UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program:

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1 UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program: Electrophysiology Implant Code Classification Table The following chart contains the codes that require notification or prior authorization as part of UnitedHealthcare s Cardiology Notification/Prior Authorization Program. Notification and prior authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific notification or prior authorization requirements by member, please call Electrophysiology Implant CODE Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Includes Generator Placement Includes Lead Placement Includes Removal of Existing Device Device Yes Yes No Pacemaker Yes Yes No Pacemaker Yes Yes No Pacemaker/ CRT Insertion of pacemaker pulse generator only; with existing single lead Yes No No Pacemaker Insertion of pacemaker pulse generator only; with existing dual leads Yes No No Pacemaker 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) Yes Yes Yes Pacemaker Insertion of pacemaker pulse generator only; with existing multiple leads Yes No No CRT 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) 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) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system Yes Yes Yes CRT Yes Yes No CRT Yes No Yes Pacemaker Yes No Yes Pacemaker Yes No Yes CRT Insertion of implantable defibrillator pulse generator only; with existing dual leads Yes No No ICD Insertion of implantable defibrillator pulse generator only; with existing multiple leads Yes No No CRT Insertion of implantable defibrillator pulse generator only; with existing single lead Yes No No ICD Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system Yes Yes No ICD/CRT Yes No Yes ICD Yes No Yes ICD Yes No Yes CRT Page 1 of 5

2 UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program: Diagnostic Catheterization Code Classification Table The following chart contains the codes that require notification or prior authorization as part of UnitedHealthcare s Cardiology Notification/Prior Authorization Program. Notification and prior authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific notification or prior authorization requirements by member, please call Code Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation 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 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization Diagnostic Catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s), catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 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 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, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Page 2 of 5

3 Health Partnership Cardiology Prior Authorization Program: Echocardiography & Stress Echocardiography Code Classification Table The following chart contains the codes that require prior authorization as part of UnitedHealthcare s Cardiology Prior Authorization Program. Prior authorization numbers represent the specific procedure requested and are valid for 45 calendar days from the date they are issued. To verify specific notification or prior authorization requirements by member, please call Code Transthoracic echocardiography for congenital cardiac anomalies Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography 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 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Stress Echocardiography 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 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 Page 3 of 5

4 Health Partnership Cardiology Notification and Prior Authorization Program: Diagnostic Catheterization Code Crosswalk Table The following chart contains codes that are interchangeable for notification or prior authorization. If a care provider obtains notification or prior authorization for a procedure that corresponds with the Crosswalk Table, then the substitution is appropriate. To verify specific notification or prior authorization status by member, please call Diagnostic Catheterization Crosswalk Prior Authorization given with this code Code Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Claim is submitted with this code Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s), catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 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 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, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Please note: There are no substitute codes for Electrophysiology Implants ; ; ; ; ; ; ; ; Page 4 of 5

5 Health Partnership Cardiology Prior Authorization Program: Echocardiogram Substitution Table The following chart contains codes that are interchangeable for prior authorization. If a care provider obtains prior authorization for a procedure that corresponds with the Crosswalk Table, then the substitution is appropriate. To verify specific notification or prior authorization status by member, please call Echocardiogram and Stress Prior Authorization given with this code Claim submitted with this code will be allowed Code Code Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study 93304; 93303; descriptions, see page 3 descriptions, see page Echocardiography, transthoracic, real-time w/image documentation, includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and w/ color flow Doppler echocardiography descriptions, see page Echocardiography, transthoracic, real-time with image documentation (2D) includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D) includes M-mode recording, when performed, follow-up or limited study 93306; ;93307 descriptions, see page 3 descriptions, see page 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 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 descriptions, see page descriptions, see page 3 Please note: There are no substitute codes for Electrophysiology Implant procedures. M / United HealthCare Services, Inc. Page 5 of 5