Prior Authorization List

Transcription

1 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum (including MAC) Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (including MAC) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less (when specified for nipple/areola reconstruction) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation Injection of collagen or other filling material Injection of collagen or other filling material Injection of collagen or other filling material Injection of collagen or other filling material Hair transplant (hairplasty), punch graft, 1 to 15 punch grafts Hair transplant (hairplasty), punch graft, more than 15 punch grafts Facial dermabrasion or acid peel/scar revision (of any kind) Dermabrasion; segmental, face Dermabrasion; regional, other than face Dermabrasion; superficial, any site (eg. tattoo removal) Abrasion; single lesion (eg. keratosis, scar) Abrasion, each additional four lesions or less Chemical peel, facial; epidermal Chemical peel, non-facial; epidermal Chemical peel, non-facial; dermal Rev 12/30/15 Page 1 of 50

2 15819 Cervicoplasty Blepharoplasty - lower eyelid Blepharoplasty - lower eyelid with extensive herniated fat pad Blepharoplasty - upper eyelid Blepharoplasty - upper eyelid; with excessive skin weighing down lid Rhytidectomy - brow or face lift Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Rhytidectomy; glabellar frown lines Malar (cheek) implants Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) Graft for facial nerve paralysis; free muscle graft (including obtaining graft) Rev 12/30/15 Page 2 of 50

3 15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique Graft for facial nerve paralysis; regional muscle transfer Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) Lipectomy/Liposuction procedures - Suction assisted lipectomy; head and neck Lipectomy/Liposuction procedures - Suction assisted lipectomy; trunk Lipectomy/Liposuction procedures - Suction assisted lipectomy; upper extremity Lipectomy/Liposuction procedures - Suction assisted lipectomy; lower extremity Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser Electrolysis epilation Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma Gynecomastia repair Mastopexy Breast Reduction (mammoplasty) Augmentation of breast - mammoplasty Augmentation of breast - mammoplasty Removal of breast implant/material (periprosthetic capsulectomy Removal of breast implant/material (periprosthetic capsulectomy Breast procedure - Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Breast procedure - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Rev 12/30/15 Page 3 of 50

4 19350 Breast procedure - Nipple/areola reconstruction Breast procedure - Correction of inverted nipples Breast procedure - Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast procedure - Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant Breast procedure - Breast reconstruction with free flap Breast procedure - Breast reconstruction with other technique Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of site Breast procedure - Revision of reconstructed breast Breast procedure - Preparation of moulage for custom breast implant Temporomandibular Disorders: Arthodesis, aspiration and/or injection; intermediate joint or bursa Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Allograft, morselized, or placement of osteopromotive material, for spine surgery only Allograft, morselized, or placement of osteopromotive material, for spine surgery only. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or Rev 12/30/15 Page 4 of 50

5 thoracic spinal surgeries related to this procedure code Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Bone Growth Stimulator - electrical stimulation to aid bone healing Bone Growth Stimulator low intensity ultrasound stimulation to aid bone healing Bone Growth Stimulators - Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative) Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance Computer-assisted surgical navigational procedure Temporomandibular Disorders: Arthrotomy, temporomandibular joint Temporomandibular Disorders: Condylectomy, temporomandibular joint (separate procedure) Temporomandibular Disorders: Meniscectomy, partial or complete, temporomandibular joint (separate procedure) Temporomandibular Disorders: Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care) Nasal (dorsal-external) implants Nasal (dorsal-external) implants Temporomandibular Disorders: Injection procedure for temporomandibular joint arthrography Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty Rev 12/30/15 Page 5 of 50

6 21122 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, mandibular body or angle; prosthetic material Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, lower jaw bone Forehead Reduction Forehead Reduction Forehead Reduction Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) Mandibular Osteotomies, Reconstruction Midface (LeFort) Mandibular Osteotomies, Reconstruction Midface (LeFort) Mandibular Osteotomies, Reconstruction superior-lateral orbital rim and lower forehead Mandibular Osteotomies, Reconstruction bifrontal, superior-lateral orbital rims and lower forehead Rev 12/30/15 Page 6 of 50

7 21179 Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (other than LeFort type) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone graft Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, mandible, segmental Mandibular Osteotomies, segmental with genioglossus advancement Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; reduction Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; mandible (includes obtaining graft) Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with allograft Rev 12/30/15 Page 7 of 50

8 21243 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with prosthetic joint replacement Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible extraoral, with transosteal bone plate (eg, mandibular staple bone plate) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, subperiosteal implant Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction mandible or maxilla, subperiosteal implant; complete Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts)(e.g., for hemifacial microsomia) Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, endosteal implant Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, endosteal implant Reconstruction zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Mandibular Osteotomies, Reconstruction of orbit (includes obtaining autografts) Malar (cheek) implants Hyoid myotomy and suspension Reconstructive repair of pectus excavatum or carinatum; open Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar Manipulation of spine under anesthesia Kyphoplasty - Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Rev 12/30/15 Page 8 of 50

9 22511 Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar body Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment Spinal fusion - Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace Spinal fusion - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment Spinal fusion - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Rev 12/30/15 Page 9 of 50

10 22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure) Exploration of spinal fusion Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Internal spinal fixation by wiring of spinous processes. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Anterior instrumentation; 2 to 3 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. Rev 12/30/15 Page 10 of 50

11 22846 Anterior instrumentation; 4 to 7 vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Anterior instrumentation; 8 or more vertebral segments. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Reinsertion of spinal fixation device Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Removal of posterior segmental instrumentation Removal of anterior instrumentation Artificial Intervertebral Discs - total disc arthroplasty, anterior approach, including diskectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical Artificial Intervertebral Discs - revision including replacement of total disc arthroplasty, lumbar, single interspace Artificial Intervertebral Discs - removal of total disc arthroplasty, anterior approach, lumbar, single interspace Kyphoplasty - unlisted procedure; spine Unlisted procedure, abdomen, musculoskeletal system Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Note: Prior authorization for this code will be required effective 5/1/16 Rev 12/30/15 Page 11 of 50

12 27280 Arthrodesis, sacroiliac joint (including obtaining graft) Autologous chondroctye transplantation - knee Autologous/Osteochondral allograft, knee, open Osteochondral autograft(s), knee, open Ankle Replacement Open osteochondral autograft-talus Extracorpeal shock wave therapy (Orthotripsy)/Orthotripsy (heel) Ossatron Subtalar Arthroereisis - Unlisted procedure, foot or toes (Orthotripsy) Temporomandibular Disorders: Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy Temporomandibular Disorders: Arthroscopy, temporomandibular joint, surgical Autologous chondrocyte transplantation/arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) (includes harvesting of the autograft) Autologous chondrocyte transplantation/arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) Meniscal Transplantation Ankle arthroscopy/surgery Electrothermal capsular shrinkage (i.e. thermal capsulorrhaphy, electrothermal capsulorrhaphy, thermal capsular shrinkage, electrothermal arthroscopy) as a technique for use in arthroscopic or open surgery for tightening the capsular or ligamentous structures of ankles, hips, knees, or wrists Excision, nasal polyp(s), simple Excision, nasal polyp(s), extensive Rosacea treatment - excision or surgical planing of skin of nose for rhinophyma Excision inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is Rev 12/30/15 Page 12 of 50

13 associated with obstructive sleep apnea or snoring Submucous resection inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring Rhinoplasty Rhinoplasty Rhinoplasty Rhinoplasty Rhinoplasty Rhinoplasty Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft Septal or other intranasal dermatoplasty (does not include obtaining graft) Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal) - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring Ethmoidectomy; intranasal, anterior - Note: Authorization is required only when the diagnosis is associated with chronic headaches Ethmoidectomy; intranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches Ethmoidectomy, extranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement Rev 12/30/15 Page 13 of 50

14 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical, with maxillary antrostomy Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical, with sphenoidotomy Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed Thorascopy, surgical: with thoracic sympathectomy Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral Insertion of epicardial electrode(s); open incision (e.g., thoracotomy, median sternotomy, subxiphoid approach) Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Cardiac Resynchronization Therapy - Insertion or replacement of temporary transvenous dual chamber pacing electrodes Cardiac Resynchronization Therapy -Insertion or replacement of pacemaker pulse generator only; dual chamber Rev 12/30/15 Page 14 of 50

15 33214 Cardiac Resynchronization Therapy - Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing; with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter defibrillator or pacemaker pulse generator Cardiac Resynchronization Therapy - Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) Cardiac Resynchronization Therapy - Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator Cardiac Resynchronization Therapy - Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator Maze Procedure - Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure) Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) Rev 12/30/15 Page 15 of 50

16 33265 Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Insertion of subcutaneous implantable defibrillator electrode Surgical ventricular restoration procedure, includes prosthetic patch, when performed (e.g., ventricular remodeling, SVR, SAVER, DOR procedures) Carotid, Vertebral and Intracranial Artery Angioplasty - Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Implantable Infusion Pumps - Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) Sclerotherapy Sclerotherapy Sclerotherapy Sclerotherapy Radiofrequency ablation of varicose veins Radiofrequency ablation of varicose veins Radiofrequency ablation of varicose veins Radiofrequency ablation of varicose veins Therapeutic apheresis; for white blood cells Rev 12/30/15 Page 16 of 50

17 36512 Therapeutic apheresis; for red blood cells Therapeutic apheresis; for platelets Therapeutic apheresis; for plasma pheresis Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion Implantable Infusion Pumps - Insertion of tunneled centrally inserted central venous access device with subcutaneous pump Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery with distal embolic protection Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery without distal embolic protection Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Tongue base suspension, permanent suture technique Tongue - Submucosal ablation of the tongue base, radiofrequency, one or more sites per session Periodontal Mucosal Grafting Palatopharynoplasty - UPPP, LAUP's, and somnoplasty Somnoplasty for snoring Tonsillectomy and adenoidectomy - review is required only for children under the age of Tonsillectomy and adenoidectomy - review is required only for children under the age of Tonsillectomy, primary or secondary - review is required only for children under the age of Tonsillectomy, primary or secondary - review is required only for children under the age of 18 Rev 12/30/15 Page 17 of 50

18 43192 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/ Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/ Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/ Ablative Techniques as a Treatment for Barrett's Esophagus - Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation] Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/ Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia Note - Prior authorization for this code will be required effective 5/1/ Ablative Techniques as a Treatment for Barrett's Esophagus - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation] Stretta or Endocinch procedure, Endoscopic treatment of GERD Gastrectomy, partial distal; with gastrojejunostomy Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult Gastric Pacemaker Gastric Pacemaker Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - revision of adjustable gastric restrictive device component only. Rev 12/30/15 Page 18 of 50

19 43772 Gastric Bypass - removal of adjustable gastric restrictive device component only Gastric Bypass - removal and replacement of adjustable gastric restrictive device component only Gastric Bypass - removal of adjustable gastric restrictive device and subcutaneous port components Gastric restrictive procedure - Laparoscopy, surgical; longitudinal gastrectomy (i.e., sleeve gastrectomy) Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass - revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Gastric Pacemaker Gastric Pacemaker Gastric restrictive procedure open; revision of subcutaneous port component only Gastric restrictive procedure open; removal of subcutaneous port component only Gastric restrictive procedure open; removal and replacement of subcutaneous port component only Chemodenervation of internal anal sphincter Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s); radiofrequency Rev 12/30/15 Page 19 of 50

20 47381 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s); cryosurgical Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed Ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed - Laparoscopy, surgical Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant Laser surgery of prostate Contact laser vaporization of prostate Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation Transurethral destruction of prostate tissue; by microwave thermotherapy Transurethral destruction of prostate tissue; by radiofrequency thermotherapy Gender Reassignment Surgery - Amputation of penis; complete Penis plastic surgery Penile Prosthesis Implantation - Insertion of penile prosthesis; non-inflatable (semi-rigid) Penile Prosthesis Implantation - Insertion of penile prosthesis; inflatable (self-contained) Penile Prosthesis Implantation - Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Rev 12/30/15 Page 20 of 50

21 54410 Penile Prosthesis Implantation - Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session Penile Prosthesis Implantation - Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Penile Prosthesis Implantation - Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session Penile Prosthesis Implantation - Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Plastic operation on penis for injury Gender Reassignment Surgery - Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach Gender Reassignment Surgery - Insertion of testicular prosthesis Gender Reassignment Surgery - Laparoscopy, surgical; orchiectomy Gender Reassignment Surgery - Scrotoplasty; complicated Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) Gender Reassignment Surgery - Intersex surgery; male to female Gender Reassignment Surgery - Intersex surgery; female to male Gender Reassignment Surgery - Vulvectomy, simple; complete Gender Reassignment Surgery - Plastic repair of introitus Gender Reassignment Surgery - Clitoroplasty for intersex state Perineoplasty, repair of perineum, nonobstetrical (separate procedure) Gender Reassignment Surgery - Vaginectomy, complete removal of vaginal wall Gender Reassignment Surgery - Construction of artificial vagina; without graft Gender Reassignment Surgery - Construction of artificial vagina; with graft Rev 12/30/15 Page 21 of 50

22 57295 Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; vaginal approach Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; open abdominal approach Vaginoplasty for intersex state Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) Supracervical Abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node biopsy(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymphadenectomy Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy Vaginal hysterectomy Vaginal hysterectomy; with removal of tube(s), and or ovary(s) Vaginal hysterectomy; with removal of tube(s), and or ovary(s) with repair of enterocele Vaginal hysterectomy, for uterus 250 grams or less; with colpo- urethrocystopexy Vaginal hysterectomy, with or without removal of tubes(s), with or without removal of ovary(s) with repair of enterocele Vaginal hysterectomy with total or partial colpectomy Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele Vaginal hysterectomy, radical (Schauta type operation) Vaginal hysterectomy, for uterus greater than 250 grams: Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries Rev 12/30/15 Page 22 of 50

23 58293 Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less; with removal of tubes(s) and/or ovary(s) Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams; with removal of tubes(s) and/or ovary(s) Laparoscopy surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and/or ovary(s) Laparoscopy, surgical with vaginal hysterectomy with or without removal of tube(s) and/or ovary(s) (laparoscopic assisted vaginal hysterectomy) Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less, with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 grams Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250, with removal of tube(s) and/or ovary(s) Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) HALT procedure (Unlisted laparoscopy procedure, uterus) Rev 12/30/15 Page 23 of 50

24 61215 Implantable Infusion Pumps - Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (list separately in addition to code for primary procedure) Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (list separately in addition to code for primary procedure) Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 simple cranial lesion Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, simple Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 complex cranial lesion Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, complex Stereotactic Radiosurgery - Application of stereotactic head frame Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperat Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with Rev 12/30/15 Page 24 of 50

25 use of intraoperative microelectrode recording; first array Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical Deep Brain Stimulation - Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array Deep Brain Stimulation - Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 2 or more days Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 1 day Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Rev 12/30/15 Page 25 of 50