Prior Authorization Code List August v1 Rev (08/07/2015) Procedures and Additional Information

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1 Prior Authorization Code List August v1 Rev (08/07/2015) Procedures and Additional Information Services Codes for UnitedHealthcare Military & Veterans Adjunctive Dental ALL D2420 D4275 D6068 D D2430 D4276 D6069 D7412 Adjunctive dental care is dental care which is medically necessary to treat an otherwise covered medical (not dental) condition; is an integral part of the treatment of such medical condition; or is required in preparation for, or as the result of, dental trauma which may be or is caused by medically necessary treatment of an injury or disease. Prior authorization must be received within 24 hours of inpatient admissions related to adjunctive dental services D2510 D4320 D6070 D D2520 D4321 D6071 D D2530 D4341 D6072 D D2542 D4342 D6073 D D2543 D4355 D6074 D D2544 D4381 D6075 D D2610 D4910 D6076 D D2620 D4920 D6077 D D2630 D4999 D6078 D D2642 D5110 D6079 D D2643 D5120 D6080 D D2644 D5130 D6090 D D2650 D5140 D6091 D D2651 D5211 D6092 D D2652 D5212 D6093 D D2662 D5213 D6094 D D2663 D5214 D6095 D D2664 D5225 D6100 D D2710 D5226 D6190 D D2712 D5281 D6194 D D2720 D5410 D6199 D D2721 D5411 D6205 D D2722 D5421 D6210 D D2740 D5422 D6211 D D2750 D5510 D6212 D D2751 D5520 D6214 D D2752 D5610 D6240 D D2780 D5620 D6241 D D2781 D5630 D6242 D D2782 D5640 D6245 D D2783 D5650 D6250 D D2790 D5660 D6251 D7911 D0120 D2791 D5670 D6252 D7912 D0140 D2792 D5671 D6253 D7920 D0145 D2794 D5710 D6545 D7940 D0150 D2799 D5711 D6548 D7941 D0160 D2910 D5720 D6600 D7943 D0170 D2915 D5721 D6601 D7944 D0180 D2920 D5730 D6602 D7945 D0210 D2930 D5731 D6603 D7946 D0220 D2931 D5740 D6604 D7947 D0230 D2932 D5741 D6605 D7948 D0240 D2933 D5750 D6606 D7949 D0250 D2934 D5751 D6607 D7950 D0260 D2940 D5760 D6608 D7951 D0270 D2950 D5761 D6609 D7953 D0272 D2951 D5810 D6610 D7955 D0273 D2952 D5811 D6611 D7960 D0274 D2953 D5850 D6612 D7963 D0277 D2954 D5851 D6613 D7970 D0290 D2955 D5860 D6614 D7971 D0310 D2957 D5861 D6615 D7972 D0322 D2960 D5862 D6624 D7981 D0330 D2961 D5867 D6634 D7991 D0340 D2962 D5875 D6710 D7995 D0350 D2970 D5899 D6720 D7996 D0360 D2971 D5911 D6721 D7997 D0362 D2975 D5912 D6722 D7998

2 Adjunctive Dental ALL- D0363 D2980 D5913 D6740 D7999 D0415 D2999 D5914 D6750 D8010 Adjunctive dental care is dental care which is medically necessary to treat an otherwise covered medical (not dental) condition; is an integral part of the treatment of such medical condition; or is required in preparation for, or as the result of, dental trauma which may be or is caused by medically necessary treatment of an injury or disease. D0416 D3110 D5915 D6751 D8020 D0417 D3120 D5916 D6752 D8030 D0418 D3220 D5919 D6780 D8040 D0421 D3221 D5922 D6781 D8050 D0425 D3222 D5923 D6782 D8060 D0431 D3230 D5924 D6783 D8070 D0460 D3240 D5925 D6790 D8080 D0470 D3310 D5926 D6791 D8090 D0472 D3320 D5927 D6792 D8210 D0473 D3330 D5928 D6793 D8220 D0474 D3331 D5929 D6794 D8660 D0475 D3332 D5931 D6920 D8670 D0476 D3333 D5932 D6930 D8680 D0477 D3346 D5933 D6940 D8690 D0478 D3347 D5934 D6950 D8691 D0479 D3348 D5935 D6970 D8692 D0480 D3351 D5936 D6972 D8693 D0481 D3352 D5937 D6973 D8999 D0482 D3353 D5951 D6975 D9110 D0483 D3355 D5952 D6976 D9120 D0484 D3356 D5953 D6977 D9211 D0485 D3357 D5954 D6980 D9212 D0486 D3410 D5955 D6985 D9215 D0502 D3421 D5958 D6999 D9220 D0999 D3425 D5959 D7111 D9221 D1110 D3426 D5960 D7140 D9230 D1120 D3430 D5982 D7210 D9241 D1203 D3450 D5983 D7220 D9242 D1204 D3460 D5984 D7230 D9248 D1206 D3470 D5985 D7240 D9310 D1310 D3910 D5986 D7241 D9410 D1320 D3920 D5987 D7250 D9420 D1330 D3950 D5988 D7260 D9440 D1351 D3999 D5991 D7261 D9450 D1510 D4210 D5999 D7270 D9610 D1515 D4211 D6010 D7272 D9612 D1520 D4230 D6012 D7280 D9630 D1525 D4231 D6040 D7282 D9910 D1550 D4240 D6050 D7283 D9911 D1555 D4241 D6053 D7285 D9920 D2140 D4245 D6054 D7286 D9930 D2150 D4249 D6055 D7287 D9940 D2160 D4260 D6056 D7288 D9941 D2161 D4261 D6057 D7290 D9942 D2330 D4263 D6058 D7291 D9950 D2331 D4264 D6059 D7292 D9951 D2332 D4265 D6060 D7293 D9952 D2335 D4266 D6061 D7294 D9970 D2390 D4267 D6062 D7310 D9971 D2391 D4268 D6063 D7311 D9972 D2392 D4270 D6064 D7320 D9973 D2393 D4271 D6065 D7340 D9974 D2394 D4273 D6066 D7350 D9999 D2410 D4274 D6067 D7410 Bariatric Surgery Inpatient Inpatient Admissions & Services Prior authorization must be received within 24 hours of inpatient admissions related to adjunctive dental services Behavioral Health- Inpatient S2083 Applies to preadmission and continued stay for nonemergency inpatient services and all care in a partial hospitalization program and includes: Substance Abuse Rehabilitation Residential Treatment Center

3 Behavioral Health- Outpatient H0037 Mental health care after the initial evaluation and eight subsequent therapy visits per benefit year. Primary Care Manager (PCM) referral not required. Note: Active Duty Service Members (ADSMs) require preauthorization prior to receiving mental health service. Medication management exceeding two times per month Psychoanalysis All psychological and neuropsychological testing Behavioral health interpretation or explanation of results (collateral visits) Electroconvulsive therapy (ECT) procedures After the Initial Eval +8 If billed more than once in a 12 month period H Behavioral Health- Partial Inpatient G0410 G0411 H0035 Biofeedback - Pain Management ALL A complementary and alternative medicine technique to teach mental control of bodily functions. Breast Reconstruction (Non Mastectomy) Cosmetic & Reconstructive Q4116 Drugs & Biologicals ALL J1573 J3365 J7626 J J1599 J3471 J7627 J9179 B4161 J1610 J3472 J7628 J9181 A drug capable of being injected intravenously, through an intravenous infusion, subcutaneously or intra-muscularly. Includes drugs and biologicals for certain chemotherapy drugs and injectable/infusion therapy delivered in the home. C2613 J1630 J3473 J7629 J9185 C9453 J1631 J3485 J7631 J9190 C9454 J1652 J3486 J7632 J9200 C9455 J1655 J3489 J7633 J9201 J0135 J1670 J3490 J7634 J9202 J0215 J1741 J3520 J7635 J9206 J0220 J1742 J3535 J7636 J9207 J0364 J1744 J3570 J7637 J9208 J0585 J1786 J3590 J7638 J9211 J0586 J1790 J7131 J7639 J9212 J0587 J1800 J7178 J7641 J9213 J0588 J1810 J7180 J7645 J9214 J0594 J1840 J7183 J7647 J9215 J0595 J1850 J7185 J7648 J9216 J0597 J1890 J7186 J7649 J9217 J0598 J1945 J7187 J7650 J9218 J0600 J1950 J7189 J7657 J9219 J0620 J1960 J7190 J7658 J9225

4 Drugs & Biologicals A drug capable of being injected intravenously, through an intravenous infusion, subcutaneously or intra-muscularly. Durable Medical ALL- J0630 J2010 J7191 J7659 J9226 J0636 J2170 J7192 J7660 J9228 J0692 J2212 J7193 J7667 J9230 Includes drugs and biologicals for certain chemotherapy drugs and injectable/infusion therapy delivered in the home. J0710 J2248 J7194 J7668 J9245 J0712 J2265 J7195 J7669 J9261 J0716 J2320 J7196 J7683 J9262 J0745 J2355 J7197 J7684 J9263 J0795 J2357 J7198 J7686 J9264 J0800 J2358 J7199 J8520 J9266 J0833 J2400 J7307 J8521 J9268 J0840 J2425 J7308 J8565 J9270 J0890 J2460 J7309 J9000 J9280 J1160 J2503 J7310 J9010 J9293 J1162 J2504 J7311 J9015 J9300 J1165 J2505 J7315 J9017 J9302 J1180 J2507 J7321 J9019 J9303 J1205 J2513 J7323 J9020 J9305 J1230 J2515 J7324 J9025 J9306 J1265 J2560 J7325 J9027 J9307 J1267 J2650 J7326 J9031 J9310 J1300 J2670 J7330 J9033 J9315 J1320 J2680 J7500 J9035 J9320 J1324 J2690 J7501 J9040 J9328 J1330 J2720 J7504 J9041 J9330 J1364 J2725 J7505 J9042 J9340 J1380 J2770 J7506 J9043 J9351 J1410 J2778 J7507 J9045 J9354 J1435 J2793 J7508 J9047 J9355 J1436 J2810 J7510 J9050 J9357 J1451 J2850 J7511 J9055 J9360 J1452 J2993 J7513 J9060 J9370 J1455 J2995 J7515 J9065 J9371 J1457 J2997 J7516 J9070 J9390 J1458 J3060 J7517 J9098 J9395 J1459 J3105 J7518 J9100 J9400 J1460 J3110 J7520 J9120 J9600 J1556 J3240 J7525 J9130 J9999 J1557 J3250 J7527 J9150 Q5101 J1559 J3265 J7599 J9151 Q9976 J1561 J3280 J7604 J9155 Q9977 J1562 J3305 J7605 J9160 Q9978 J1566 J3350 J7612 J9165 J1568 J3355 J7614 J9171 J1569 J3364 J7622 J9175 ALL- A4313 E0197 E0958 E2228 K0800 A4316 E0198 E0959 E2231 K0801 A4321 E0202 E0960 E2310 K0802 Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped rentals. Also see Orthotics and Prosthetics. A4327 E0205 E0961 E2311 K0806 A4328 E0217 E0966 E2312 K0807 A4330 E0221 E0967 E2313 K0808 A4351 E0225 E0968 E2321 K0813 A4354 E0235 E0969 E2322 K0814 A4355 E0236 E0983 E2325 K0815 A4356 E0239 E0984 E2326 K0816 A4362 E0249 E0985 E2327 K0820 A4379 E0250 E0986 E2328 K0821 A4380 E0251 E0988 E2329 K0822 A4382 E0255 E1002 E2330 K0823 A4383 E0256 E1003 E2340 K0824 A4392 E0260 E1004 E2341 K0825 A4435 E0261 E1005 E2342 K0826 A4604 E0265 E1006 E2343 K0827 A4630 E0266 E1007 E2351 K0828 A4639 E0271 E1008 E2359 K0829 A4648 E0272 E1010 E2361 K0835 A4650 E0277 E1014 E2363 K0836 A5105 E0290 E1016 E2364 K0837 A5113 E0291 E1017 E2365 K0838 A5501 E0292 E1018 E2366 K0839 A6023 E0293 E1020 E2367 K0840 A6203 E0294 E1028 E2368 K0841 A6229 E0295 E1029 E2369 K0842 A6233 E0296 E1030 E2370 K0843 A6236 E0297 E1031 E2371 K0848 A6238 E0300 E1035 E2372 K0849 A6241 E0301 E1036 E2373 K0850 A6242 E0302 E1037 E2374 K0851 A6243 E0303 E1038 E2375 K0852 A6244 E0304 E1039 E2376 K0853 A6245 E0305 E1050 E2377 K0854 A6246 E0310 E1060 E2378 K0855 A6247 E0316 E1070 E2382 K0856 A6253 E0326 E1083 E2383 K0857 A6411 E0328 E1084 E2384 K0858 A6550 E0329 E1087 E2385 K0859 A7000 E0371 E1088 E2386 K0860 A7025 E0372 E1092 E2388 K0861 A7026 E0373 E1093 E2389 K0862 A7040 E0600 E1100 E2391 K0863 A7041 E0601 E1110 E2396 K0864 A7044 E0604 E1150 E2397 Q0478

5 Durable Medical Durable Medical Rental for all DME categorized by Centers for Medicare and Medicaid ALL- A7045 E0606 E1160 E2402 Q0479 A7046 E0610 E1161 E2500 Q0480 A8000 E0615 E1170 E2502 Q0481 Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped rentals. Also see Orthotics and Prosthetics. Diabetic Testing and Treatment including supplies and equipment including glucose monitors A8001 E0617 E1171 E2504 Q0482 A8002 E0618 E1172 E2506 Q0483 A8003 E0619 E1180 E2508 Q0484 A9279 E0620 E1190 E2510 Q0485 B4034 E0630 E1195 E2511 Q0486 B4035 E0635 E1200 E2512 Q0487 B4036 E0636 E1220 E2599 Q0489 B4081 E0637 E1221 E2603 Q0490 B4082 E0638 E1222 E2604 Q0491 B4083 E0641 E1223 E2605 Q0492 B4087 E0642 E1224 E2606 Q0493 B4088 E0691 E1225 E2607 Q0494 B4149 E0692 E1226 E2608 Q0495 B4150 E0693 E1227 E2611 Q0496 B4152 E0694 E1228 E2612 Q0497 B4153 E0705 E1230 E2613 Q0498 B4154 E0740 E1231 E2614 Q0499 B4155 E0744 E1232 E2615 Q0501 B4164 E0745 E1233 E2616 Q0502 B4168 E0762 E1234 E2620 Q0503 B4176 E0764 E1235 E2621 Q0504 B4178 E0766 E1236 E2622 Q0506 B4180 E0770 E1237 E2623 V2311 B4185 E0779 E1238 E2624 V2312 B4189 E0780 E1239 E2625 V2313 B4193 E0781 E1240 E2626 V2314 B4197 E0782 E1270 E2627 V2315 B4199 E0783 E1280 E2628 V2318 B4216 E0784 E1295 E2629 V2319 B4220 E0785 E1296 E2630 V2320 B4222 E0786 E1297 E2631 V2321 B4224 E0791 E1298 E2632 V2501 B5000 E0830 E1310 E2633 V2502 B5100 E0850 E1700 K0001 V2503 B9000 E0855 E1800 K0002 V2510 B9002 E0856 E1801 K0003 V2511 B9004 E0860 E1802 K0004 V2512 B9006 E0870 E1805 K0005 V2513 B9998 E0880 E1806 K0006 V2520 E0117 E0890 E1810 K0007 V2521 E0140 E0900 E1811 K0009 V2522 E0144 E0910 E1812 K0010 V2523 E0147 E0911 E1815 K0011 V2530 E0149 E0912 E1816 K0012 V2531 E0162 E0920 E1818 K0014 V2623 E0165 E0930 E1825 K0015 V2625 E0168 E0935 E1830 K0037 V2626 E0170 E0935 E1831 K0070 V2627 E0171 E0936 E1840 K0098 V2628 E0181 E0940 E1841 K0195 V2700 E0182 E0941 E2000 K0455 V2710 E0184 E0941 E2120 K0605 V2730 E0185 E0947 E2201 K0606 V2745 E0186 E0948 E2202 K0607 V2762 E0187 E0949 E2203 K0608 V2786 E0193 E0955 E2204 K0609 E0194 E0956 E2221 K0672 E0196 E0957 E2227 K A4206 A4232 E2100 S A4210 A4245 E2101 S1031 A4231 A4230 E0607 K0602 S1034 Orthotics- ALL L0112 L1005 L2035 L3003 L3764 Devices that are used to help L0113 L1085 L2036 L3010 L3765 stabilize or immobilize a body L0130 L1100 L2037 L3020 L3766 part, prevent deformity, protect L0160 L1110 L2038 L3030 L3806 against injury or assist with L0170 L1200 L2040 L3031 L3807 function of a body part. L0172 L1210 L2050 L3040 L3808 L0174 L1220 L2060 L3050 L3809 L0180 L1230 L2070 L3060 L3900 L0190 L1300 L2080 L3070 L3901 L0200 L1310 L2090 L3080 L3904 L0220 L1600 L2106 L3090 L3905 L0450 L1610 L2108 L3100 L3906 L0454 L1620 L2112 L3140 L3913 L0455 L1630 L2114 L3150 L3915 L0456 L1640 L2116 L3170 L3916 L0457 L1650 L2126 L3224 L3918 L0458 L1652 L2128 L3225 L3919 L0460 L1660 L2132 L3300 L3921 L0462 L1680 L2134 L3310 L3924 L0464 L1685 L2136 L3330 L3930 L0466 L1686 L2182 L3332 L3931 L0467 L1690 L2186 L3334 L3933 L0468 L1700 L2188 L3340 L3935 L0469 L1710 L2192 L3350 L3956 L0470 L1720 L2250 L3360 L3960 L0472 L1730 L2260 L3370 L3961 L0480 L1755 L2280 L3380 L3962 L0482 L1820 L2300 L3390 L3967

6 Durable Medical Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped Durable Medical Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped rentals. Also see Orthotics and Prosthetics. ALL- L0484 L1831 L2320 L3400 L3971 L0486 L1832 L2330 L3410 L3973 L0488 L1833 L2335 L3420 L3975 L0490 L1834 L2340 L3430 L3976 L0491 L1836 L2350 L3440 L3977 Orthotics- ALL L0492 L1840 L2370 L3450 L3978 Devices that are used to help stabilize or immobilize a body part, prevent deformity, protect against injury or assist with function of a body part. Osteogenesis Stimulators (Bone Growth Stimulators) L0622 L1843 L2385 L3455 L3980 L0627 L1844 L2387 L3460 L3982 L0630 L1845 L2395 L3465 L3984 L0631 L1846 L2425 L3470 L4000 L0633 L1847 L2500 L3480 L4010 L0635 L1848 L2510 L3500 L4020 L0636 L1850 L2520 L3510 L4030 L0637 L1860 L2525 L3520 L4040 L0638 L1900 L2526 L3530 L4045 L0639 L1904 L2530 L3540 L4050 L0640 L1907 L2530 L3550 L4055 L0641 L1910 L2540 L3560 L4060 L0642 L1920 L2550 L3570 L4070 L0643 L1930 L2570 L3580 L4080 L0648 L1932 L2580 L3590 L4090 L0649 L1940 L2600 L3595 L4100 L0650 L1945 L2610 L3600 L4110 L0651 L1950 L2620 L3610 L4130 L0700 L1951 L2622 L3620 L4360 L0710 L1960 L2624 L3630 L4361 L0810 L1970 L2627 L3640 L4370 L0820 L1971 L2628 L3671 L4386 L0830 L1980 L2630 L3674 L4387 L0859 L1990 L2640 L3675 L4396 L0861 L2000 L2660 L3702 L4397 L0974 L2005 L2670 L3720 L4631 L0976 L2010 L2680 L3730 L0978 L2020 L3000 L3740 L1000 L2030 L3001 L3760 L1001 L2034 L3002 L3763 E0747 E0749 E0748 E0760 Oxygen A7027 E0430 E0457 E0486 E1355 A7028 E0431 E0459 E0487 E1356 A7029 E0433 E0460 E0500 E1357 A7030 E0434 E0461 E0550 E1358 A7031 E0435 E0462 E0555 E1372 A7032 E0439 E0463 E0560 E1390 A7033 E0440 E0464 E0562 E1391 A7034 E0441 E0470 E0565 E1392 A7035 E0442 E0471 E0570 E1399 A7036 E0443 E0472 E0572 E1405 A7037 E0444 E0480 E0574 E1406 A7038 E0445 E0481 E0575 K0738 A7039 E0446 E0482 E0585 E0424 E0450 E0483 E1352 E0425 E0455 E0485 E1354 Prosthetics- ALL An artificial device extension that replaces a missing body part. Prostheses are typically used to replace parts lost by injury (traumatic) or missing from birth (congenital), or to supplement defective body parts. L5000 L5653 L5925 L6625 L7170 L5010 L5654 L5930 L6628 L7180 L5020 L5655 L5940 L6629 L7181 L5050 L5656 L5950 L6630 L7185 L5060 L5658 L5960 L6635 L7186 L5100 L5661 L5961 L6637 L7190 L5105 L5665 L5962 L6638 L7191 L5150 L5670 L5964 L6640 L7360 L5160 L5671 L5966 L6641 L7362 L5200 L5672 L5968 L6642 L7364 L5210 L5673 L5969 L6645 L7366 L5220 L5676 L5970 L6646 L7367 L5230 L5677 L5971 L6647 L7368 L5250 L5678 L5972 L6648 L7400 L5270 L5679 L5973 L6650 L7401 L5280 L5680 L5974 L6672 L7402 L5301 L5681 L5975 L6675 L7403 L5312 L5682 L5976 L6676 L7404 L5321 L5683 L5978 L6677 L7405 L5331 L5684 L5979 L6680 L7499 L5341 L5690 L5980 L6682 L7900 L5400 L5692 L5981 L6684 L8000

7 Durable Medical Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped rentals. Durable Medical ALL- L5410 L5694 L5982 L6686 L8001 L5420 L5695 L5984 L6687 L8002 L5430 L5696 L5985 L6688 L8020 Prosthetics- ALL An artificial device extension that replaces a missing body part. Prostheses are typically used to replace parts lost by injury (traumatic) or missing from birth (congenital), or to supplement defective body parts. L5450 L5697 L5986 L6689 L8030 L5460 L5698 L5987 L6690 L8031 L5500 L5699 L5988 L6691 L8035 L5505 L5700 L5990 L6692 L8040 L5510 L5701 L5999 L6693 L8041 L5520 L5702 L6000 L6694 L8042 L5530 L5703 L6010 L6695 L8043 L5535 L5704 L6020 L6696 L8044 L5540 L5705 L6025 L6697 L8045 L5560 L5706 L6050 L6698 L8046 L5570 L5707 L6055 L6703 L8047 L5580 L5710 L6100 L6704 L8310 L5585 L5711 L6110 L6706 L8500 L5590 L5712 L6120 L6707 L8501 L5595 L5714 L6130 L6708 L8507 L5600 L5716 L6200 L6709 L8510 L5610 L5718 L6205 L6711 L8511 L5611 L5722 L6250 L6712 L8512 L5613 L5724 L6300 L6713 L8513 L5614 L5726 L6310 L6714 L8514 L5616 L5728 L6320 L6715 L8515 L5617 L5780 L6350 L6721 L8600 L5618 L5781 L6360 L6722 L8603 L5620 L5782 L6370 L6805 L8605 L5622 L5785 L6380 L6810 L8606 L5624 L5790 L6382 L6880 L8609 L5626 L5795 L6384 L6881 L8610 L5628 L5810 L6386 L6882 L8612 L5629 L5811 L6388 L6883 L8613 L5630 L5812 L6400 L6884 L8629 L5631 L5814 L6450 L6885 L8630 L5632 L5816 L6500 L6890 L8631 L5634 L5818 L6550 L6895 L8641 L5636 L5822 L6570 L6900 L8642 L5637 L5824 L6580 L6905 L8658 L5638 L5826 L6582 L6910 L8659 L5639 L5828 L6584 L6915 L8670 L5640 L5830 L6586 L6920 L8679 L5642 L5840 L6588 L6925 L8680 L5643 L5845 L6590 L6930 L8681 L5644 L5848 L6600 L6935 L8682 L5645 L5850 L6605 L6960 L8683 L5646 L5855 L6610 L6970 L8684 L5647 L5856 L6611 L6975 L8689 ALL- L5648 L5857 L6615 L7007 L8695 L5649 L5858 L6620 L7008 L8699 L5650 L5859 L6621 L7009 L5651 L5910 L6623 L7040 L5652 L5920 L6624 L7045 Rental for all DME categorized by Centers for Medicare and Medicaid Services (CMS) as capped rentals. Also see Orthotics and Prosthetics. Seat Lift Mechanisms E0627 E0628 E0629 Trans. Electrical Nerve Stim. E0720 E0731 A4556 A4557 E0730 (Tens Units & Supplies) E0650 E0657 E0667 E0671 E0676 E0651 E0660 E0668 E0672 E0652 E0665 E0669 E0673 E0656 E0666 E0670 E0675 Experimental / Unproven 0347T 0353T 0359T 0365T 0371T 0348T 0354T 0360T 0366T 0372T 0349T 0355T 0361T 0367T 0373T 0350T 0356T 0362T 0368T 0374T 0351T 0357T 0363T 0369T 0352T 0358T 0364T 0370T Extended Health Care Options (ECHO) Services Pneumatic Compression Devices ALL G0151 G0156 S9123 E G0152 S1040 S9124 E8002 ECHO is a supplemental program to the basic TRICARE program. ECHO provides financial assistance for an integrated set of services and supplies to eligible active duty family members (including family members of activated National Guard or Reserve members) G0154 S8940 T G0155 S9122 E8000

8 Hearing Services: Cochlear & Auditory Implants ALL L8619 L L8614 L8621 L Hearing services, including devices such as cochlear implants, implantable hearing devices and bone-anchored hearing aids L8615 L8622 L L8616 L8623 L L8617 L8624 L L8618 L8627 S2230 Home Health Care Outpatient G0159 S0281 S G0160 S5180 S9209 Services All services which are homebased including but not limited to G0161 S5181 S G0162 S9097 S9212 home infusion G0163 S9098 S G0164 S9125 S G0153 S0270 S G0157 S0272 S G0158 S0280 S9131 Hospice ALL- Q5001 Q5004 Q5007 Q5009 S0271 A type of care and philosophy of care that focuses on the palliation of a terminally ill or seriously ill patient's symptoms. Q5002 Q5005 Q5008 Q5010 S9126 Q5003 Q5006 T2042 T2043 Hyperbaric Oxygen Therapy ALL Non-emergent hyperbaric oxygen treatments L1 Laboratory Developed Tests LDT#1-#4 TRICARE Evaluation of CMS Approved Laboratory Developed Testing Demonstration Project (TOM Chp. 18, Section 13) ALL- Laboratory developed tests (LDT) are identified by Food and Drug Administration (FDA) regulation as a medical devices requiring FDA premarket clearance or premarket approval to be eligible for cost-sharing by TRICARE. Myriad and Genomics Health Only LDT#1 Oncotype DX Breast Cancer Assay- GENOMICS HEALTH ONLY LDT#2 BRAS Analysis MYRIAD ONLY LDT#3 Colaris for Lynch Syndrome (Colaris) MYRIAD ONLY LDT#4 Colaris AP for detection of germline mutations in the Adenomatous Polyposis Coli (APC) and muty (MYH) genes MYRIAD ONLY S L2 Laboratory Developed Tests TMA Evaluation of Non- United States FDA Laboratory Developed Tests Demonstration Project (TOM Chp. 18, Section 17) ALL Laboratory developed tests (LDT) are identified by Food and Drug Administration (FDA) regulation as a medical devices requiring FDA premarket clearance or premarket approval to be eligible for cost-sharing by TRICARE. Any CLIA Certified provider L2 Laboratory Developed Tests [Genes]: As identified in Tom Chp and UHC M&V PA Code List]* *Cystic fibrosis transmembrane conductance regulator (CTFR) for an indication of Preconception and Prenatal Carrier Screening does not require prior authorization. All other CFTR indications as identified under TOM require PA review Laboratory Developed Tests 0006M 0007M 0008M

9 Non Emergency Transportation ALL- A0140 A0430 A0433 A0435 T2005 A0426 A0431 A0434 A0999 T2007 Non-urgent ambulance A0428 transportation by air, land, or other method between specified locations. Orthognatic Other S F C2644 S1035 S1036 Rehabilitation: Occupational Physical & Speech Therapy M 0010M B4160 Outpatient Outpatient rehabilitation services, when provided by a licensed physical therapist, licensed occupational therapist, or licensed speech therapist Radiology Transplants Inpatient All solid organ and stem cell transplants Surgery T 0393T

10 Recently Removed Codes V L6940 L6945 L6950 Date Removed 03/20/15 L6955 L3632 Inpatient Admissions & Services Inpatient Inpatient admissions related to the following services: Cancer care trials Dental anesthesia and institutional benefit Prior Authorization of inpatient facility admissions within 24 hours of the admission Prior Authorization of discharge from facilities within 24 hours of the discharge Continued stay review for inpatient admissions for all behavioral health care, surgical and other listed services or upon request by UnitedHealthcare. Admissions or transfers from inpatient setting to skilled nursing facility, acute rehabilitation and long term acute care (LTAC) Bariatric surgery Medically necessary cosmetic, reconstructive and plastic surgery All solid organ and stem cell transplants Also see Behavioral Health sections for additional requirements Smoking Cessation Non-Network Provider Services ALL- A referral from a network physician, or health care provider to a hospital, physician or other health care provider who is not contracted with UnitedHealthcare Military & Veterans or a Military Treatment Facility. Preservation of Stem Cells ALL- The gathering and saving of nutrient rich stem cells present in the body, especially the umbilical cord at birth. Outpatient- Smoking cessation counseling for third quit attempt in a 12- month period.

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