services B4104 ADDITIVE FOR ENTERAL FORMULA Enteral Services B4149 ENTRAL F MANF BLNDRIZD NAT FOODS W/NUTRIENTS Enteral Services B4150 ENTRAL F NUTRITIONALLY CMPL W/INTACT NUTRIENTS Enteral Services B4152 ENTRAL F NUTRITION CMPL CAL DENSE INTACT NUTRNTS Enteral Services B4153 ENTRAL FORMULA NUTIONALLY CMPL HYDROLYZED PROTS Enteral Services B4154 ENTRAL F NUTRITION CMPL NO INHERITED DZ METAB Enteral Services B4155 ENTRAL F NUTRITIONALLY INCMPL/MODULAR NUTRIENTS Enteral Services B4157 ENTRAL F NUTRITION CMPL INHERITED DZ METAB Enteral Services B4158 ENTRAL F PED NUTRITION CMPL W/INTACT NUTRNTS Enteral Services B4159 ENTRAL F PED NUTRITN CMPL SOY BASD INTCT NUTRNTS Enteral Services B4160 ENTRAL F PED NUTRITION CMPL CAL DENSE NUTRNTS Enteral Services B4161 ENTRAL F PED HYDROLYZED/AA&PEPTIDE CHAIN PROTS Enteral Services B4162 ENTRAL F PED SPCL METAB NEEDS INHERITED DZ METAB Enteral Services B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM Enteral Services B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM Enteral Services B9998 NOC FOR ENTERAL SUPPLIES Enteral Services B9999 NOC FOR PARENTERAL SUPPLIES Experimental & Investigational 33477

Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

Experimental & Investigational 36514 THERAPEUTIC APHERESIS PLASMA PHERESIS Experimental & Investigational 54240 PENILE PLETHYSMOGRAPY


Experimental & Investigational 55866 LAPS PROSTECT RETROPUBIC RAD W/NRV SPARING ROBOT Experimental & Investigational 61863 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY Experimental & Investigational 61864 STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY Experimental & Investigational 61867 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY Experimental & Investigational 61868 STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY Experimental & Investigational 61886 INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/Greater than ELTRDS Experimental & Investigational 62264 PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY Experimental & Investigational 62290 INJECTION PX DISCOGRAPHY EACH LEVEL LUMBAR Experimental & Investigational 62291 INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC Experimental & Investigational 62292 INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC Experimental & Investigational 64555 PRQ IMPLTJ NEUROSTIMULATOR ELTRD PERIPHERAL NRV Experimental & Investigational 64566 POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE Experimental & Investigational 64722 DECOMPRESSION UNSPECIFIED NERVE Experimental & Investigational 65765 KERATOPHAKIA Experimental & Investigational 65767 EPIKERATOPLASTY Experimental & Investigational 66180 AQUEOUS SHUNT EXTRAOCULAR RESERVOIR Experimental & Investigational 95250 GLUC MNTR CONT REC FROM INTERSTITIAL TISS FLUID Experimental & 95251 GLUC MNTR CONT REC FROM NTRSTL TISS FLU I&R


Investigational Experimental & Investigational 95965 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY Experimental & Investigational 95966 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY Experimental & Investigational 95967 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL Experimental & Investigational 95978 ELEC ALYS NSTIM PLS GEN CPLX DP BRN 1ST HR Experimental & Investigational 96002 DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC Experimental & Investigational 0085T BREATH TEST HEART TRANSPLANT REJECTION Experimental & Investigational 0191T ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT Experimental & Investigational 0269T REV/REMVL CRTD SNS BRORFLX ACTV DEV TOT SYS Experimental & Investigational 0270T REV/REMVL CRTD SNS BRORFLX ACTV DEV LEAD UNI Experimental & Investigational 0271T REV/REMVL CRTD SNS BRORFLX ACTV DEV PLS GEN Experimental & Investigational 0282T PERC/OPEN IMPLNT NEUROSTIM ELECTRODE SUBQ TRIAL Experimental & Investigational 0283T PERC/OPEN IMPLNT NEUROSTIM ELECTRODE SUBQ PERM Experimental & Investigational 0285T ELEC ANLYS IMPLANT SUBQ FIELD STIM PG REPROGRAMM Experimental & Investigational A4638 REPLACEMENT BATTRY PT-OWNED EAR PULSE GEN EA Experimental & Investigational A6000 NON-CNTC WND WARMING WND COVR W/DEVC&CARD Experimental & Investigational A9274 EXTERNAL AMB INSULIN DEL SYSTEM DISPOSABLE EA Experimental & Investigational A9276 SENSOR;INVSV DISP INTRSTL CONT GLU MON SYS 1U=1D


Experimental & Investigational A9277 TRANSMITTER; EXT INTERSTITIAL CONT GLU MON SYS Experimental & Investigational A9278 RECEIVER MON; EXT INTERSTITIAL CONT GLU MON SYS Experimental & Investigational E0231 NON-CNTC WND WARMING DEVC W/WARMING CARD&COVR Experimental & Investigational E1831 STATIC PROGRESSIVE STRETCH TOE DEVICE Experimental & Investigational S0810 PHOTOREFRACTIVE KERATECTOMY Experimental & Investigational S1030 CONT NONINVASIVE GLU MONITORING DEVICE PURCHASE Experimental & Investigational S1031 CONT NONINVAS GLU MON DEVC RENTAL SENSOR REPL Experimental & Investigational S1040 CRANIAL REMOLDING ORTHOTIC PED RIGID CUSTOM FAB Experimental & Investigational S2102 ISLET CELL TISS TRANSPLANT FROM PANC; ALLOGENEIC Experimental & Investigational S3652 SALIVA TST HORMONE LEVL; ASSESS PRTERM LABR RISK Experimental & Investigational S8262 MANDIBULAR ORTHOPEDIC REPOSITIONING DEVICE EACH Experimental & Investigational S9988 SERV PROVIDED AS PART OF PHASE 1 CLINICAL TRIAL Experimental & Investigational S9990 SERVICES PROVIDED AS PART PHASE II CLIN TRIAL Experimental & Investigational S9991 SERVICES PROVIDED AS PART PHASE III CLIN TRIAL Femoroacetabular Impingement Syndrome (FAI) 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) Femoroacetabular Impingement Syndrome (FAI) 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) Femoroacetabular 29916 Arthroscopy, hip, surgical; with labral repair


Impingement Syndrome (FAI) Functional Endoscopic Sinus Surgery (FESS) 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy Functional Endoscopic Sinus Surgery (FESS) 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection Functional Endoscopic Sinus Surgery (FESS) 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) Functional Endoscopic Sinus Surgery (FESS) 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) Functional Endoscopic Sinus Surgery (FESS) 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy Functional Endoscopic Sinus Surgery (FESS) 31267

Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus

Functional Endoscopic Sinus Surgery (FESS) 31276

Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

Functional Endoscopic Sinus Surgery (FESS) 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy Functional Endoscopic Sinus Surgery (FESS) 31288

Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

Home Health Care 99503 HOME VISIT RESPIRATORY THERAPY CARE Home Health Care G0151 SERVICE PHYS THERAP HOME HLTH/HOSPICE EA 15 MIN Home Health Care G0152 SERVICE OCCUP THERAP HOME HLTH/HOSPICE EA 15 MIN Home Health Care G0153 SRVC SPCH&LANG PATH HOME HLTH/HOSPICE EA 15 MIN Home Health Care G0155 SRVC CLINICAL SOCIAL WORKER HH/HOSPICE EA 15 MIN Home Health Care G0156 SRVC HH/HOSPICE AIDE IN HH/HOSPICE SET EA 15 MIN Home Health Care G0157 SERVICES PT ASSIST HOME HEALTH/HOSPICE EA 15 MIN Home Health Care G0158 SERVICE OT ASSIST HOME HEALTH/HOSPICE EA 15 MIN Home Health Care G0159 SERVICES PT HOME HEALTH EST/DEL PT MP EA 15 MINS

Home Health Care G0160

Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and Effective occupational therapy maintenance program, each 15 minutes



Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and Effective speech-language pathology maintenance program, each 15 minutes


Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home health or hospice setting)

Home Health Care G0163 SKILLED SERVICE LPN/RN OBS & ASSESS PT EA 15 MIN Home Health Care G0164 SKL SRVC LPN/RN TRN&/ED PT/FAM HH/HOSPICE 15 MIN

Home Health Care G0299 Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes

Home Health Care G0300 Direct skilled nursing services of a license practical nurse (lpn) in the home health or hospice setting, each 15 minutes

Home Health Care S9122 HOM HLTH AIDE/CERT NURSE ASST PROV CARE HOM;-HR Home Health Care S9123 NURSING CARE THE HOME; REGISTERED NURSE PER HOUR Home Health Care S9124 NURSING CARE IN THE HOME; BY LPN PER HOUR Home Health Care S9127 SOCIAL WORK VISIT IN THE HOME PER DIEM Home Health Care S9128 SPEECH THERAPY IN THE HOME PER DIEM Home Health Care S9129 OCCUPATIONAL THERAPY IN THE HOME PER DIEM Home Health Care S9131 PHYSICAL THERAPY; IN THE HOME PER DIEM Home Health Care S9474 ENTRSTML TX REGISTERED NRS CERT ENTRSTML TX-DIEM Home Health Care T1021 Home health aide or certified nurse assistant, per visit Hospice T2042 Hospice routine home care; per diem Hospice T2043 Hospice continuous home care; per hour Hospice T2044 Hospice inpatient respite care; per diem Hospice T2045 Hospice general inpatient care; per diem Injectable Medications - Acthar J0800 INJECTION CORTICOTROPIN UP TO 40 UNITS Injectable Medications - Botulinum Toxin J0585 BOTULINUM TOXIN TYPE A PER UNIT Injectable Medications - Botulinum Toxin J0586 INJECTION ABOBOTULINUMTOXINA 5 UNITS Injectable Medications - Botulinum Toxin J0587 INJECTION RIMABOTULINUMTOXINB 100 UNITS Injectable Medications - J0588 INJECTION INCOBOTULINUMTOXIN A 1 UNIT


Botulinum Toxin Injectable Medications - IVIG 90283 IMMUNE GLOBULIN IGIV HUMAN IV USE Injectable Medications - IVIG 90284 IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA Injectable Medications - IVIG J1459 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1556 Injection, immune globulin (bivigam), 500 mg Injectable Medications - IVIG J1557 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1559 INJECTION IMMUNE GLOBULIN HIZENTRA 100 MG Injectable Medications - IVIG J1561 INJECTION IMMUNE GLOBULIN NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1566 INJ IG IV LYPHILIZED NOT OTHERWISE SPEC 500 MG Injectable Medications - IVIG J1568 INJ IG OCTOGAM IV NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1569 INJ IG GAMMAGARD LIQ IV NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1572 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG Injectable Medications - IVIG J1575 Injection, immune globulin/hyaluronidase, (HyQvia), 100 mg immuneglobulin Injectable Medications - IVIG J1599 INJ IG IV NONLYOPHILIZED E.G. LIQUID NOS 500 MG Injectable Medications - Makena/17P J1725 INJECTION HYDROXYPROGESTERONE CAPROATE 1 MG Injectable Medications - Makena/17P J2675 INJECTION PROGESTERONE PER 50 MG Injectable Medications - Synagis 90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E Injectable Medications - Xolair J2357 INJECTION OMALIZUMAB 5 MG


Joint Replacement 23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY Joint Replacement 23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER

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

Joint Replacement 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Joint Replacement 24360 ARTHROPLASTY ELBOW W/MEMBRANE Joint Replacement 24361 ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT Joint Replacement 24362 ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ Joint Replacement 24363 ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCMT

Joint Replacement 24370 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component

Joint Replacement 24371 Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar componen

Joint Replacement 27120 ACETABULOPLASTY Joint Replacement 27122 ACETABULOPLASTY RESECTION FEMORAL HEAD Joint Replacement 27125 HEMIARTHROPLASTY HIP PARTIAL Joint Replacement 27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT Joint Replacement 27132 CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT Joint Replacement 27134 REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT Joint Replacement 27137 REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT Joint Replacement 27138 REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT Joint Replacement 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE Joint Replacement 27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT Joint Replacement 27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT CMPRTS Joint Replacement 27486 REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT Joint Replacement 27487 REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONENT Joint Replacement 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST Joint Replacement 29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT

Joint Replacement 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or latera

Joint Replacement J7330 AUTOLOGOUS CULTURED CHONDROCYTES IMPLANT Joint Replacement S2112 ARTHROSCOPY KNEE SURGICAL HARVESTING CARTILAGE


Medical Policy Alignment 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less Medical Policy Alignment 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc Medical Policy Alignment 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc Medical Policy Alignment 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc Medical Policy Alignment 15570 Formation of direct or tubed pedicle, with or without transfer; trunk Medical Policy Alignment 15732 MUSCLE-SKIN GRAFT HEAD/NECK Medical Policy Alignment 15736 MUSCLE-SKIN GRAFT ARM Medical Policy Alignment 15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel Medical Policy Alignment 15775 Punch graft for hair transplant; 1 to 15 punch grafts Medical Policy Alignment 15776 Punch graft for hair transplant; more than 15 punch grafts Medical Policy Alignment 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) Medical Policy Alignment 15781 Dermabrasion; segmental, face Medical Policy Alignment 15782 Dermabrasion; regional, other than face Medical Policy Alignment 15783 Dermabrasion; superficial, any site, (eg, tattoo removal) Medical Policy Alignment 15786 Abrasion; single lesion (eg, keratosis, scar)

Medical Policy Alignment 15787 Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure)

Medical Policy Alignment 15788 Chemical peel, facial; epidermal Medical Policy Alignment 15789 Chemical peel, facial; dermal Medical Policy Alignment 15792 Chemical peel, nonfacial; epidermal Medical Policy Alignment 15793 Chemical peel, nonfacial; dermal Medical Policy Alignment 15819 Cervicoplasty Medical Policy Alignment 15824 Rhytidectomy; forehead Medical Policy Alignment 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Medical Policy Alignment 15826 Rhytidectomy; glabellar frown lines Medical Policy Alignment 15828 Rhytidectomy; cheek, chin, and neck Medical Policy Alignment 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Medical Policy Alignment 15832 EXCISE EXCESSIVE SKIN TISSUE Medical Policy Alignment 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Medical Policy Alignment 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Medical Policy Alignment 15835 EXCISE EXCESSIVE SKIN TISSUE Medical Policy Alignment 15836 EXCISE EXCESSIVE SKIN TISSUE


Medical Policy Alignment 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Medical Policy Alignment 15838 EXCISE EXCESSIVE SKIN TISSUE Medical Policy Alignment 15839 EXCISE EXCESSIVE SKIN TISSUE Medical Policy Alignment 15876 Suction assisted lipectomy; head and neck Medical Policy Alignment 15878 SUCTION ASSISTED LIPECTOMY Medical Policy Alignment 15879 SUCTION ASSISTED LIPECTOMY Medical Policy Alignment 17380 Electrolysis epilation, each 30 minutes Medical Policy Alignment 20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less

Medical Policy Alignment 21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

Medical Policy Alignment 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) Medical Policy Alignment 21243 RECONSTRUCTION OF JAW JOINT Medical Policy Alignment 21270 Malar augmentation, prosthetic material Medical Policy Alignment 22103 REMOVE EXTRA SPINE SEGMENT Medical Policy Alignment 22116 REMOVE EXTRA SPINE SEGMENT Medical Policy Alignment 22208 CUT SPINE 3 COL ADDL SEG Medical Policy Alignment 22216 REVISE EXTRA SPINE SEGMENT Medical Policy Alignment 22222 REVISION OF THORAX SPINE Medical Policy Alignment 22226 REVISE EXTRA SPINE SEGMENT Medical Policy Alignment 22505 Manipulation of spine requiring anesthesia, any region

Medical Policy Alignment 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level

Medical Policy Alignment 22527

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

Medical Policy Alignment 22534 LAT THOR/LUMB ADDL SEG Medical Policy Alignment 22552 REMOVE NECK DISK; FUSE S Medical Policy Alignment 22585 ADDITIONAL SPINAL FUSION Medical Policy Alignment 22614 SPINE FUSION EXTRA SEGMENT Medical Policy Alignment 22632 SPINE FUSION EXTRA SEGMENT Medical Policy Alignment 22634 ARTHDSIS POST/POSTERLATRL/POSTINTRBD Medical Policy Alignment 22840 INSERT SPINE FIXATION DEVICE


Medical Policy Alignment 22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

Medical Policy Alignment 22842 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22843 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22844 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22845 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22846 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22847 INSERT SPINE FIXATION DEVICE Medical Policy Alignment 22848 INSERT PELV FIXATION DEVICE Medical Policy Alignment 22851 APPLY SPINE PROSTH DEVICE Medical Policy Alignment 22857 LUMBAR ARTIF DISKECTOMY Medical Policy Alignment 22862 REVISE LUMBAR ARTIF DISC Medical Policy Alignment 25259 Manipulation, wrist, under anesthesia Medical Policy Alignment 27194 TREAT PELVIC RING FRACTURE Medical Policy Alignment 27275 Manipulation, hip joint, requiring general anesthesia Medical Policy Alignment 27415 OSTEOCHONDRAL KNEE ALLOGRAFT Medical Policy Alignment 27416 OSTEOCHONDRAL KNEE AUTOGRAFT Medical Policy Alignment 27445 ARTHROPLASTY KNEE HINGE PROSTHESIS

Medical Policy Alignment 27860 Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

Medical Policy Alignment 28446 Open osteochondral autograft, talus (includes obtaining graft[s])


Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia

Medical Policy Alignment 30120 Excision or surgical planing of skin of nose for rhinophyma


Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance (e.g., fibrin glue), if performed

Medical Policy Alignment 31660 BRONCHOSCOPIC THERMOPLASTY ONE LOBE Medical Policy Alignment 31661 BRONCHOSCOPIC THERMOPLASTY 2/Greater than LOBES


Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure)


Medical Policy Alignment 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

Medical Policy Alignment 36476 ENDOVENOUS RF VEIN ADD-ON Medical Policy Alignment 36479 ENDOVENOUS LASER VEIN ADDON Medical Policy Alignment 43257 UPPR GI SCOPE W/THRML TXMNT


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


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

Medical Policy Alignment 63035 SPINAL DISK SURGERY ADD-ON Medical Policy Alignment 63043 LAMINOTOMY ADDL CERVICAL Medical Policy Alignment 63044 LAMINOTOMY ADDL LUMBAR Medical Policy Alignment 63048 REMOVE SPINAL LAMINA ADD-ON Medical Policy Alignment 63057 DECOMPRESS SPINE CORD ADD-ON Medical Policy Alignment 63066 DECOMPRESS SPINE CORD ADD-ON Medical Policy Alignment 63076 NECK SPINE DISK SURGERY Medical Policy Alignment 63078 SPINE DISK SURGERY THORAX Medical Policy Alignment 63082 REMOVE VERTEBRAL BODY ADD-ON Medical Policy Alignment 63086 REMOVE VERTEBRAL BODY ADD-ON Medical Policy Alignment 63088 REMOVE VERTEBRAL BODY ADD-ON Medical Policy Alignment 63091 REMOVE VERTEBRAL BODY ADD-ON Medical Policy Alignment 63103 REMOVE VERTEBRAL BODY ADD-ON Medical Policy Alignment 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic Medical Policy Alignment 64405 Injection, anesthetic agent; greater occipital nerve Medical Policy Alignment 64633 DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRV Medical Policy Alignment 64634 DSTR NROLYTC AGNT PARVERTEB FCT ADDL CR Medical Policy Alignment 64635 DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMB Medical Policy Alignment 64636 DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMB Medical Policy Alignment 69090 Ear piercing Medical Policy Alignment 69300 Otoplasty, protruding ear, with or without size reduction


Medical Policy Alignment 77424 Intraoperative radiation treatment delivery, x-ray, single treatment session Medical Policy Alignment 77425 Intraoperative radiation treatment delivery, electrons, single treatment session Medical Policy Alignment 77469 Intraoperative radiation treatment management


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


Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities

Medical Policy Alignment 81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis

Medical Policy Alignment 81507 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy

Medical Policy Alignment 82172 ASSAY OF APOLIPOPROTEIN Medical Policy Alignment 83695 ASSAY OF LIPOPROTEIN(A) Medical Policy Alignment 83698 ASSAY LIPOPROTEIN PLA2 Medical Policy Alignment 88240 Cryopreservation, freezing and storage of cells, each cell line Medical Policy Alignment 91117 COLON MOTILITY 6 HR STUDY Medical Policy Alignment 91132 Electrogastrography, diagnostic, transcutaneous Medical Policy Alignment 91133 Electrogastrography, diagnostic, transcutaneous; with provocative testing Medical Policy Alignment 93740 Temperature gradient studies Medical Policy Alignment 93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral Medical Policy Alignment 99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral

Medical Policy Alignment 0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score

Medical Policy Alignment 0019T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy

Medical Policy Alignment 0054T

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)

Medical Policy Alignment 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)

Medical Policy Alignment 0099T IMPLANT CORNEAL RING


Medical Policy Alignment 0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy

Medical Policy Alignment 0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy

Medical Policy Alignment 0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle

Medical Policy Alignment 0103T Holotranscobalamin, quantitative Medical Policy Alignment 0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes Medical Policy Alignment 0126T CHD RISK IMT STUDY


Total 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)

Medical Policy Alignment 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

Medical Policy Alignment 0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level


Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure)


Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure)


Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation

Medical Policy Alignment 0182T High dose rate electronic brachytherapy, per fraction

Medical Policy Alignment 0195T Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace


Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure)


Percutaneous 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


Medical Policy Alignment 0201T PERQ SACRAL AUGMT BILAT INJ


Posterior 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


Intravascular catheter-based coronary vessel or graft spectroscopy (eg, infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure)


Computerized database analysis of multiple cycles of digitized cardiac electrical data from two or more ECG leads, including transmission to a remote center, application of multiple nonlinear mathematical transformations, with coronary artery obstruction severity assessment

Medical Policy Alignment 0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral

Medical Policy Alignment 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

Medical Policy Alignment 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

Medical Policy Alignment 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


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)


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; cervical or thoracic

Medical Policy Alignment 0275T PERQ LAMOT/LAM ANY METH SINGLE/MLT LVL

Medical Policy Alignment 0299T Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound


Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure)


Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure)

Medical Policy Alignment 0311T N-INVAS CAL & ALYS CNTRL ARTL PRESSURE WAVEFORM


Medical Policy Alignment 0337T Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral

Medical Policy Alignment 0342T Therapeutic apheresis with selective HDL delipidation and plasma reinfusion


Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) upper extremity(ies), (includes shoulder, elbow and wrist, when performed)


Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed)

Medical Policy Alignment 0351T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative

Medical Policy Alignment 0352T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative interpretation and report, real time or referred

Medical Policy Alignment 0353T Optical coherence tomography of breast, surgical cavity; real time intraoperative

Medical Policy Alignment 0354T Optical coherence tomography of breast, surgical cavity; real time intraoperative interpretation and report, real time or referred

Medical Policy Alignment 0355T Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report

Medical Policy Alignment 0356T Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each

Medical Policy Alignment 0358T Bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report

Medical Policy Alignment 0377T Anoscopy with directed submucosal injection of bulking agent for fecal incontinence Medical Policy Alignment 0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular Medical Policy Alignment 0388T Transcatheter removal of permanent leadless pacemaker, ventricular


Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system


Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

Medical Policy Alignment 0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

Medical Policy Alignment 0406T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant


Medical Policy Alignment 0407T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement

Medical Policy Alignment C9349 PuraPly, and PuraPly Antimicrobial, any type, per sq cm Medical Policy Alignment E0840 Traction frame, attached to headboard, cervical traction Medical Policy Alignment E1700 JAW MOTION REHABILITATION SYSTEM Medical Policy Alignment E1701 REPL CUSHNS JAW MOT REHAB SYS PKG 6 Medical Policy Alignment E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200

Medical Policy Alignment G0428 Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)

Medical Policy Alignment G6017 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

Medical Policy Alignment G9147

Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration.

Medical Policy Alignment M0300 IV chelation therapy (chemical endarterectomy) Medical Policy Alignment Q2028 Injection, sculptra, 0.5 mg Medical Policy Alignment S1090 Mometasone furoate sinus implant, 370 micrograms Medical Policy Alignment S2140 CORD BLD HARVEST TPLNT ALLOGENEIC Medical Policy Alignment S2325 HIP CORE DECOMPRESSION

Medical Policy Alignment S2348 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar

Medical Policy Alignment S3870 Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability

Medical Policy Alignment S8130 INTERFERENTIAL CURRENT STIMULATOR 2 CHANNEL Medical Policy Alignment S8131 INTERFERENTIAL CURRENT STIMULATOR 4 CHANNEL Medical Policy Alignment S9001 Home uterine monitor with or without associated nursing services Medical Policy Alignment S9090 Vertebral axial decompression, per session

Medical Policy Alignment S9335

Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately), per diem


Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem



Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Medical Policy Alignment S9355 HOME INFUS TX CHELATION; PER DIEM


Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g. infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem


Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Medical Policy Alignment T1502 Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit

Non-Emergent Air Ambulance Transport A0430 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY Non-Emergent Air Ambulance Transport A0431 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY Non-Emergent Air Ambulance Transport A0435 FIXED WING AIR MILEAGE PER STATUTE MILE Non-Emergent Air Ambulance Transport A0436 ROTARY WING AIR MILEAGE PER STATUTE MILE Non-Emergent Air Ambulance Transport S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) Non-Emergent Air Ambulance Transport S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) Non-Emergent Ground Ambulance TX MANDATE A0382 BLS routine disposable supplies Non-Emergent Ground Ambulance TX MANDATE A0398 ALS routine disposable supplies Non-Emergent Ground Ambulance TX MANDATE A0420 Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments Non-Emergent Ground Ambulance TX MANDATE A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation Non-Emergent Ground Ambulance TX MANDATE A0424

Extra ambulance attendant, ground (als or bls) or air (fixed or rotary winged); (requires medical review)

Non-Emergent Ground A0425 Ground mileage, per statute mile


Ambulance TX MANDATE Non-Emergent Ground Ambulance TX MANDATE A0426 Ambulance service, advanced life support, non-emergency transport, level Non-Emergent Ground Ambulance TX MANDATE A0428 Ambulance service, basic life support, non-emergency transport (BLS) Non-Emergent Ground Ambulance TX MANDATE A0433 Advanced life support, level 2 (ALS 2) Non-Emergent Ground Ambulance TX MANDATE A0434 Specialty care transport (SCT) Orthognathic Surgery 21121 GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE Orthognathic Surgery 21122 GENIOPLASTY 2/Greater than SLIDING OSTEOTOMIES Orthognathic Surgery 21123 GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS Orthognathic Surgery 21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL Orthognathic Surgery 21127 AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL Orthognathic Surgery 21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT Orthognathic Surgery 21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT Orthognathic Surgery 21143 RCNSTJ MIDFACE LEFORT I 3/Greater thanPIECE W/O BONE GRAFT Orthognathic Surgery 21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS Orthognathic Surgery 21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS Orthognathic Surgery 21147 RCNSTJ MIDFACE LEFORT I 3/Greater thanPIECE W/BONE GRAFTS Orthognathic Surgery 21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION Orthognathic Surgery 21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS Orthognathic Surgery 21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I Orthognathic Surgery 21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I Orthognathic Surgery 21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I Orthognathic Surgery 21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I Orthognathic Surgery 21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT&BONE GRAFTS Orthognathic Surgery 21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF Orthognathic Surgery 21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT Orthognathic Surgery 21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD Orthognathic Surgery 21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ Orthognathic Surgery 21198 OSTEOTOMY MANDIBLE SEGMENTAL Orthognathic Surgery 21199 OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT


Orthognathic Surgery 21206 OSTEOTOMY MAXILLA SEGMENTAL Orthognathic Surgery 21208 OSTEOPLASTY FACIAL BONES AUGMENTATION Orthognathic Surgery 21209 OSTEOPLASTY FACIAL BONES REDUCTION Orthognathic Surgery 21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS Orthognathic Surgery 21215 GRAFT BONE MANDIBLE Orthognathic Surgery 21240 ARTHRP TEMPOROMANDIBULAR JOINT W/WO AUTOGRAFT Orthognathic Surgery 21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT Orthognathic Surgery 21244 RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE Orthognathic Surgery 21245 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL Orthognathic Surgery 21246 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE Orthognathic Surgery 21247 RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS Orthognathic Surgery 21248 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL Orthognathic Surgery 21249 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE Orthognathic Surgery 21255 RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG Orthognathic Surgery 21296 REDUCTION MASSETER MUSCLE&BONE INTRAORAL Orthognathic Surgery 21299 Unlisted craniofacial and maxillofacial procedure Orthognathic Surgery 30465 REPAIR NASAL VESTIBULAR STENOSIS Orthotics/Prosthetic Greater than $500 L0112 CRANIL CERV ORTHOT CONGN TORTICOLLIS TYPE CUSTOM Orthotics/Prosthetic Greater than $500 L0170 CERVICAL COLLAR MOLDED TO PATIENT MODEL Orthotics/Prosthetic Greater than $500 L0456 TLSO FLEX TRNK SACROCOCCYGEAL TO SCAP SPN PRFAB Orthotics/Prosthetic Greater than $500 L0458 TLSO TRIPLANAR 2 RIGD SHELL ANT TO XIPHOID PRFAB Orthotics/Prosthetic Greater than $500 L0460 TLSO TRIPLANAR 2 SHELL ANT TO STERNL NOTCH PRFAB Orthotics/Prosthetic Greater than $500 L0462 TLSO TRIPLANAR 3 SHELL ANT TO STERNL NOTCH PRFAB Orthotics/Prosthetic Greater than $500 L0464 TLSO TRIPLANAR 4 SHELL ANT TO STERNL NOTCH PRFAB Orthotics/Prosthetic Greater than $500 L0470 TLSO TRIPLANAR POST FRME&ANT APRON W/STRAP PRFAB


Orthotics/Prosthetic Greater than $500 L0480 TLSO TRIPLANAR 1 PIECE W/O INTERFCE LINER CSTM Orthotics/Prosthetic Greater than $500 L0482 TLSO TRIPLANAR 1 PIECE W/INTERFCE LINER CSTM Orthotics/Prosthetic Greater than $500 L0484 TLSO TRIPLANAR 2 PIECE W/O INTERFCE LINER CSTM Orthotics/Prosthetic Greater than $500 L0486 TLSO TRIPLANAR 2 PIECE W/INTERFCE LINER CSTM Orthotics/Prosthetic Greater than $500 L0488 TLSO TRIPLANAR 1 PIECE W/INTERFCE LINER PRFAB Orthotics/Prosthetic Greater than $500 L0491 TLSO TWO RIGID PLASTIC SHELLS PREFABRICATED Orthotics/Prosthetic Greater than $500 L0624 SACROIL ORTHOT W/ RIGD/SEMI-RIGD PANELS CSTM FAB Orthotics/Prosthetic Greater than $500 L0629 LUMBAR-SACRAL ORTHOTIC FLEXIBLE CUSTOM FAB Orthotics/Prosthetic Greater than $500 L0631 LUMB-SACRAL ORTHOTIC RIGID ANT/POST PANEL PREFAB Orthotics/Prosthetic Greater than $500 L0632 LUMBAR-SACR ORTHOT W/RIGD ANT&POST PANL CSTM FAB Orthotics/Prosthetic Greater than $500 L0634 LUMBAR-SAC ORTHOT RIGD POST FRAME/PANL CSTM FAB Orthotics/Prosthetic Greater than $500 L0635 LSO LUMB FLEX RIGD POST FRAME/PANL PREFAB Orthotics/Prosthetic Greater than $500 L0636 LSO LUMB FLEX RIGD POST FRAME/PANL CSTM FAB Orthotics/Prosthetic Greater than $500 L0637 LSO W/RIGID ANT & POST FRAME/PANEL PREFAB Orthotics/Prosthetic Greater than $500 L0638 LSO W/RIGID ANT & POST FRAME/PANEL CUSTOM FAB Orthotics/Prosthetic Greater than $500 L0639 LUMBA-SACRAL ORTHOTIC RIGID SHELL/PANEL PREFAB Orthotics/Prosthetic Greater than $500 L0640 LUMBAR-SACRAL ORTHOT RIGID SHELL/PANEL CSTM FAB Orthotics/Prosthetic L0700 CTLSO ANT-POSTERIOR-LAT CONTROL MOLDED PT MODEL


Greater than $500 Orthotics/Prosthetic Greater than $500 L0710 CTLSO ANT-POST-LAT CNTRL MOLD PT-INTRFCE MATL Orthotics/Prosthetic Greater than $500 L0810 HALO PROC CERV HALO INCORPORATED IN JACKET VEST Orthotics/Prosthetic Greater than $500 L0820 HALO PROC CERV HALO INC IN PLASTR BDY JACKET Orthotics/Prosthetic Greater than $500 L0830 HALO PROC CERV HALO INC IN MLWAKEE TYPE ORTHOSIS Orthotics/Prosthetic Greater than $500 L0859 ADD HALO PROC MRI COMPAT SYS RINGS&PINS ANY MATL Orthotics/Prosthetic Greater than $500 L0861 ADD HALO PROC REPLCMT LINER/INTERFCE MATERIAL Orthotics/Prosthetic Greater than $500 L1000 CTLSO INCLUSIVE FURNISHING INIT ORTHOS INCL MDL Orthotics/Prosthetic Greater than $500 L1005 TENSION BASED SCOLIOSIS ORTHOTIC&ACCESSORY PADS Orthotics/Prosthetic Greater than $500 L1200 TLSO INCLUSIVE FURNISHING INITIAL ORTHOTIC ONLY Orthotics/Prosthetic Greater than $500 L1300 OTH SCOLIOSIS PROC BODY JACKET MOLDED PT MODEL Orthotics/Prosthetic Greater than $500 L1310 OTH SCOLIOSIS PROC POSTOPERATIVE BODY JACKET Orthotics/Prosthetic Greater than $500 L1499 SPINAL ORTHOTIC NOT OTHERWISE SPECIFIED Orthotics/Prosthetic Greater than $500 L1680 HIP ORTHOT DYN PELV CONTROL THIGH CUFF CSTM FAB Orthotics/Prosthetic Greater than $500 L1685 HIP ORTHOS ABDCT CNTRL POSTOP HIP ABDCT CSTM Orthotics/Prosthetic Greater than $500 L1686 HIP ORTHOT ABDUCT CNTRL POSTOP HIP PRFAB-FIT&ADJ Orthotics/Prosthetic Greater than $500 L1690 COMB BIL LUMBO-SAC HIP FEM ORTHOT PRFB W/FIT&ADJ Orthotics/Prosthetic Greater than $500 L1700 LEGG PERTHES ORTHOTIC TORONTO CUSTOM FABRICATED


Orthotics/Prosthetic Greater than $500 L1710 LEGG PERTHES ORTHOTIC NEWINGTON CUSTOM FAB Orthotics/Prosthetic Greater than $500 L1720 LEGG PERTHES ORTHOTIC TRILAT TACHDIJAN CSTM FAB Orthotics/Prosthetic Greater than $500 L1730 LEGG PERTHES ORTHOTIC SCOTTISH RITE CUSTOM FAB Orthotics/Prosthetic Greater than $500 L1755 LEGG PERTHES ORTHOTIC PATTEN BOTTOM CSTM FAB Orthotics/Prosthetic Greater than $500 L1810 KO ELASTIC W/JOINTS PREFAB INCLUDES FITTING&ADJ Orthotics/Prosthetic Greater than $500 L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf Orthotics/Prosthetic Greater than $500 L1820 KO ELAST W/CONDYLR PADS&JNT PRFAB INCL FIT&ADJ Orthotics/Prosthetic Greater than $500 L1830 KO IMMOBLIZR CANVAS LNGTUDNL PRFAB INCL FIT&ADJ Orthotics/Prosthetic Greater than $500 L1831 KNEE ORTHOT LOCK KNEE JNT PSTN ORTHOT PRFAB Orthotics/Prosthetic Greater than $500 L1832 KO ADJ KNEE JNT UNICENT/POLYCNT RIGD PREFAB Orthotics/Prosthetic Greater than $500 L1834 KO WITHOUT KNEE JOINT RIGID CUSTOM FABRICATED Orthotics/Prosthetic Greater than $500 L1836 KNEE ORTHOTIC RIGID WITHOUT JOINT PREFABRICATED Orthotics/Prosthetic Greater than $500 L1840 KO DEROTATION MEDIAL-LATERAL ACL CUSTOM FAB Orthotics/Prosthetic Greater than $500 L1843 KNEE ORTHOSIS SINGLE UPRIGHT THIGH & CALF PREFAB Orthotics/Prosthetic Greater than $500 L1844 KO 1 UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB Orthotics/Prosthetic Greater than $500 L1845 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT PREFAB Orthotics/Prosthetic Greater than $500 L1846 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB Orthotics/Prosthetic L1847 KO DBL UPRT W/ADJ JNT-INFLAT AIR SUPP CHMB PRFAB


Greater than $500 Orthotics/Prosthetic Greater than $500 L1860 KO MOD SUPRACONDYLR PROSTHETIC SOCKT CSTM FAB Orthotics/Prosthetic Greater than $500 L1932 AFO RIGD ANT TIBL TOT CARB FIBER/EQUL MATL PRFAB Orthotics/Prosthetic Greater than $500 L1945 AFO MOLD PT MDL PLSTC RIGD ANT TIBL SECT CSTM Orthotics/Prosthetic Greater than $500 L1950 ANKLE FOOT ORTHOTIC SPIRAL PLASTIC CUSTOM-FAB Orthotics/Prosthetic Greater than $500 L1951 ANK FT ORTHOT SPIRAL PLSTC/OTH MATL PRFAB W/FIT Orthotics/Prosthetic Greater than $500 L1970 AFO PLASTIC WITH ANKLE JOINT CUSTOM FABRICATED Orthotics/Prosthetic Greater than $500 L2000 KAFO 1 UPRT FREE KNEE FREE ANK SOLID STIRUP CSTM Orthotics/Prosthetic Greater than $500 L2005 KAFO ANY MATL AUTO LOCK&SWNG RLSE W/ANK JNT CSTM Orthotics/Prosthetic Greater than $500 L2010 KAFO 1 UPRT SOLID STIRUP W/O KNEE JNT CSTM FAB Orthotics/Prosthetic Greater than $500 L2020 KAFO DBL UPRT SOLID STIRUP THI&CALF CSTM FAB Orthotics/Prosthetic Greater than $500 L2030 KAFO DBL UPRT SOLID STIRUP W/O KNEE JNT CSTM Orthotics/Prosthetic Greater than $500 L2034 KAFO PLASTIC MED LAT ROTAT CNTRL CSTM FAB Orthotics/Prosthetic Greater than $500 L2036 KAFO FULL PLASTIC DOUBLE UPRIGHT CSTM FAB Orthotics/Prosthetic Greater than $500 L2037 KAFO FULL PLASTIC SINGLE UPRIGHT CUSTOM FAB Orthotics/Prosthetic Greater than $500 L2038 KAFO FULL PLASTIC MX-AXIS ANKLE CUSTOM FAB Orthotics/Prosthetic Greater than $500 L2060 HKAFO TORSION CNTRL BIL TORSION BALL BEAR CSTM Orthotics/Prosthetic Greater than $500 L2106 AFO FX ORTHOTIC TIB FX CAST THERMOPLSTC CSTM FAB


Orthotics/Prosthetic Greater than $500 L2108 AFO FX ORTHOTIC TIB FX CAST ORTHOSIS CSTM FAB Orthotics/Prosthetic Greater than $500 L2114 AFO TIBL FX ORTHOS SEMI-RIGD PRFAB W/FIT & ADJ Orthotics/Prosthetic Greater than $500 L2116 AFO TIB FX ORTHOTIC RIGID PRFAB W/FIT & ADJ Orthotics/Prosthetic Greater than $500 L2126 KAFO FEM FX CAST ORTHOTIC THERMOPLSTC CSTM FAB Orthotics/Prosthetic Greater than $500 L2128 KAFO FX ORTHOTIC FEM FX CAST ORTHOSIS CSTM FAB Orthotics/Prosthetic Greater than $500 L2132 KAFO FEM FX CAST ORTHOTIC SFT PRFAB W/FIT & ADJ Orthotics/Prosthetic Greater than $500 L2134 KAFO FEM FX CAST ORTHOT SEMI-RIGD PRFAB FIT&ADJ Orthotics/Prosthetic Greater than $500 L2136 KAFO FEM FX CAST ORTHOTIC RIGD PRFAB W/FIT & ADJ Orthotics/Prosthetic Greater than $500 L2350 ADD LOW EXTREM PROSTHETIC TYPE SOCKT MOLD PT MDL Orthotics/Prosthetic Greater than $500 L2510 ADD LW EXTRM THI/WT BEAR QUADRI-LAT BRIM MOLD PT Orthotics/Prosthetic Greater than $500 L2525 ADD LW EXTRM ISCH M-L BRIM MOLD PT MDL Orthotics/Prosthetic Greater than $500 L2526 ADD LW EXTRM ISCH M-L BRIM CSTM FIT Orthotics/Prosthetic Greater than $500 L2627 ADD LW EXT PELV PLSTC MOLD PT MDL HIP JNT&CABLES Orthotics/Prosthetic Greater than $500 L2628 ADD LW EXT PELV METL FRME RECIP HIP JNT&CABLES Orthotics/Prosthetic Greater than $500 L2999 LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIED Orthotics/Prosthetic Greater than $500 L3000 FT INSRT MOLD PT MDL UCB TYPE BERKLY SHELL EA Orthotics/Prosthetic Greater than $500 L3010 FT INSRT REMV MOLD PT MDL LNGTUDNL ARCH SUPP EA Orthotics/Prosthetic L3020 FOOT INSRT REMV MOLD PT MDL LNGTUDNL/MT SUPP EA


Greater than $500 Orthotics/Prosthetic Greater than $500 L3031 FOOT INSRT/PLAT REMV ADD LW EXT ORTHOT HI STRGTH Orthotics/Prosthetic Greater than $500 L3160 FOOT ADJUSTABLE SHOE-STYLED POSITIONING DEVICE Orthotics/Prosthetic Greater than $500 L3201 ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR INFNT Orthotics/Prosthetic Greater than $500 L3202 ORTHOPED SHOE OXFORD W/SUPINATOR/PRONATOR CHILD Orthotics/Prosthetic Greater than $500 L3203 ORTHOPEDIC SHOE OXFORD W/SUPINATOR/PRONATOR JR Orthotics/Prosthetic Greater than $500 L3204 ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR INFNT Orthotics/Prosthetic Greater than $500 L3206 ORTHOPED SHOE HIGHTOP W/SUPINATOR/PRONATOR CHILD Orthotics/Prosthetic Greater than $500 L3207 ORTHOPEDIC SHOE HIGHTOP W/SUPINATOR/PRONATOR JR Orthotics/Prosthetic Greater than $500 L3212 BENESCH BOOT PAIR INFANT Orthotics/Prosthetic Greater than $500 L3213 BENESCH BOOT PAIR CHILD Orthotics/Prosthetic Greater than $500 L3214 BENESCH BOOT PAIR JUNIOR Orthotics/Prosthetic Greater than $500 L3215 ORTHOPEDIC FOOTWEAR LADIES SHOE OXFORD EACH Orthotics/Prosthetic Greater than $500 L3216 ORTHOPEDIC FOOTWEAR LADIES SHOE DEPTH INLAY EACH Orthotics/Prosthetic Greater than $500 L3217 ORTHOPED FTWEAR LADIES SHOE HITOP DEPTH INLAY EA Orthotics/Prosthetic Greater than $500 L3219 ORTHOPEDIC FOOTWEAR MENS SHOE OXFORD EACH Orthotics/Prosthetic Greater than $500 L3221 ORTHOPEDIC FOOTWEAR MENS SHOE DEPTH INLAY EACH Orthotics/Prosthetic Greater than $500 L3222 ORTHOPED FOOTWEAR MENS SHOE HITOP DEPTH INLAY EA


Orthotics/Prosthetic Greater than $500 L3230 ORTHOPEDIC FOOTWEAR CUSTOM SHOE DEPTH INLAY EACH Orthotics/Prosthetic Greater than $500 L3250 ORTHOPED FTWEAR CSTM MOLD REMV INNR MOLD PROSTH Orthotics/Prosthetic Greater than $500 L3251 FOOT SHOE MOLDED PATIENT MODEL SILICONE SHOE EA Orthotics/Prosthetic Greater than $500 L3252 FOOT SHOE MOLDED PT MDL PLASTAZOTE CSTM FABR EA Orthotics/Prosthetic Greater than $500 L3253 FOOT MOLDED SHOE PLASTAZOTE CUSTOM FITTED EACH Orthotics/Prosthetic Greater than $500 L3265 PLASTAZOTE SANDAL EACH Orthotics/Prosthetic Greater than $500 L3649 ORTHOPED SHOE MODIFICATION ADDITION/TRANSFER NOS Orthotics/Prosthetic Greater than $500 L3671 SHLDR ORTHOTIC SHLDR JNT DESN W/O JNTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3674 SHLDR ORTHOSIC ABDUCT PSTN TH COMP SUPP BAR CSTM Orthotics/Prosthetic Greater than $500 L3720 EO DBL UPRT W/FORARM/ARM CUFF FREE MOT CSTM FAB Orthotics/Prosthetic Greater than $500 L3730 EO DBL UPRT W/CUFF EXT/FLX ASST CSTM FAB Orthotics/Prosthetic Greater than $500 L3740 EO DBL UPRT W/CUFF ADJ LOCK W/ACTV CNTRL CSTM Orthotics/Prosthetic Greater than $500 L3763 EWHO RIGID W/O JOINTS CUSTOM FABRICATED Orthotics/Prosthetic Greater than $500 L3764 EWHO INCL 1/MORE NONTORSION JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3765 EWHFO RIGID W/O JOINTS CUSTOM FABRICATED Orthotics/Prosthetic Greater than $500 L3766 EWHFO INCL 1/MORE NONTORSION JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3900 WHFO DYN FLEXOR HINGE WRST/FNGR DRIVEN CSTM FAB Orthotics/Prosthetic L3901 WHFO DYN FLEXOR HINGE CABLE DRIVEN CSTM FAB


Greater than $500 Orthotics/Prosthetic Greater than $500 L3904 WHFO EXTERNAL POWERED ELECTRIC CUSTOM FABRICATED Orthotics/Prosthetic Greater than $500 L3905 WHO INCL 1/MORE NONTORSION JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3960 SEWHO ABDUCT PSTN AIRPLANE DESN PREFAB W/FIT&ADJ Orthotics/Prosthetic Greater than $500 L3961 SEWHO SHOULDER CAP DESIGN W/O JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3962 SEWHO ABDUCT PSTN ERBS PALS DESN PRFAB W/FIT&ADJ Orthotics/Prosthetic Greater than $500 L3967 SEWHO ABDUCTION POSITIONING W/O JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3971 SEWHO SHOULDER CAP DESIGN CSTM FAB Orthotics/Prosthetic Greater than $500 L3973 SEWHO ABDUCT PSTN THOR CMPNT&SUPP BAR CSTM FAB Orthotics/Prosthetic Greater than $500 L3975 SEWHFO SHOULDER CAP DESIGN W/O JOINTS CSTM FAB Orthotics/Prosthetic Greater than $500 L3976 SEWHFO ABDUCT PSTN THOR CMPNT W/O JOINTS CUS FAB Orthotics/Prosthetic Greater than $500 L3977 SEWHFO SHOULD CAP DESIGN CUSTOM FAB Orthotics/Prosthetic Greater than $500 L3978 SEWHFO ABDUCT PSTN THOR CMPNT&SUPP BAR CSTM FAB Orthotics/Prosthetic Greater than $500 L3999 UPPER LIMB ORTHOSIS NOT OTHERWISE SPECIFIED Orthotics/Prosthetic Greater than $500 L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS Orthotics/Prosthetic Greater than $500 L4010 REPLACE TRILATERAL SOCKET BRIM Orthotics/Prosthetic Greater than $500 L4020 REPLACE QUADRILAT SOCKET BRIM MOLDED PT MODEL Orthotics/Prosthetic Greater than $500 L4631 AFO WALK BOOT TYP ROCKR BOTTM ANT TIB SHELL CSTM


Orthotics/Prosthetic Greater than $500 L5000 PART FT SHOE INSERT W/LONGTUDNL ARCH TOE FILLER Orthotics/Prosthetic Greater than $500 L5010 PARTIAL FT MOLDED SOCKET ANK HEIGHT W/TOE FILLER Orthotics/Prosthetic Greater than $500 L5020 PART FT MOLDED SOCKET TIB TUBERCLE HT W/TOE FIL Orthotics/Prosthetic Greater than $500 L5050 ANKLE SYMES MOLDED SOCKET SACH FOOT Orthotics/Prosthetic Greater than $500 L5060 ANK SYMES METL FRME MOLD LEATHR SOCKT ARTIC ANK Orthotics/Prosthetic Greater than $500 L5100 BELOW KNEE MOLDED SOCKET SHIN SACH FOOT Orthotics/Prosthetic Greater than $500 L5105 BELOW KNEE PLSTC SOCKT JNT&THIGH LACER SACH FOOT Orthotics/Prosthetic Greater than $500 L5150 KNEE DISRTC MOLD SOCKT EXT KNEE JNT SHIN SACH FT Orthotics/Prosthetic Greater than $500 L5160 KNEE DISARTIC MOLD SOCKT BENT KNEE EXT KNEE JNT Orthotics/Prosthetic Greater than $500 L5200 ABVE KNEE MOLD SOCKT 1 AXIS CONSTANT FRICTION Orthotics/Prosthetic Greater than $500 L5210 ABVE KNEE SHRT PROSTH NO KNEE JNT NO ANK JNT EA Orthotics/Prosthetic Greater than $500 L5220 ABVE KNEE SHRT PROSTH W/ARTIC ANK/FOOT DYN Orthotics/Prosthetic Greater than $500 L5230 ABVE KNEE PROX FEM FOCAL DEFIC SACH FOOT Orthotics/Prosthetic Greater than $500 L5250 HIP DISARTIC CANADIAN TYPE; MOLD SOCKT HIP JNT Orthotics/Prosthetic Greater than $500 L5270 HIP DISRTC TILT TABLE; MOLD SCKT LOCK HIP JNT Orthotics/Prosthetic Greater than $500 L5280 HEMIPELVECT CANADIAN TYPE; MOLD SOCKT HIP JNT Orthotics/Prosthetic Greater than $500 L5301 BELW KNEE MOLD SOCKT SHIN SACH FT ENDOSKEL SYS Orthotics/Prosthetic L5312 KNEE DISARTIC MOLD SOCKET 1 AXIS KNEE SACH FOOT


Greater than $500 Orthotics/Prosthetic Greater than $500 L5321 ABOVE KNEE OPEN END SACH FT ENDO SYS 1 AXIS KNEE Orthotics/Prosthetic Greater than $500 L5331 JOINT SINGLE AXIS KNEE SACH FOOT Orthotics/Prosthetic Greater than $500 L5341 SINGLE AXIS KNEE SACH FOOT Orthotics/Prosthetic Greater than $500 L5400 IMMED POSTSURG/ERLY FIT APPLY RIGD DRESS W/1 CHG Orthotics/Prosthetic Greater than $500 L5420 IMMED POSTSURG INIT RIGD DRESS 1 CHG AK/KNEE Orthotics/Prosthetic Greater than $500 L5460 IMMED POSTSURG APPLIC NONWT BEAR RIGD ABVE KNEE Orthotics/Prosthetic Greater than $500 L5500 INIT BELW KNEE PTB SOCKT NON-ALIGN DIR FORMED Orthotics/Prosthetic Greater than $500 L5505 INIT ABVE KNEE-DISARTC ISCH LEVL SOCKT NON-ALIGN Orthotics/Prosthetic Greater than $500 L5510 PREP BELW KNEE PTB SOCKT NON-ALIGN MOLD MDL Orthotics/Prosthetic Greater than $500 L5520 PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=DIR FORM Orthotics/Prosthetic Greater than $500 L5530 PREP BK PTB SCKT NON-ALIGN THERMOPLSTC/=MOLD MDL Orthotics/Prosthetic Greater than $500 L5535 PREP BELOW KNEE PTB NON-ALIGN PRFAB ADJ OPEN END Orthotics/Prosthetic Greater than $500 L5540 PREP BK PTB SCKT NON-ALIGN LAMNATD SCKT MOLD MDL Orthotics/Prosthetic Greater than $500 L5560 PREP AK-DISRTC ISCH LEVL PLASTER SOCKET MOLD MDL Orthotics/Prosthetic Greater than $500 L5570 PREP AK-DISRTC ISCH LEVL THERMOPLSTC/=DIR FORMED Orthotics/Prosthetic Greater than $500 L5580 PREP AK DISARTIC NON-ALIGN THERMOPLSTC/=MOLD MDL Orthotics/Prosthetic Greater than $500 L5585 PREP AK-DISARTC NON-ALIGN PRFAB ADJ OPN END SCKT


Orthotics/Prosthetic Greater than $500 L5590 PREP AK-DISARTIC NON-ALIGN LAMINATED SCKT MOLD Orthotics/Prosthetic Greater than $500 L5595 PREP HIP DISARTIC-HEMIPELVECT THERMOPLSTC/=MOLD Orthotics/Prosthetic Greater than $500 L5600 PREP HIP DISARTIC-HEMIPELVECT LAMINATD SCKT MOLD Orthotics/Prosthetic Greater than $500 L5610 ADD LW EXTRM ENDO SYS ABVE KNEE HYDRACADENCE SYS Orthotics/Prosthetic Greater than $500 L5611 ADD LW EXTRM ENDO AK-DISRTC 4-BAR LINK W/FRICT Orthotics/Prosthetic Greater than $500 L5613 ADD LW EXTRM ENDO AK-DISARTIC 4-BAR W/HYDRAULIC Orthotics/Prosthetic Greater than $500 L5614 ADD LW EXT EXOSKEL SYS AK-DISARTC 4-BAR PNEUMAT Orthotics/Prosthetic Greater than $500 L5616 ADD LW EXTRM ENDO AK UNIVERSAL MXPLX SYS FRICT Orthotics/Prosthetic Greater than $500 L5639 ADDITION LOWER EXTREMITY BELOW KNEE WOOD SOCKET Orthotics/Prosthetic Greater than $500 L5640 ADDITION LOWER EXTREM KNEE DISARTIC LEATHR SOCKT Orthotics/Prosthetic Greater than $500 L5642 ADDITION LOWER EXTREM ABOVE KNEE LEATHER SOCKET Orthotics/Prosthetic Greater than $500 L5643 ADD LW EXT HIP DISARTIC FLX INNR SOCKT EXT FRAME Orthotics/Prosthetic Greater than $500 L5644 ADDITION LOWER EXTREMITY ABOVE KNEE WOOD SOCKET Orthotics/Prosthetic Greater than $500 L5645 ADD LW EXT BELW KNEE FLXIBLE INNR SOCKT EXT FRME Orthotics/Prosthetic Greater than $500 L5646 ADD LOW EXT BELOW KNEE AIR FL GEL/= CUSHN SOCKT Orthotics/Prosthetic Greater than $500 L5647 ADDITION LOWER EXTREM BELOW KNEE SUCTION SOCKET Orthotics/Prosthetic Greater than $500 L5648 ADD LOW EXT ABOVE KNEE AIR FL GEL/= CUSHN SOCKT Orthotics/Prosthetic L5649 ADD LW EXT ISCHIAL CONTAINMENT/NARROW M-L SOCKET


Greater than $500 Orthotics/Prosthetic Greater than $500 L5651 ADD LW EXT ABVE KNEE FLXIBLE INNR SOCKT EXT FRME Orthotics/Prosthetic Greater than $500 L5653 ADD LOW EXTREM KNEE DISARTIC XPNDABLE WALL SOCKT Orthotics/Prosthetic Greater than $500 L5661 ADD LOW EXTREM SOCKT INSERT MULTIDUROMETER SYMES Orthotics/Prosthetic Greater than $500 L5673 ADD LW EXT CSTM MOLD/PRFAB FOR USE W/LOCK MECH Orthotics/Prosthetic Greater than $500 L5679 ADD LW EXT BK/AK CSTM MOLD/PRFAB NOT W/LOCK MECH Orthotics/Prosthetic Greater than $500 L5681 ADD LW EXT CSTM INSRT CNGN/ATYP TRAUMAT AMP INIT Orthotics/Prosthetic Greater than $500 L5682 ADD LW EXTRM BELW KNEE THI LACER GLUTL/ISCH MOLD Orthotics/Prosthetic Greater than $500 L5683 ADD LW EXT CSTM INSRT NO CNGN/TRAUMAT AMP INIT Orthotics/Prosthetic Greater than $500 L5700 REPLACEMENT SOCKET BELOW KNEE MOLDED PT MODEL Orthotics/Prosthetic Greater than $500 L5701 REPL SOCKT ABVE KNEE/KNEE DISARTIC W/ATTCH PLAT Orthotics/Prosthetic Greater than $500 L5702 REPLCMT SOCKT HIP DISARTIC W/HIP JNT MOLD PT MDL Orthotics/Prosthetic Greater than $500 L5703 ANKLE SYMES MOLD PT MODEL SACH FOOT REPL ONLY Orthotics/Prosthetic Greater than $500 L5705 CUSTOM SHAPED PROTECTIVE COVER ABOVE KNEE Orthotics/Prosthetic Greater than $500 L5706 CUSTOM SHAPED PROTECTIVE COVER KNEE DISARTIC Orthotics/Prosthetic Greater than $500 L5707 CUSTOM SHAPED PROTECTIVE COVER HIP DISARTIC Orthotics/Prosthetic Greater than $500 L5716 ADD EXOSKEL KNEE-SHIN POLYCNTRC MECH STANCE LOCK Orthotics/Prosthetic Greater than $500 L5718 ADD EXOSKL KNEE-SHIN POLYCNTRC FRICT SWING CNTRL


Orthotics/Prosthetic Greater than $500 L5722 ADD EXOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRL Orthotics/Prosthetic Greater than $500 L5724 ADD EXOSKEL KNEE-SHIN FLUID SWING PHASE CNTRL Orthotics/Prosthetic Greater than $500 L5726 ADD EXOSKEL KNEE-SHIN EXT JOINT FL SWING CNTRL Orthotics/Prosthetic Greater than $500 L5728 ADD EXOSKEL KNEE-SHIN FLUID SWING&STANCE CNTRL Orthotics/Prosthetic Greater than $500 L5780 ADD EXOSKL KNEE-SHIN PNEUMAT/HYDRA PNEUMAT CNTRL Orthotics/Prosthetic Greater than $500 L5781 ADD LW LIMB PROS RESIDUL LIMB VOL MGMT SYS Orthotics/Prosthetic Greater than $500 L5782 ADD LW LIMB PROS RESIDUL LIMB MGMT SYS HEVY DUTY Orthotics/Prosthetic Greater than $500 L5790 ADD EXOSKEL SYSTEM ABVE KNEE ULTRA-LGHT MATERIAL Orthotics/Prosthetic Greater than $500 L5795 ADD EXOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATL Orthotics/Prosthetic Greater than $500 L5811 ADD ENDOSKEL KNEE-SHIN MNL LOCK ULTRA-LGHT MATL Orthotics/Prosthetic Greater than $500 L5812 ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRL Orthotics/Prosthetic Greater than $500 L5814 ADD ENDOSKEL KNEE-SHIN HYDRAULIC SWING MECH LOCK Orthotics/Prosthetic Greater than $500 L5816 ADD ENDOSKEL KNEE-SHIN MECH STANCE PHASE LOCK Orthotics/Prosthetic Greater than $500 L5818 ADD ENDOSKEL KNEE-SHIN FRICT SWING&STANCE CNTRL Orthotics/Prosthetic Greater than $500 L5822 ADD ENDOSKEL KNEE-SHIN PNEUMAT SWING FRICT CNTRL Orthotics/Prosthetic Greater than $500 L5824 ADD ENDOSKEL KNEE-SHIN FLUID SWING PHASE CNTRL Orthotics/Prosthetic Greater than $500 L5826 ADD ENDO KNEE-SHIN HYDRAUL SWNG MIN HI ACTV FRME Orthotics/Prosthetic L5828 ADD ENDO KNEE-SHIN FL SWING&STANCE PHASE CNTRL


Greater than $500 Orthotics/Prosthetic Greater than $500 L5830 ADD ENDOSKEL KNEE-SHIN PNEUMAT/SWING PHASE CNTRL Orthotics/Prosthetic Greater than $500 L5840 ADD ENDO KNEE-SHIN 4-BAR LINK/MX-AXIAL PNEUMAT Orthotics/Prosthetic Greater than $500 L5845 ADD ENDOSKEL KNEE-SHIN STANCE FLX FEATUR ADJ Orthotics/Prosthetic Greater than $500 L5848 ADD ENDOSKEL KNEE-SHIN SYS FLUID STANCE EXTENSN Orthotics/Prosthetic Greater than $500 L5856 ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSE Orthotics/Prosthetic Greater than $500 L5857 ADD LOW EXT PROS KNEE-SHIN SYS SWING PHASE ONLY Orthotics/Prosthetic Greater than $500 L5858 ADD LW EXT PROS KNEE SHIN SYS STANCE PHASE ONLY Orthotics/Prosthetic Greater than $500 L5930 ADD ENDOSKEL SYSTEM HIGH ACTV KNEE CONTROL FRAME Orthotics/Prosthetic Greater than $500 L5950 ADD ENDOSKEL SYSTEM ABVE KNEE ULTRA-LGHT MATL Orthotics/Prosthetic Greater than $500 L5960 ADD ENDOSKEL SYSTEM HIP DISARTIC ULTRA-LGHT MATL Orthotics/Prosthetic Greater than $500 L5961 ADD ENDO SYS POLYCNTRC HIP JOINT ROTATION CNTRL Orthotics/Prosthetic Greater than $500 L5962 ADD ENDOSKEL BK FLXIBLE PROTVE OUTR SURF COVRING Orthotics/Prosthetic Greater than $500 L5964 ADD ENDOSKEL AK FLXIBLE PROTVE OUTR SURF COVR Orthotics/Prosthetic Greater than $500 L5966 ADD ENDO HIP DISRTC FLXIBL PROTVE OUTR SURF COVR Orthotics/Prosthetic Greater than $500 L5968 ADD LW LIMB PROSTH MX-AXIAL ANK W/SWING PHASE Orthotics/Prosthetic Greater than $500 L5973 ENDOSKEL ANK FOOT SYS MICRPROCSS CONTROL PWR SRC Orthotics/Prosthetic Greater than $500 L5976 ALL LOWER EXTREM PROSTHESES ENERGY STORING FOOT


Orthotics/Prosthetic Greater than $500 L5979 ALL LW EXTRM PRSTH MX-AXL ANK DYN RSPN FT 1 PECE Orthotics/Prosthetic Greater than $500 L5980 ALL LOWER EXTREMITY PROSTHESES FLEX-FOOT SYSTEM Orthotics/Prosthetic Greater than $500 L5981 ALL LOWER EXTREM PROSTH FLEX-WALK SYSTEM/EQUAL Orthotics/Prosthetic Greater than $500 L5982 ALL EXOSKEL LOW EXTREM PROSTH AXIAL ROTAT UNIT Orthotics/Prosthetic Greater than $500 L5984 ALL ENDOSKEL LOW EXT PROSTH AXIAL ROTAT UNIT ADJ Orthotics/Prosthetic Greater than $500 L5986 ALL LOW EXTREM PROSTH MULTI-AXIAL ROTATION UNIT Orthotics/Prosthetic Greater than $500 L5987 ALL LW XTRM PRSTH SHNK FT SYS W/VRTCL LOAD PYLN Orthotics/Prosthetic Greater than $500 L5988 ADD LW LIMB PROSTH VERTCL SHOCK RDUC PYLN FEATUR Orthotics/Prosthetic Greater than $500 L5990 ADD LOW EXTREM PROSTH USER ADJUSTBLE HEEL HT Orthotics/Prosthetic Greater than $500 L5999 LOWER EXTREMITY PROSTHESIS NOS Orthotics/Prosthetic Greater than $500 L6000 PARTIAL HAND THUMB REMAINING Orthotics/Prosthetic Greater than $500 L6010 PARTIAL HAND LITTLE & OR RING FINGER REMAINING Orthotics/Prosthetic Greater than $500 L6020 PARTIAL HAND NO FINGER REMAINING Orthotics/Prosthetic Greater than $500 L6050 WRST DISARTIC MOLD SOCKET FLEX ELB HNG TRICP PAD Orthotics/Prosthetic Greater than $500 L6055 WRST DISARTIC MOLD SOCKT W/XPNDABLE INTERFCE Orthotics/Prosthetic Greater than $500 L6100 BELW ELB MOLD SOCKT FLXIBLE ELB HINGE TRICP PAD Orthotics/Prosthetic Greater than $500 L6110 BELOW ELBOW MOLDED SOCKET Orthotics/Prosthetic L6120 BELW ELB MOLD DBL WALL SCKT STEP-UP HNG 1/2 CUFF


Greater than $500 Orthotics/Prosthetic Greater than $500 L6130 BELW ELB STUMP ACTVATD LOCK HINGE HALF CUFF Orthotics/Prosthetic Greater than $500 L6200 ELB DISARTC MOLD SOCKT OUTSIDE LOCK HINGE FORARM Orthotics/Prosthetic Greater than $500 L6205 ELB DISARTC MOLD SCKT W/XPND INTRFCE LOCK FORARM Orthotics/Prosthetic Greater than $500 L6250 ABVE ELB MOLD DBL WALL SCKT INTRL LCK ELB FORARM Orthotics/Prosthetic Greater than $500 L6300 SHLDR DISARTIC MOLD SOCKET INTRL LOCK ELB FORARM Orthotics/Prosthetic Greater than $500 L6310 SHOULDER DISARTIC PASSIVE REST COMPLETE PROSTH Orthotics/Prosthetic Greater than $500 L6320 SHOULDER DISART PASSIVE REST SHOULDER CAP ONLY Orthotics/Prosthetic Greater than $500 L6350 INTERSCAP THOR HUM SECT INTRL LOCK ELB FORARM Orthotics/Prosthetic Greater than $500 L6360 INTERSCAPULAR THOR PASSIVE REST CMPL PROSTH Orthotics/Prosthetic Greater than $500 L6370 INTERSCAPULAR THOR PASSIVE REST SHLDR CAP ONLY Orthotics/Prosthetic Greater than $500 L6380 IMMED POSTSURG RIGD DRSG 1 CAST CHG WRST DISRTC Orthotics/Prosthetic Greater than $500 L6382 IMMED POSTSURG RIGD DRSG 1 CAST CHG ELB DISARTIC Orthotics/Prosthetic Greater than $500 L6384 IMMED POSTSURG RIGD DRSG 1 CAST CHG SHLDR DISRTC Orthotics/Prosthetic Greater than $500 L6400 BE MOLD SCKT ENDOSKEL SYS W/SFT PROSTH TISS SHAP Orthotics/Prosthetic Greater than $500 L6450 ELB DISRTC MOLD SCKT ENDOSKEL W/SFT PROSTH TISS Orthotics/Prosthetic Greater than $500 L6500 ABVE ELB MOLD SCKT ENDOSKEL W/SFT PROSTH TISS Orthotics/Prosthetic Greater than $500 L6550 SHLDR DISRTC MOLD SCKT ENDOSKEL W/SFT PROS TISS


Orthotics/Prosthetic Greater than $500 L6570 INTRSCAP THOR MOLD SCKT ENDOSKEL W/SFT PROS TISS Orthotics/Prosthetic Greater than $500 L6580 PREP WRST DISRTC/BELW ELB 1 WALL PLSTC SCKT MOLD Orthotics/Prosthetic Greater than $500 L6582 PREP WRST DISRTC/BELW ELB 1 WALL SCKT DIR FORMED Orthotics/Prosthetic Greater than $500 L6584 PREP ELB DISRTC/ABVE ELB 1 WALL PLSTC SOCKT MOLD Orthotics/Prosthetic Greater than $500 L6586 PREP ELB DISRTC/ABVE ELB 1 WALL SOCKT DIR FORMED Orthotics/Prosthetic Greater than $500 L6588 PREP SHLDR DISRTC THOR 1 WALL PLSTC SCKT MOLD Orthotics/Prosthetic Greater than $500 L6590 PREP SHLDR DISRTC THOR 1 WALL SOCKET DIR FORM Orthotics/Prosthetic Greater than $500 L6621 UP EXTREM PROS ADD FLEXION/EXTENSION WRIST Orthotics/Prosthetic Greater than $500 L6623 UP EXT ADD SPRNG ASST ROTATL WRST U W/LATCH RLSE Orthotics/Prosthetic Greater than $500 L6624 UPPER EXTREMITY ADD FLX/EXT ROTATION WRIST UNIT Orthotics/Prosthetic Greater than $500 L6646 UP EXT ADD SHLDR JNT MX PSTN W/BDY/EXT PWR SYS Orthotics/Prosthetic Greater than $500 L6648 UP EXTREM ADD SHLDR LOCK MECH EXT PWR ACTUATOR Orthotics/Prosthetic Greater than $500 L6686 UPPER EXTREMITY ADDITION SUCTION SOCKET Orthotics/Prosthetic Greater than $500 L6687 UP EXTRM ADD FRME TYPE SCKT BELW ELB/WRST DISRTC Orthotics/Prosthetic Greater than $500 L6689 UPPER EXTREM ADD FRAME TYPE SOCKT SHLDR DISARTIC Orthotics/Prosthetic Greater than $500 L6690 UPPER EXTREM ADD FRAME TYPE SOCKT INTERSCAP-THOR Orthotics/Prosthetic Greater than $500 L6692 UPPER EXTREM ADDITION SILCON GEL INSERT/EQUAL EA Orthotics/Prosthetic L6693 UPPER EXTREM ADD LOCK ELB FORARM COUNTERBALANCE


Greater than $500 Orthotics/Prosthetic Greater than $500 L6694 ADD UP EXT PROS BELW/ABVE ELB CSTM W/LOCK MECH Orthotics/Prosthetic Greater than $500 L6695 ADD UP EXT PROS BELW/ABVE ELB CSTM W/O LOCK MECH Orthotics/Prosthetic Greater than $500 L6696 ADD UP EXT PROS ELB CSTM CNGN/TRAUMAT AMP INIT Orthotics/Prosthetic Greater than $500 L6697 ADD UP EXT PROS ELB CSTM NOT CNGN/TRAUM AMP INIT Orthotics/Prosthetic Greater than $500 L6704 TERMINAL DEVICE SPORT/RECREATIONAL/WORK ATTACH Orthotics/Prosthetic Greater than $500 L6707 TERMINAL DEVICE HOOK MECH VOLUNTARY CLOSING Orthotics/Prosthetic Greater than $500 L6708 TERMINAL DEVICE HAND MECH VOLUNTARY OPENING Orthotics/Prosthetic Greater than $500 L6709 TERMINAL DEVICE HAND MECH VOLUNTARY CLOSING Orthotics/Prosthetic Greater than $500 L6711 TERM DVC HOOK MECH VOL OPN ANY MATL ANY SZ PED Orthotics/Prosthetic Greater than $500 L6712 TERM DVC HOOK MECH VOL CLOS ANY MATL ANY SZ PED Orthotics/Prosthetic Greater than $500 L6713 TERM DVC HAND MECH VOL OPN ANY MATL ANY SIZE PED Orthotics/Prosthetic Greater than $500 L6714 TERM DEVC HAND MECH VOL CLOS ANY MATL ANY SZ PED Orthotics/Prosthetic Greater than $500 L6715 TERM DEV MX ARTIC DIGIT W/MOTORS INIT ISSUE/REPL Orthotics/Prosthetic Greater than $500 L6880 ELEC HND SWTCH/MYOLELEC CNTRL INDEP ARTC DIG MTR Orthotics/Prosthetic Greater than $500 L6881 AUTOMATIC GRASP ADD UPPER LIMB ELEC PROSTH DEVC Orthotics/Prosthetic Greater than $500 L6882 MICRPRROCSS CNTRL FEATUR ADD UP LIMB PROSTH DEVC Orthotics/Prosthetic Greater than $500 L6883 REPL SOCKET BE/WD MOLDED TO PATIENT MODEL


Orthotics/Prosthetic Greater than $500 L6884 REPL SOCKET ABOVE ELBOW/ELBOW DISART MOLD TO PT Orthotics/Prosthetic Greater than $500 L6885 REPL SOCKET SD/INTERSCAPULAR THOR MOLD PT MODEL Orthotics/Prosthetic Greater than $500 L6895 ADD UP EXT PROSTH GLOV TERM DEVC MATL CSTM FAB Orthotics/Prosthetic Greater than $500 L6900 HAND REST PART HAND W/GLOVE THUMB/1 FNGR REMAIN Orthotics/Prosthetic Greater than $500 L6905 HAND REST PART HAND W/GLOVE MX FNGR REMAIN Orthotics/Prosthetic Greater than $500 L6910 HAND REST PART HAND W/GLOVE NO FNGR REMAIN Orthotics/Prosthetic Greater than $500 L6915 HAND RESTORATION REPLACEMENT GLOVE FOR ABOVE Orthotics/Prosthetic Greater than $500 L6920 WRST DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6925 WRST DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6930 BELW ELB OTTO BOCK/=SWITCH CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6935 BELW ELB OTTO BOCK/=MYOELEC CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6940 ELB DISARTIC OTTO BOCK/=SWITCH CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6945 ELB DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6950 ABVE ELB OTTO BOCK/=SWITCH CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6955 ABVE ELB OTTO BOCK/=MYOELEC CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6960 SHLDR DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVC Orthotics/Prosthetic Greater than $500 L6965 SHLDR DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM Orthotics/Prosthetic L6970 INTERSCAP-THOR OTTO BOCK/=SWTCH CNTRL TERM DEVC


Greater than $500 Orthotics/Prosthetic Greater than $500 L6975 INTERSCAP-THOR OTTO BOCK/=MYOELEC CNTRL TERM DVC Orthotics/Prosthetic Greater than $500 L7007 ELECTRIC HAND SWITCH/MYOELECTRIC CONTROL ADULT Orthotics/Prosthetic Greater than $500 L7008 ELECTRIC HAND SWITCH/MYOELECTRIC CNTRL PEDIATRIC Orthotics/Prosthetic Greater than $500 L7009 ELECTRIC HOOK SWITCH/MYOELECTRIC CONTROL ADULT Orthotics/Prosthetic Greater than $500 L7040 PREHENSILE ACTUATOR SWITCH CONTROLLED Orthotics/Prosthetic Greater than $500 L7045 ELEC HOOK SWITCH/MYOELECTRIC CONTOL PEDIATRIC Orthotics/Prosthetic Greater than $500 L7170 ELECTRONIC ELBOW HOSMER/EQUAL SWITCH CONTROLLED Orthotics/Prosthetic Greater than $500 L7180 ELEC ELB MICROPRC SEQENTIAL CNTRL ELB&TERM DEVC Orthotics/Prosthetic Greater than $500 L7181 ELEC ELB MICROPRC SIMULTAN CNTRL ELB&TERM DEVC Orthotics/Prosthetic Greater than $500 L7185 ELEC ELB ADOLES VRITY VILLAGE/EQUAL SWITCH CNTRL Orthotics/Prosthetic Greater than $500 L7186 ELEC ELB CHILD VRITY VILLAGE/EQUAL SWITCH CNTRL Orthotics/Prosthetic Greater than $500 L7190 ELEC ELB ADOLES VRITY VILLAGE/= MYOELEC CNTRL Orthotics/Prosthetic Greater than $500 L7191 ELEC ELB CHLD VRITY VILL/= MYOELECTRNICALY CNTRL Orthotics/Prosthetic Greater than $500 L7405 ADD UP EXTREM PROS SD/INTERSCAP THOR ACRYLC MATL Orthotics/Prosthetic Greater than $500 L7499 UPPER EXTREMITY PROSTHESIS NOS Orthotics/Prosthetic Greater than $500 L8035 CSTM BREAST PROSTH POST MASTECT MOLDED PT MODEL Orthotics/Prosthetic Greater than $500 L8040 NASAL PROSTHESIS PROVIDED BY A NON-PHYSICIAN


Orthotics/Prosthetic Greater than $500 L8041 MIDFACIAL PROSTHESIS PROVIDED BY A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8042 ORBITAL PROSTHESIS PROVIDED BY A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8043 UPPER FACIAL PROSTHESIS PROVIDED A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8044 HEMI-FACIAL PROSTHESIS PROVIDED A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8045 AURICULAR PROSTHESIS PROVIDED BY A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8046 PARTIAL FACIAL PROSTHESIS PROVIDED NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8047 NASAL SEPTAL PROSTHESIS PROVIDED A NON-PHYSICIAN Orthotics/Prosthetic Greater than $500 L8499 UNLISTED PROC MISCELLANEOUS PROSTHETIC SERVICES Orthotics/Prosthetic Greater than $500 L8500 ARTIFICIAL LARYNX ANY TYPE Orthotics/Prosthetic Greater than $500 L8605 Tissue expander implant Orthotics/Prosthetic Greater than $500 L8609 ARTIFICIAL CORNEA Orthotics/Prosthetic Greater than $500 L8610 OCULAR IMPLANT Orthotics/Prosthetic Greater than $500 L8612 AQUEOUS SHUNT Orthotics/Prosthetic Greater than $500 L8631 MPJ REPLCMT TWO/MORE PECES METL CERAM-LIKE MATL Orthotics/Prosthetic Greater than $500 L8659 IP FNGR JNT REPLCMT 2/MORE PECES METL CERAM-LIKE Orthotics/Prosthetic Greater than $500 V2623 PROSTHETIC EYE PLASTIC CUSTOM Orthotics/Prosthetic Greater than $500 V2627 SCLERAL COVER SHELL Outpatient Therapy 97010 APPLICATION MODALITY 1/Greater than AREAS HOT/COLD PACKS


Outpatient Therapy 97012 APPL MODALITY 1/Greater than AREAS TRACTION MECHANICAL Outpatient Therapy 97014 APPL MODALITY 1/Greater than AREAS ELEC STIMJ UNATTENDED Outpatient Therapy 97016 APPL MODALITY 1/Greater than AREAS VASOPNEUMATIC DEVICES Outpatient Therapy 97018 APPL MODALITY 1/Greater than AREAS PARAFFIN BATH Outpatient Therapy 97022 APPLICATION MODALITY 1/Greater than AREAS WHIRLPOOL Outpatient Therapy 97026 APPLICATION MODALITY 1/Greater than AREAS INFRARED Outpatient Therapy 97028 APPL MODALITY 1/Greater than AREAS ULTRAVIOLET Outpatient Therapy 97033 APPL MODALITY 1/Greater than AREAS IONTOPHORESIS EA 15 MIN Outpatient Therapy 97034 APPL MODALITY 1/Greater than AREAS CONTRAST BATHS EA 15 MIN Outpatient Therapy 97039 UNLIST MODALITY SPEC TYPE&TIME CONSTANT ATTENDCE Outpatient Therapy 97110 THERAPEUTIC PX 1/Greater than AREAS EACH 15 MIN EXERCISES Outpatient Therapy 97112 THER PX 1/Greater than AREAS EACH 15 MIN NEUROMUSC REEDUCAJ Outpatient Therapy 97113 THER PX 1/Greater than AREAS EACH 15 MIN AQUA THER W/XERSS Outpatient Therapy 97116 THER PX 1/Greater than AREAS EA 15 MIN GAIT TRAINJ W/STAIR Outpatient Therapy 97124 THER PX 1/Greater than AREAS EACH 15 MINUTES MASSAGE Outpatient Therapy 97140 MANUAL THERAPY TQS 1/Greater than REGIONS EACH 15 MINUTES Outpatient Therapy G0129 OCCUP TX REQ SKILLS QUAL OCCUP TRPST PER SESSION Outpatient Therapy S8990 PHYSICAL/MANIP TX MAINT RATHER THAN RESTORATION Outpatient Therapy - Speech 92508 TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC 2/Greater than Outpatient Therapy - Speech 92526 TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING Outpatient Therapy - Speech & Home Health 92507 TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC INDIV Outpatient Therapy & Home Health 97799 UNLISTED PHYSICAL MEDICINE/REHAB SERVICE/PROC Personal Care Service S5125 HCPC Codes Attendant care services; per 15 minutes Private Duty Nursing T1000 PRIV DUTY/INDEPEND NRS SERVICE LIC UP 15 MIN Private Duty Nursing T1002 Rn services, up to 15 minutes Private Duty Nursing T1003 Lpn/lvn services, up to 15 minutes Proton Beam Therapy 77520 PROTON TX DELIVERY SIMPLE W/O COMPENSATION Proton Beam Therapy 77522 PROTON TX DELIVERY SIMPLE W/COMPENSATION Proton Beam Therapy 77523 PROTON TX DELIVERY INTERMEDIATE


Proton Beam Therapy 77525 PROTON TX DELIVERY COMPLEX Radiology 70336 MRI TMPRMAND JT Radiology 70450 CT HEAD/BRN C-MATRL Radiology 70460 CT HEAD/BRN C+ MATRL Radiology 70470 CT HEAD/BRN C-/C+ Radiology 70480 CT ORBIT SELLA/POST FOSSA/EAR C-MATRL Radiology 70481 CT ORBIT SELLA/POST FOSSA/EAR C+ MATRL Radiology 70482 CT ORBIT SELLA/POST FOSSA/EAR C-/C+ Radiology 70486 CT MAXLFCL AREA C-MATRL Radiology 70487 CT MAXLFCL AREA C+ MATRL Radiology 70488 CT MAXLFCL AREA C-/C+ Radiology 70490 CT SOFT TISS NCK C-MATRL Radiology 70491 CT SOFT TISS NCK C+ MATRL Radiology 70492 CT SOFT TISS NCK C-/C+ Radiology 70496 CT ANGIOGRAPHY HEAD W/CONTRAST/ NONCONTRAST Radiology 70498 CT ANGIOGRAPHY NECK W/CONTRAST/ NONCONTRAST Radiology 70540 MRI ORBIT FACE &/NECK W/O CONTRAST Radiology 70542 MRI ORBIT FACE&NCK C+ MATRL Radiology 70543 MRI ORBIT FACE&NCK C-/C+ Radiology 70544 MRA HEAD C-MATRL Radiology 70545 MRA HEAD C+ MATRL Radiology 70546 MRA HEAD C-/C+ Radiology 70547 MRA NCK C-MATRL Radiology 70548 MRA NCK C+ MATRL Radiology 70549 MRA NCK C-/C+ Radiology 70551 MRI BRN BRN STEM C-MATRL Radiology 70552 MRI BRN BRN STEM C+ MATRL Radiology 70553 MRI BRN BRN STEM C-/C+ Radiology 70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION Radiology 70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION Radiology 71250 CT THORAX C-MATRL Radiology 71260 CT THORAX C+ MATRL


Radiology 71270 CT THORAX C-/C+ Radiology 71275 CT ANGIOGRAPHY CHEST W/CONTRAST/ NONCONTRAST Radiology 71550 MRI CH C-MATRL Radiology 71551 MRI CH C+ MATRL Radiology 71552 MRI CH C-/C+ Radiology 71555 MRA CH C+-MATRL Radiology 72125 CT CRV SPI C-MATRL Radiology 72126 CT CRV SPI C+ MATRL Radiology 72127 CT CRV SPI C-/C+ Radiology 72128 CT THRC SPI C-MATRL Radiology 72129 CT THRC SPI C+ MATRL Radiology 72130 CT THRC SPI C-/C+ Radiology 72131 CT LMBR SPI C-MATRL Radiology 72132 CT LMBR SPI C+ MATRL Radiology 72133 CT LMBR SPI C-/C+ Radiology 72141 MRI SPI CANAL&CNTS CRV C-MATRL Radiology 72142 MRI SPI CANAL&CNTS CRV C+ MATRL Radiology 72146 MRI SPI CANAL&CNTS THRC C-MATRL Radiology 72147 MRI SPI CANAL&CNTS THRC C+ MATRL Radiology 72148 MRI SPI CANAL&CNTS LMBR C-MATRL Radiology 72149 MRI SPI CANAL&CNTS LMBR C+ MATRL Radiology 72156 MRI SPI CANAL&CNTS C-/C+ CRV Radiology 72157 MRI SPI CANAL&CNTS C-/C+ Radiology 72158 MRI SPI CANAL&CNTS C-/C+ LMBR Radiology 72159 MRA SPI CANAL&CNTS C+-MATRL Radiology 72191 CT ANGIOGRAPHY PELVIS W/CONTRAST/ NONCONTRAST Radiology 72192 CT PELVIS C-MATRL Radiology 72193 CT PELVIS C+ MATRL Radiology 72194 CT PELVIS C-/C+ Radiology 72195 MRI PELVIS C-MATRL Radiology 72196 MRI PELVIS C+ MATRL Radiology 72197 MRI PELVIS C-/C+


Radiology 72198 MRA PELVIS C+-MATRL Radiology 73200 CT UXTR C-MATRL Radiology 73201 CT UXTR C+ MATRL Radiology 73202 CT UXTR C-/C+ Radiology 73206 CT ANGIOGRAPHY UPPER EXTREMITY Radiology 73218 MRI UXTR OTH/THN JT C-MATRL Radiology 73219 MRI UXTR OTH/THN JT C+ MATRL Radiology 73220 MRI UXTR OTH/THN JT C-/C+ Radiology 73221 MRI ANY JT UXTR C-MATRL Radiology 73222 MRI ANY JT UXTR C+ MATRL Radiology 73223 MRI ANY JT UXTR C-/C+ Radiology 73225 MRA UXTR C+-MATRL Radiology 73700 CT LXTR C-MATRL Radiology 73701 CT LXTR C+ MATRL Radiology 73702 CT LXTR C-/C+ Radiology 73706 CT ANGIOGRAPHY LOWER EXTREMITY Radiology 73718 MRI LXTR OTH/THN JT C-MATRL Radiology 73719 MRI IMG LXTR OTH/THN JT C+ MATRL Radiology 73720 MRI LXTR OTH/THN JT C-/C+ Radiology 73721 MRI ANY JT LXTR C-MATRL Radiology 73722 MRI ANY JT LXTR C+ MATRL Radiology 73723 MRI ANY JT LXTR C-/C+ Radiology 73725 MRA LXTR C+-MATRL Radiology 74150 CT ABD C-MATRL Radiology 74160 CT ABD C+ MATRL Radiology 74170 CT ABD C-/C+ Radiology 74174 CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGES Radiology 74175 CT ANGIOGRAPHY ABDOMEN W/ CONTRAST/NONCONTRAST Radiology 74176 CT ABD & PELVIS W/O CONTRAST Radiology 74177 CT ABD & PELVIS W/CONTRAST Radiology 74178 CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS Radiology 74181 MRI ABD C-MATRL


Radiology 74182 MRI ABD C+ MATRL Radiology 74183 MRI ABD C-/C+ Radiology 74185 MRA ABD C+-MATRL Radiology 74261 CT COLONOGRPHY DX IMAGE POSTPROCESS NO CONTRAST Radiology 74262 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST Radiology 74263 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING Radiology 74712 MRI FETAL SNGL/1ST GESTATION Radiology 74713 MRI FETAL EA ADDL GESTATION Radiology 75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST Radiology 75559 CARDIAC MRI W/O CONTRAST W STRESS IMAGING Radiology 75561 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ Radiology 75563 CARDIAC MRI W/W/O CONTRAST W STRESS Radiology 75571 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM Radiology 75572 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH Radiology 75573 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT DX Radiology 75574 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST Radiology 75635 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST- PXESSING Radiology 76376 3D RNDR I&R CT MRI US/OTH X REQ POSTPCX Radiology 76377 3D RNDR I&R CT MRI US/OTH REQ POSTPCX Radiology 76380 CT LMTD/LOCLZD F-UP STD Radiology 76497 UNLIS CT PX Radiology 76498 UNLIS MRI PX Radiology 77021 MR GUIDANCE NEEDLE PLACEMENT Radiology 77058 MRI BREAST UNILATERAL Radiology 77059 MRI BREAST BILATERAL Radiology 77084 BONE MARROW BLOOD SUPPLY Radiology 78012 THYROID UPTAKE MEASUREMENT Radiology 78013 THYROID IMAGING W/BLOOD FLOW Radiology 78014 THYROID IMG W/BF W/QUANT MEAS Radiology 78015 THYR CARC METASTASES IMG LMTD AREA Radiology 78016 THYR CARC METASTASES IMG ADDL STD Radiology 78018 THYR CARC METASTASES IMG WHBDY


Radiology 78070 PARATHYR IMG Radiology 78071 PARATHYRD PLANAR W/WO SUBTRJ Radiology 78072 PARATHYRD PLANAR W/SPECT&CT Radiology 78075 ADRNL IMG CORTEX&/MEDULLA Radiology 78099 UNLIS ENDOC PX DX NUC MED Radiology 78102 B1 MARROW IMG LMTD AREA Radiology 78103 B1 MARROW IMG MLT AREAS Radiology 78104 B1 MARROW IMG WHBDY Radiology 78185 SPLEEN IMG ONLY +-VASC FLO Radiology 78195 LYMPHATICS&LYMPH NOD IMG Radiology 78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED Radiology 78201 LVR IMG STATIC ONLY Radiology 78202 LVR IMG VASC FLO Radiology 78205 LVR IMG SPECT Radiology 78206 LVR IMG SPECT VASC FLO Radiology 78215 LVR&SPLEEN IMG STATIC ONLY Radiology 78216 LVR&SPLEEN IMG VASC FLO Radiology 78226 HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER Radiology 78227 HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ Radiology 78230 SALIVARY GLND IMG Radiology 78231 SALIVARY GLND IMG SRL IMAGES Radiology 78232 SALIVARY GLND FUNCJ STD Radiology 78258 ESOPHGL MOTILITY Radiology 78261 GSTR MUCOSA IMG Radiology 78262 G-ESOP RFLX STD Radiology 78264 GSTR EMPTYING STD Radiology 78265 GASTRIC EMPTYING IMAG STUDY Radiology 78266 GASTRIC EMPTYING IMAG STUDY Radiology 78278 AQT GI BLD LOSS IMG Radiology 78282 GI PROTEIN LOSS Radiology 78290 INT IMG Radiology 78291 PRTL-VEN SHUNT PATENCY TST


Radiology 78299 UNLIS GI PX DX NUC MED Radiology 78300 B1&/JT IMG LMTD AREA Radiology 78305 B1&/JT IMG MLT AREAS Radiology 78306 B1&/JT IMG WHBDY Radiology 78315 B1&/JT IMG 3 PHASE STD Radiology 78320 B1&/JT IMG TOMOG SPECT Radiology 78399 UNLIS MUSCSKEL PX DX NUC MED Radiology 78428 CAR SHUNT DETCJ Radiology 78445 NON-CAR VASC FLO IMG Radiology 78451 MYOCARDIAL SPECT MULTIPLE STUDIES Radiology 78452 MYOCARDIAL SPECT MULTIPLE STUDIES Radiology 78453 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS Radiology 78454 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES Radiology 78456 AQT VEN THROMBOSIS IMG PEPTIDE Radiology 78457 VEN THROMBOSIS IMG VENOGRAM UNI Radiology 78458 VEN THROMBOSIS IMG VENOGRAM BI Radiology 78459 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL Radiology 78466 MYOCRD IMG INFARCT AVID PLNR QUAL/ QUAN Radiology 78468 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ Radiology 78469 MYOCRD IMG INFARCT AVID PLNR TOMOG SPECT +-QUAN Radiology 78472 CARD BPI GTD =BRM PLNR 1 STD REST/ STRS Radiology 78473 CARD BPI GTD =BRM MLT STD WALL MOTION STD Radiology 78481 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT Radiology 78483 CARD BPI PLNR 1ST PS MLT STD PLUS EJEC FXJ Radiology 78491 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD Radiology 78492 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD Radiology 78494 CARD BPI GTD =BRM SPECT REST WALL MOTION Radiology 78496 CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT Radiology 78499 UNLIS CV DX NUC MED Radiology 78579 PULMONARY VENTILATION IMAGING Radiology 78580 PULMONARY PERFUSION IMAGING PARTICULATE Radiology 78582 PULMONARY VENTILATION & PERFUSION IMAGING


Radiology 78597 QUANT DIFFERENTIAL PULM PERFUSION W/ WO IMAGING Radiology 78598 QUANT DIFF PULM PRFUSION & VENTLAJ W/ WO IMAGING Radiology 78599 UNLIS RESPIR PX DX NUC MED Radiology 78600 BRAIN IMAGING <4 STATIC VIEWS Radiology 78601 BRAIN IMAGING >4 STATIC VIEWS W VASCULAR FLOW Radiology 78605 BRAIN IMAGING MIN 4 STATIC VIEWS Radiology 78606 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW Radiology 78607 BRAIN IMAGING TOMOGRAPHIC SPECT Radiology 78608 BRN IMG P+ EMIJ TOMOG METAB EVAL Radiology 78609 BRN IMG P+ EMIJ TOMOG PRFUJ EVAL Radiology 78610 BRN IMG VASC FLO ONLY Radiology 78630 CEREBSP FLU FLO IMG X INTRO MATRL CISTRNG Radiology 78635 CEREBSP FLU FLO IMG X INTRO MATRL VENTRG Radiology 78645 CEREBSP FLU FLO IMG X INTRO MATRL SHUNT EVAL Radiology 78647 CEREBSP FLU FLO IMG X INTRO MATRL TOMOG SPECT Radiology 78650 CEREBSP FLU LEAKAGE DETCJ&LOCLZJ Radiology 78660 RP DACRYOCSTOGRAPY Radiology 78699 UNLIS NRVS SYS PX DX NUC MED Radiology 78700 KIDNEY IMAGING MORPHOLOGY Radiology 78701 KDN IMG VASC FLO Radiology 78707 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX Radiology 78708 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W RX Radiology 78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE Radiology 78710 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC Radiology 78740 URTRL RFLX STD RP VOIDING CSTOGRAM Radiology 78761 TESTICULAR IMAGING WITH VASCULAR FLOW Radiology 78799 UNLIS GENITOUR DX NUC MED Radiology 78800 RP LOCLZJ TUM/DSTRBJ AGT LMTD AREA Radiology 78801 RP LOCLZJ TUM/DSTRBJ AGT MLT AREAS Radiology 78802 RP LOCLZJ TUM/DSTRBJ AGT WHBDY 1 D IMG Radiology 78803 RP LOCLZJ TUM/DSTRBJ AGT TOMOG SPECT Radiology 78804 RP LOCLZJ TUM/DSTRBJ AGT WHBDY REQ 2/> D IMG


Radiology 78805 RP LOCLZJ INFLAMMATORY PROCESS LMTD AREA Radiology 78806 RP LOCLZJ INFLAMMATORY PROCESS WHBDY Radiology 78807 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT Radiology 78811 PET IMAGING LIMITED AREA CHEST HEAD/ NECK Radiology 78812 PET IMAGING SKULL BASE TO MID-THIGH Radiology 78813 PET IMAGING WHOLE BODY Radiology 78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA Radiology 78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH Radiology 78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY Radiology 78999 UNLIS MISC DX NUC MED Radiology C8900 MRA ABD C+-MATRL Radiology C8901 MRA ABD C+-MATRL Radiology C8902 MRA ABD C+-MATRL Radiology C8903 MRI BREAST UNILATERAL Radiology C8904 MRI BREAST UNILATERAL Radiology C8905 MRI BREAST UNILATERAL Radiology C8906 MRI BREAST BILATERAL Radiology C8907 MRI BREAST BILATERAL Radiology C8908 MRI BREAST BILATERAL Radiology C8909 MRA CH C+-MATRL Radiology C8910 MRA CH C+-MATRL Radiology C8911 MRA CH C+-MATRL Radiology C8912 MRA LXTR C+-MATRL Radiology C8913 MRA LXTR C+-MATRL Radiology C8914 MRA LXTR C+-MATRL Radiology C8918 MRA PELVIS C+-MATRL Radiology C8919 MRA PELVIS C+-MATRL Radiology C8920 MRA PELVIS C+-MATRL Radiology C8931 MR ANGIOGRAPHY W/CONTRAST SPINAL CANAL CONTENTS Radiology C8932 MR ANGIOGRAPHY W/O CONTRST SPINAL CANAL CONTENTS Radiology C8933 MR ANGIO NO CONTRST FLW W/CONTRST SP CANAL CNTN Radiology C8934 MR ANGIOGRAPHY WITH CONTRAST UPPER EXTREMITY


Radiology C8935 MR ANGIOGRAPHY WITHOUT CONTRAST UPPER EXTREMITY Radiology C8936 ANGIO W/O CONTRST FOLLOWED W/ CONTRST UP EXT Radiology G0235 PET IMAGING, ANY SITE NOT OTHERWISE SPECIFIED Radiology G0252 PET, FULL AND PARTIAL RING, FOR INITIAL DX OF BREAST CANCER Radiology G0297 CT THORAX C-MATRL LOW DOSE Radiology S8032 CT THORAX C-MATRL LOW DOSE Radiology S8037 MRI ABD C-/C+ Radiology S8042 MRI, LOW FIELD Radiology S8085 FLOURINE-18 IMAGING

Radiology S8092 ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINET)

Rhinoplasty 30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NASAL TIP Rhinoplasty 30410 RHINP PRIM COMPLETE XTRNL PARTS Rhinoplasty 30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR Rhinoplasty 30430 RHINOPLASTY SECONDARY MINOR REVISION Rhinoplasty 30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION Rhinoplasty 30450 RHINOPLASTY SECONDARY MAJOR REVISION Rhinoplasty 30460 RHINP DFRM W/COLUM LNGTH TIP ONLY Rhinoplasty 30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT

Sinuplasty 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa

Sinuplasty 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) Sinuplasty 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) Sleep Apnea Procedures & Surgeries 21685 HYOID MYOTOMY & SUSPENSION Sleep Apnea Procedures & Surgeries 41530 SUBMUCOSAL ABLTJ TONGUE RF 1/Greater than SITES PR SESSION Sleep Apnea Procedures & Surgeries 41599 Unlisted procedure, tongue, floor of mouth Sleep Apnea Procedures & Surgeries 42145 PALATOPHARYNGOPLASTY Sleep Studies - Attended 95805 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG Sleep Studies - Attended 95807 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN


Sleep Studies - Attended 95808 POLYSOMNOGRAPHY SLEEP STAGING 1-3 ADDL PARAM Sleep Studies - Attended 95810 POLYSOMNOGRAPHY SLEEP STAGING 4/Greater than ADDL PARAM Sleep Studies - Attended 95811 POLYSM SLEEP STAGING 4/Greater than ADDL PARAM W/CPAP TX Spinal Stimulator for Pain Management 63650 PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL Spinal Stimulator for Pain Management 63655 LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL Spinal Stimulator for Pain Management 63685 INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING Spinal Surgery 22100 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV Spinal Surgery 22101 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC Spinal Surgery 22102 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR Spinal Surgery 22110 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV Spinal Surgery 22112 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC Spinal Surgery 22114 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR Spinal Surgery 22206 OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC Spinal Surgery 22207 OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR Spinal Surgery 22210 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV Spinal Surgery 22212 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC Spinal Surgery 22214 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR Spinal Surgery 22220 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM CRV Spinal Surgery 22224 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM LMBR Spinal Surgery 22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC Spinal Surgery 22533 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR Spinal Surgery 22548 ARTHRD ANT TRANSORAL/XTRORAL C1-C2 W/WOEXC ODNTD Spinal Surgery 22551 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 Spinal Surgery 22554 ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 Spinal Surgery 22556 ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC Spinal Surgery 22558 ARTHRODESIS ANTERIOR INTERBODY LUMBAR

Spinal Surgery 22586

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

Spinal Surgery 22590 ARTHRODESIS POSTERIOR CRANIOCERVICAL


Spinal Surgery 22595 ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 Spinal Surgery 22600 ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM Spinal Surgery 22610 ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC Spinal Surgery 22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR Spinal Surgery 22630 ARTHRODESIS POSTERIOR INTERBODY LUMBAR Spinal Surgery 22633 ARTHDSIS POST/POSTEROLATRL/POSTINTERBODY LUMBAR Spinal Surgery 22800 ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG Spinal Surgery 22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG Spinal Surgery 22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13/Greater than VRT SEG Spinal Surgery 22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG Spinal Surgery 22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG Spinal Surgery 22812 ARTHRODESIS POSTERIOR SPINAL DFRM 8/Greater than VRT SEG Spinal Surgery 22818 KYPHECTOMY SINGLE OR TWO SEGMENTS Spinal Surgery 22819 KYPHECTOMY 3 OR MORE SEGMENTS Spinal Surgery 22830 EXPLORATION SPINAL FUSION Spinal Surgery 22849 REINSERTION SPINAL FIXATION DEVICE Spinal Surgery 22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION Spinal Surgery 22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION Spinal Surgery 22855 REMOVAL ANTERIOR INSTRUMENTATION Spinal Surgery 22856 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV Spinal Surgery 22861 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV Spinal Surgery 22864 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL Spinal Surgery 22865 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR Spinal Surgery 22899 Unlisted procedure, spine Spinal Surgery 63001 LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV Spinal Surgery 63003 LAMINECTOMY W/O FFD 1/2 VERT SEG THORACIC Spinal Surgery 63005 LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR Spinal Surgery 63011 LAMINECTOMY W/O FFD 1/2 VERT SEG SACRAL Spinal Surgery 63012 LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR Spinal Surgery 63015 LAMINECTOMY W/O FFD Greater than 2 VERT SEG CERVICAL Spinal Surgery 63016 LAMINECTOMY W/O FFD Greater than 2 VERT SEG THORACIC Spinal Surgery 63017 LAMINECTOMY W/O FFD Greater than 2 VERT SEG LUMBAR


Spinal Surgery 63020 LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC CERVC Spinal Surgery 63030 LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR Spinal Surgery 63040 LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC CERVICAL Spinal Surgery 63042 LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR Spinal Surgery 63045 LAM FACETEC&FORAMOT 1 SEGMENT CERVICAL Spinal Surgery 63046 LAM FACETEC&FORAMOT 1 SEGMENT THORACIC Spinal Surgery 63047 LAM FACETEC&FORAMOT 1 SEGMENT LUMBAR Spinal Surgery 63050 LAMOP CERVICAL W/DCMPRN SPI CORD 2/Greater than VERT SEG Spinal Surgery 63055 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG THORACIC Spinal Surgery 63056 TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG LUMBAR Spinal Surgery 63064 COSTOVERTEBRAL DCMPRN SPINAL CORD THORACIC 1 SEG Spinal Surgery 63075 DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC Spinal Surgery 63077 DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC Spinal Surgery 63081 VERTEBRAL CORPECTOMY ANT DCMPRN CERVICAL 1 SEG Spinal Surgery 63085 VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC 1 SEG Spinal Surgery 63087 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SEG Spinal Surgery 63090 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SEG Spinal Surgery 63101 VERTEB CORPECT LAT XTRCAVITARY DCMPRN THRC 1 SEG Spinal Surgery 63102 VERTEB CORPECT LAT XTRCAVITARY DCMPRN LMBR 1 SEG Spinal Surgery 63170 LAM W/MYELOTOMY CERVICAL/THORACIC/THORACOLUMBAR Spinal Surgery 63172 LAM W/DRG INTRMEDULLARY CYST/SYRINX SUBARACHNOID Spinal Surgery 63173 LAM W/DRG INTRMEDULRY CYST/SYRINX PRTL/PLEURAL Spinal Surgery 63180 LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV 1/2 SEG Spinal Surgery 63182 LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV Greater than2 SEG Spinal Surgery 63185 LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS Spinal Surgery 63190 LAMINECTOMY W/RHIZOTOMY Greater than 2 SEGMENTS Spinal Surgery 63191 LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE Spinal Surgery 63194 LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT CERVICAL Spinal Surgery 63195 LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT THORACIC Spinal Surgery 63196 LAM CORDOTOMY SCTJ BOTH SPINOTHALMIC TRACTS CRV Spinal Surgery 63198 LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES CERVICAL Spinal Surgery 63199 LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES THORACIC


Spinal Surgery 63200 LAMINECTOMY RELEASE TETHERED SPINAL CORD LUMBAR Spinal Surgery 63250 LAM EXC/OCCLUSION AVM SPINAL CORD CERVICAL Spinal Surgery 63251 LAM EXC/OCCLUSION AVM SPINAL CORD THORACIC Spinal Surgery 63252 LAM EXC/OCCLUSION AVM SPI CORD THORACOLMBR Spinal Surgery 63265 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CRV Spinal Surgery 63267 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL LMBR Spinal Surgery 63268 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SAC Spinal Surgery 63270 LAM EXC ISPI LES OTH/THN NEO IDRL CERVICAL Spinal Surgery 63271 LAM EXC ISPI LES OTH/THN NEO IDRL THORACIC Spinal Surgery 63272 LAM EXC ISPI LES OTH/THN NEO IDRL LUMBAR Spinal Surgery 63286 LAM BX/EXC ISPI NEO IDRL IMED THORACIC Spinal Surgery 63300 VCRPEC LES 1 SGM XDRL CERVICAL Spinal Surgery 63301 VCRPEC LES 1 SGM XDRL THORACIC TTHRC Spinal Surgery 63302 VCRPEC LES 1 SEG XDRL THRC THORACOLMBR Spinal Surgery 63303 VCRPEC LES 1 SEG XDRL LMBR/SAC TRANSPRTL/RPR Spinal Surgery 63304 VERTEBRAL CORPECTOMY EXC LES 1 SEG IDRL CERVICAL Spinal Surgery 63305 VERTEBRAL CORPECTOMY LES 1 SEG IDRL THRC TTHRC Spinal Surgery 63306 VERTEBRL CORPECT LES 1 SEG IDRL THRC THORACOLMBR Spinal Surgery 63307 VCRPEC LES 1 SEG IDRL LMBR/SAC TRANSPRTL/RPR Spinal Surgery 63308 VERTEBRAL CORPECTOMY EXC INDRL LES EACH SEG Spinal Surgery 64553 PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE Spinal Surgery 64570 REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATOR Spinal Surgery 0095T RMVL TOT DISC ARTHRP ANT APPR CRV EA NTRSPC Spinal Surgery 0098T REVJ TOT DISC ARTHRP ANT APPR CRV EA NTRSPC Spinal Surgery 0164T RMVL TOT DISC ARTHRP ANT APPR LMBR EA NTRSPC Transplants 32850 Donor pneumonectomy(s) (including cold preservation), from cadaver donor Transplants 32851 Lung transplant, single; without cardiopulmonary bypass Transplants 32852 Lung transplant, single; with cardiopulmonary bypass Transplants 32853 Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass Transplants 32854 Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass


Transplants 32855

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral

Transplants 32856

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilate

Transplants 33930 Donor cardiectomy-pneumonectomy (including cold preservation)

Transplants 33933

Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation

Transplants 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy Transplants 33940 Donor cardiectomy (including cold preservation)

Transplants 33944

Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation

Transplants 33945 Heart transplant, with or without recipient cardiectomy Transplants 38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

Transplants 38208 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor

Transplants 38209 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor

Transplants 38210 Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion

Transplants 38212 Transplant preparation of hematopoietic progenitor cells; red blood cell removal Transplants 38213 Transplant preparation of hematopoietic progenitor cells; platelet depletion Transplants 38214 Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion

Transplants 38215 Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer

Transplants 38232 Bone marrow harvesting for transplantation; autologous Transplants 38240 Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor Transplants 38241 Hematopoietic progenitor cell (HPC); autologous transplantation Transplants 38242 Allogeneic lymphocyte infusions Transplants 44132 Donor enterectomy (including cold preservation), open; from cadaver donor Transplants 44133 Donor enterectomy (including cold preservation), open; partial, from living donor


Transplants 44135 Intestinal allotransplantation; from cadaver donor Transplants 44136 Intestinal allotransplantation; from living donor Transplants 44137 Removal of transplanted intestinal allograft, complete

Transplants 44715 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein

Transplants 44720 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each

Transplants 44721 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each

Transplants 47133 Donor hepatectomy (including cold preservation), from cadaver donor Transplants 47135 Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age

Transplants 47140 Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)

Transplants 47141 Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)

Transplants 47142 Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)

Transplants 47143

Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split

Transplants 47144

Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])

Transplants 47145

Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (ie, left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII))

Transplants 47146 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each

Transplants 47147 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each


Transplants 48551

Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery

Transplants 48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each

Transplants 48554 Transplantation of pancreatic allograft Transplants 50300 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral Transplants 50320 Donor nephrectomy (including cold preservation); open, from living donor

Transplants 50323

Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary

Transplants 50325

Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary

Transplants 50340 Recipient nephrectomy (separate procedure) Transplants 50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy Transplants 50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy Transplants 50370 Removal of transplanted renal allograft Transplants 50380 Renal autotransplantation, reimplantation of kidney Transplants 50547 Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor Transplants S2060 Lobar lung transplantation Transplants S2061 Donor lobectomy (lung) for transplantation, living donor

Transplants S2152

Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- andpost-transplant care in the global definition

Vagus Nerve Stimulation 61885 INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR Vagus Nerve Stimulation 64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER Vagus Nerve Stimulation L8680 IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH Vagus Nerve Stimulation L8682 IMPLANTABLE NEUROSTIMULATOR RADIOFREQ RECEIVER Vagus Nerve Stimulation L8685 IMPLANT NEUROSTIM 1 ARRAY RECHARGEABLE


Vagus Nerve Stimulation L8686 IMPLANT NEUROSTIM 1 ARRAY NON-RECHARGEABLE Vagus Nerve Stimulation L8687 IMPLANT NEUROSTIM 2 ARRAY RECHARGEABLE Vagus Nerve Stimulation L8688 IMPLANT NEUROSTIM 2 ARRAY NON-RECHARGEABLE Vein Procedures 36468 1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK Vein Procedures 36475 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN Vein Procedures 36478 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN Vein Procedures 37700 LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ Vein Procedures 37718 LIG DIV&STRIPPING SHORT SAPHENOUS VEIN Vein Procedures 37722 LIG DIV&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW Vein Procedures 37780 LIG&DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX Ventricular Assist Device (VAD) 33975 INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE Ventricular Assist Device (VAD) 33976 INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR Ventricular Assist Device (VAD) 33979 INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC Ventricular Assist Device (VAD) 33981 RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP Ventricular Assist Device (VAD) 33982 PLCMT VAD PMP IMPLTBL ICORP 1 VENTR W/O BYPASS Ventricular Assist Device (VAD) 33983 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/BYPASS Ventricular Assist Device (VAD) 0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy Ventricular Assist Device (VAD) 0052T Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) Ventricular Assist Device (VAD) 0053T

Replacement or repair of implantable component or components of total replacement heart system (artificial heart) excluding thoracic unit

Ventricular Assist Device (VAD) Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Ventricular Assist Device (VAD) Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device Ventricular Assist Device (VAD) Q0509

Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A


Wound Vac E2402 NEG PRESS WOUND THERAPY ELEC PUMP STATION/PRTBLE

Orthotics/Prosthetic Greater than $500 L6026

Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device

Medical Policy Alignment 96002 Cardiology 33270

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