Prior Authorization Updates

Transcription

1 Prior Authorization Updates Managed Health Services (MHS) requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all products offered by MHS, with changes effective July 1, Refer to the Frequently Asked Questions below for guidance regarding how to obtain prior authorizations from MHS. 1. Quantitative Testing for Drugs of Abuse & Genetic/Molecular Diagnostic Testing Laboratory providers have experienced a high number of claim denials for both Quantitative Testing for Drugs of Abuse and Genetic/Molecular Diagnostic Testing due to lack of prior authorization by the ordering provider. MHS will be requiring laboratory providers to contact ordering providers to verify that a prior authorization number has been obtained for these services. It is the ordering provider s responsibility to request prior authorization for Quantitative Testing for Drugs of Abuse and Genetic/Molecular Diagnostic Testing services. 2. Specialized Radiation Therapy MHS will be requiring ordering providers to obtain prior authorization for prior authorization for services categorized as Radiation Oncology. It is the ordering provider s responsibility to request prior authorization for Intensity Modulation Radiation Therapy, Proton and Neutron Beam Therapy, and Stereotactic Radiotherapy. 3. Durable Medical Equipment MHS is making updates to our 2014 authorization requirements. Please reference the attached list or visit the provider portal at mhsindiana.com to review HCPC codes that will require authorization for MHS contracted and non-contracted providers. FREQUENTLY ASKED QUESTIONS How do I determine if a specific service requires prior authorization? You may determine which specific codes require prior authorization by visiting our Prior Auth PreScreen tool at mhsindiana.com. Just enter the CPT or HCPC code and the PreScreen Tool will advise you whether the service requires prior authorization. Additionally, enclosed is a spreadsheet which also lists the updated codes in these categories which require prior authorization. How do I request a prior authorization for these services? You may submit the prior authorization request by faxing an authorization to The fax authorization form can be found on our website at mhsindiana.com. You may call MHS Medical Management at You may submit the prior authorization request utilizing our Secure Web Portal at mhsindiana.com. If your request is approved, you will receive verification through the Secure Web Portal. If you are not currently registered on our Secure Web Portal, you may register through a quick and simple process. What information will I be required to submit in connection with the prior authorization request? CPT or HCPC code Diagnosis Code Name, Tax ID number, and NPI number for both the requesting and servicing providers Medical records to substantiate the need for the service If you have any questions regarding this information, you may contact Provider Services at or contact your dedicated Provider Relations Specialist. You may request an electronic copy of the attached code set via the MHS website using the Contact Us or Secure Messaging functions. 1

2 When the services listed are Covered Services, the services require Prior Authorization. Highlighted codes listed on the following pages have required prior authorization since May 1, Non-highlighted codes are codes that will require prior authorization as of July 1, Quantitative Testing for Drugs of Abuse & Genetic/Molecular Diagnostic Testing Quantitative Testing for Drugs of Abuse CPT CODE DESCRIPTION DRUG SCREEN QUANTITATIVE BENZODIAZEPINES DRUG SCREEN QUANTITATIVE PHENOBARBITAL AMPHETAMINE OR METHAMPHETAMINE, CHEMICAL, QUANTITATIVE BARBITURATES; QUANTITATIVE COCAINE, QUANTITATIVE DIHYDROCODEINONE DIHYDROMORPHINONE, QUANTITATIVE MEPROBAMATE, BLOOD OR URINE METHADONE NICOTINE ASSAY OF OPIATES PHENCYCLIDINE (PCP) CPT CODE DESCRIPTION Genetic/Molecular Diagnostic Testing DMD DUPLICATION/DELETION ANALYSIS ASPA GENE APC GENE ANALYSIS FULL GENE SEQUENCE APC GENE ANALYSIS KNOWN FAMILIAL VARIANTS APC GENE ANALYSIS DUPLICATION/DELETION VARIANTS BCKDHB GENE BCR/ABL1 GENE MAJOR BP BCR/ABL1 GENE MINOR BP BCR/ABL1 GENE OTHER BP BLM GENE BRAF GENE BRCA1&2 SEQ & COM DUP/DEL BRCA1&2 185&5385&6174 VAR BRCA1&2 UNCOM DUP/DEL VAR BRCA1 FULL SEQ & COM DUP/DEL BRCA1 GENE KNOWN FAM VARIANT BRCA2 GENE FULL SEQUENCE 2

3 Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION BRCA2 GENE KNOWN FAM VARIANT CFTR GENE COM VARIANTS CFTR GENE KNOWN FAM VARIANTS CFTR GENE DUP/DELET VARIANTS CFTR GENE FULL SEQUENCE CFTR GENE INTRON POLY T CYP2C19 GENE COM VARIANTS CYP2D6 GENE COM VARIANTS CYP2C9 GENE COM VARIANTS CYTOGEN MICRARRAY COPY NMBR CYTOGEN M ARRAY COPY NO&SNP EGFR GENE ANALYSIS COMMON VARIANTS F2 GENE F5 GENE FANCC GENE FMR1 GENE DETECTION FMR1 GENE CHARACTERIZATION FLT3 GENE G6PC GENE GBA GENE GJB2 GENE ANALYSIS FULL GENE SEQUENCE GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS GJB6 GENE ANALYSIS COMMON VARIANTS HEXA GENE HFE GENE HBA1/HBA2 GENE IKBKAP GENE IGH GENE REARRANGE AMP METH IGH GENE REARRANG DIR PROBE IGH VARI REGIONAL MUTATION IGK REARRANGEABN CLONAL POP STR MARKERS SPECIMEN ANAL STR MARKERS SPEC ANAL ADDL CHIMERISM ANAL NO CELL SELEC CHIMERISM ANAL W/CELL SELECT JAK2 GENE 3

4 CPT CODE DESCRIPTION KRAS GENE LONG QT SYND GENE FULL SEQ LONG QT SYND KNOWN FAM VAR LONG QT SYN GENE DUP/DLT VAR Genetic/Molecular Diagnostic Testing MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis MCOLN1 GENE MTHFR GENE MLH1 GENE FULL SEQ MLH1 GENE KNOWN VARIANTS MLH1 GENE DUP/DELETE VARIANT MSH2 GENE FULL SEQ MSH2 GENE KNOWN VARIANTS MSH2 GENE DUP/DELETE VARIANT MSH6 GENE FULL SEQ MSH6 GENE KNOWN VARIANTS MSH6 GENE DUP/DELETE VARIANT MICROSATELLITE INSTABILITY MECP2 GENE FULL SEQ MECP2 GENE KNOWN VARIANT MECP2 GENE DUP/DELET VARIANT NPM1 GENE PML/RARALPHA COM BREAKPOINTS PML/RARALPHA 1 BREAKPOINT PMS2 GENE FULL SEQ ANALYSIS PMS2 KNOWN FAMILIAL VARIANTS PMS2 GENE DUP/DELET VARIANTS PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT SMPD1 GENE COMMON VARIANTS SNRPN/UBE3A GENE SERPINA1 GENE TRB@ GENE REARRANGE AMPLIFY 4

5 CPT CODE DESCRIPTION GENE REARRANGE DIRPROBE TRG GENE REARRANGEMENT ANAL UGT1A1 GENE VKORC1 GENE HLA I & II TYPING LR HLA I & II TYPE VERIFY LR HLA I TYPING COMPLETE LR HLA I TYPING 1 LOCUS LR HLA I TYPING 1 ANTIGEN LR HLA II TYPING AG EQUIV LR HLA II TYPING 1 LOCUS LR HLA II TYPE 1 AG EQUIV LR HLA I & II TYPING HR HLA I TYPING COMPLETE HR HLA I TYPING 1 LOCUS HR HLA I TYPING 1 ALLELE HR HLA II TYPING 1 LOC HR HLA II TYPING 1 ALLELE HR MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL MOPATH PROCEDURE LEVEL 9 Genetic/Molecular Diagnostic Testing UNLISTED MOLELCULAR PATHOLOGY PROCEDURE ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS ONCOLOGY (TISSUE OF ORIGIN), MICROARRAY GENE EXPRESSION PROFILING OF > 2000 GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS TISSUE SIMILARITY SCORES ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL 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 FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS 5

6 Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS FETAL CONGENITAL ABNOR ASSAY THREE ANAL FETAL CONGENITAL ABNOR ASSAY FOUR ANAL FETAL CONGENITAL ABNOR ASSAY FIVE ANAL UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS MOLECULE ISOLATE MOLECULE ISOLATE NUCLEIC MOLECULAR DIAGNOSTICS MOLECULE DOT/SLOT/BLOT MOLECULE GEL ELECTROPHOR MOLECULAR DX; NUCLEIC ACID PROBE EA MOLECULE NUCLEIC TRANSFER MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ MOLECULAR DX; REVERSE TRANSCRIPTION MOLEC DX; MUTATION SCAN BY PHYS PROP-1 SEGMT EA MOLEC DX; MUTATION ID-SEQUENCING-1 SGMT EA MOLEC DX; MUTATION ID-ALLELE SPEC TRANSCRIP-1-EA MOLEC DX; MUTATION ID-ALLELE SPEC TRANSLAT-1-EA LYSE CELLS FOR NUCLEIC EXT MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE NUCLEIC ACID HIGH RESOLUTE MOLECULAR DX; INTERPT & REPORT RNA STABILIZATION MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA NUCLEOTIDASE 5' TISSUE TYPING; HLA TYPING, A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN TISSUE TYPING; HLA TYPING, A, B, AND/OR C (EG, A10, B7, B27), MULTIPLE A TISSUE TYPING; HLA TYPING, DR/DQ, SINGLE ANTIGEN TISSUE TYPING; HLA TYPING, DR/DQ, MULTIPLE ANTIGENS TISSUE TYPING; LYMPHOCYTE CULTURE, MIXED(MLC) TISSUE TYPING; LYMPHOCYTE CULTURE, PRIMED(PLC) HLA X-MATCH, NON-CYTOTOXIC HLA X-MATCH, NON-CYT ADD-ON HLA CLASS I&II ANTIBODY QUAL 6

7 Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION HLA CLASS I/II ANTIBODY QUAL HLA CLASS I PHENOTYPE QUAL HLA CLASS II PHENOTYPE QUAL HLA CLASS I HIGH DEFIN QUAL HLA CLASS II HIGH DEFIN QUAL HLA CLASS I SEMIQUANT PANEL HLA CLASS II SEMIQUANT PANEL TISS CULTURE NON-NEOPLAS DISORD; LYMPHOCYTE TISS CULTURE NON-NEOPLAS DISORD; SKIN/SOLID TISS TISS CULTURE NON-NEOPLAS DISORD; AMNIOTIC FLUID TISS CULTURE NEOPLAS DISORD; MARROW/BLD CELLS TISS CULTURE NEOPLAS DISORD; SOLID TUMOR CRYOPRESERV-FREEZE & STORE CELLS EA CELL LINE THAWING & EXPANSION FROZEN CELLS EA ALIQUOT CHROMOSOME ANALY BREAK SYNDROM; SCE CELLS CHROMOSOME ANALY; BASELINE BREAKAGE CHROMOSOME ANALY BREAK SYNDROM; CLASTOGEN STRESS CHROMO ANALY; CT 5 CELLS 1 KARYOTYPE W/BANDING CHROMO ANALY; CT CELLS 2 KARYOTYPES W/BAND CHROMO ANALY; CT 45 CEL MOSAICISM 2 KARYO W/BAND CHROMOSOME ANALY; ANALY CELLS CHROMO ANALY AMNIO FLUID CT 15 CELLS 1 KARYOTYPE CHROMO ANALY AMNIO FLUID CELLS CT 6-12 COLONIES MOLEC CYTOGEN; DNA PROBE EA MOLEC CYTOGEN; CHROMOSOM IN SITU HYBRID 3-5 CELL MOLEC CYTOGEN; CHROMOSOM HYBRID CELLS MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID CHROMOSOME ANALY; ADD KARYOTYPES EA STUDY CHROMOSOME ANALY; ADD SPECIALIZED BANDING TECH CHROMOSOME ANALY; ADD CELLS COUNTED EA STUDY CHROMOSOME ANALY; ADD HIGH RESOLUTION STUDY CYTOGEN & MOLEC CYTOGEN INTERPT & REPORT UNLISTED CYTOGENETIC STUDY RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 7

8 Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS S3713 KRAS MUTATION ANALYSIS S3800 GENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS (ALS) S3818 COMPLETE GENE SEQUENCE ANALYSIS S3819 COMPLETE GENE SEQUENCE ANALYSIS S3820 COMPLETED BRCA1 AND BRCA2 GENE SEQUENCE ANALYSIS FOR SUSCEP S3822 SINGLE MUTATION ANALYSIS FOR SUSCE TO BREAST AND OVARION CANCER S MUTATION ANALYSIS FOR SUSCEP/BREAST &OVARION CANCER IN ASHKENAZI INDI S3828 COMPLETE GENE SEQUENCE ANALYSIS, MLH1 GENE S3829 COMPLETE GENE SEQUENCE ANALYSIS, MLH2 GENE S3830 COMPLETE MLH1 AND MLH2 GENE SEQUENCE ANALYSIS S3831 SINGLE MUTATION ANALYSIS S3833 COMPLETE APC GENE SEQUENCE ANAL/SUSCEPTIBILITY TO (FAP) S3834 SINGLE-MUTATION ANALYSIS /SUSCEPTIBILITY TO (FAP)&ATTENUATED FAP S3835 COMPLETE GENE SEQUENCE ANALYSIS FOR CYSTIC FIBROSIS GENETIC TESTING S3837 COMPLETE GENE SEQUENCE ANALYSIS FOR HEMOCHROMATOSIS GENETIC TESTING S3840 DNA ANALYSIS FOR GERMLINE MUTATIONS OF THE RET PROTO-ONCOGENE S3841 GENETIC TESTING FOR RETINOBLASTOMA S3842 GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE S3843 DNA ANALYSIS OF THE F5 GENE FOR SUSCEP TO FACTOR V LEIDEN THROMBOPHILIA S3844 DNA ANLYSS/CONNEXIN 26 GENE (GJB2)/SUSCEP/CONGENITAL, PRFND DEAFNESS S3845 GENETIC TESTING FOR ALPHA-THALASSEMIA S3846 GENETCI TESTING FOR HEMOGLOBIN E BETA-THALASSEMIA S3847 GENETIC TESTING FOR TAY-SACHS DISEASE S3848 GENETIC TESTING FOR GAUCHER DISEASE S3849 GENETIC TESTING FOR NIEMANN-PICK DISEASE S3850 GENETIC TESTING FOR SICKLE CELL ANEMIA S3851 GENETIC TESTING FOR CANAVAN DISEASE S3852 DNA ANLYS/APOE EPILSON 4 ALLELE FOR SUSCEP ALZHEIMER'S DISEASE S3853 GENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHY S3854 GENE EXPRESSION PROFILING PANEL FOR US IN MGMT OF BREAST CANCER TRTMNT 8

9 2. Specialized Radiation Therapy CPT CODE CODE DESCRIPTION Specialized Radiation Therapy Stereotactic radiosurgery (SRS) (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion SRS; each additional cranial lesion, simple SRS; 1 complex cranial lesion SRS; each additional cranial lesion, complex SRS; 1 spinal lesion SRS; each additional spinal lesion Intensity modulated radiotherapy (IMRT) plan, including dose-volume histograms for target and critical structure partial tolerance specifications Multi-leaf collimator (MLC) device(s) for IMRT, design and construction per IMRT plan Radiation treatment delivery, SRS, complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source cobalt 60 based Radiation treatment delivery, SRS, complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Stereotactic body radiation therapy (SBRT), treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking. High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) SBRT, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions Proton treatment; simple, without compensation Proton treatment delivery; simple, with compensation Proton treatment delivery; intermediate Proton treatment delivery; complex 0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session 9

10 HCPCS G0173 G0251 G0339 G0340 CODE DESCRIPTION Linear accelerator based SRS, complete course of therapy in one session Linear accelerator based SRS, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment Image-guided robotic linear accelerator-based SRS, complete course of therapy in one session or first session of fractionated treatment Image-guided robotic linear accelerator-based SRS, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment 3. Durable Medical Equipment CPT CODE A6501 A6503 A6507 A6511 A8003 B4224 E0147 E0371 E0372 E0373 E0575 E0585 E0604 E0617 E0618 E0619 E0781 E0782 E0783 E0786 E0791 E1050 E1405 E1406 E1600 E1610 E1615 CODE DESCRIPTION COMPRS BURN GARMNT BDYSUIT CSTM FAB COMPRS BRN GARMNT FCE HOOD CSTM FAB COMPRS BRN GARMNT FT KNEE LEN CSTM COMPRS BRN GARMNT LW TRNK LEG OPN HELMET PROTECTIVE HARD CUSTOM FABR INCL ALL COMPONENTS/ACCESSOR PARENTERAL NUTRITION ADMIN KIT PER DAY WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RSISTANCE NONPWR ADV PRESS REDUC MATRS OVERLAY STAN L/W PWR AIR MATRS OVERLAY STAN MATRS LENGTH/WIDTH NONPWR ADV PRESS REDUC MATRS NEBULIZER ULTRASONIC NEBULIZER W/COMPRESSOR & HEATER BREAST PUMP HEAVY DUTY HOSPITAL GRADE EXT DEFIB W/INTEGRATED ECG ANALY APNEA MONITOR W/O RECORDING FEATURE APNEA MONITOR W/RECORDING FEATURE AMBULATORY INFUSION PUMP 1/MULTI CHAN PT WEARS INFUS PUMP IMPL NON-PROGMMABLE INFUS PUMP SYST IMPLNT PROGRAMABLE (INCL COMPON) IMPLNT PROGRAM INFUS PUMP REPLCMT PARENTERAL INFUSION PUMP STATIONARY 1/MULTICHANL FULL RECLINE WHEELCHAIR FIX ARM DETACHABLE LEGS OXYGEN & WATER VAPOR ENRICH W/HEATED DELIVERY OXYGEN & WATER VAPOR ENRICH WO HEATED DELIVERY DELIVERY/INSTALL CHARGES RENAL DIALYSIS EQUIP REVERSE OSMOSIS WATER PURIFICATION SYSTEM DEIONIZER WATER PURIFICATION SYSTEM 10

11 CPT CODE E1800 E1801 E1802 E1805 E1810 E1811 E1815 E1816 E1818 E1825 E1830 E1840 E1841 E2000 E2100 E2120 E2227 E2228 E2402 E2626 E2627 E2628 E2629 E2630 K0730 L0430 L0632 L0700 L3330 L5973 L6709 L7181 L8619 Q0479 Q0480 Q0481 Q0482 Q0483 Q0484 Q0489 CODE DESCRIPTION DYN ADJUS ELBOW EXTENSION/FLEXION DEVICE SPS ELBOW DEVICE DYN ADJUSTBL FORARM PRON/SUPIN DEVC DYN ADJUS WRIST EXTENSION/FLEXION DEVICE DYN ADJUS KNEE EXTENSION/FLEXION DEVICE SPS KNEE DEVICE DYN ADJUS ANKLE EXTENSION/FLEXION DEVICE SPS ANKLE DEVICE SPS FOREARM DEVICE DYN ADJUS FINGER EXTEN/FLEXION DEVICE DYN ADJUS TOE EXTENSION/FLEXION DEVICE DYNAMIC ADJUSTABLE SHOULDER FLEXION MXIDIR STATIC PROGS STRETCH SHLDR DEVC INCL CUFF GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER PULSE GNRTR SYS/TYMPANIC TRTMNT OF INNER EAR ENDOLYMPHATIC FLUID GEAR REDUCTION DRIVE WHEEL MWC ACC WHEELCHAIR BRAKE NEG PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE SEO MOBILE ARM SUP ATT TO WC ARM SUPP ATT TO WC RANCHO TY MOBILE ARM SUPPORTS RECLININ FRICTION DAMPENING ARM SUPP MONOSUSPENSION ARM/HAND SUPP CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM DEWALL POSTURE PROTECTOR LSO SAG RIGID FRAME CUST SPINAL-CERVICAL-THORACIC- LIFT, ELEVATION, METAL EX ANK-FOOT SYS DORS-PLANT F TERM DEV MECH HAND VOL CLOSE ELECTRONIC ELBO SIMULTANEOUS REPLACE COCHLEAR PROCESSOR POWER MODULE COMBO VAD, R DRIVER PNEUMATIC VAD, REP MICROPRCSR CU ELEC VAD, REP MICROPRCSR CU COMBO VAD, REP MONITOR ELEC VAD, REP MONITOR ELEC OR COMB VAD REP PWR PCK BASE COMBO VAD, REP 11

12 CPT CODE CODE DESCRIPTION Q0490 EMR PWR SOURCE ELEC VAD, REP Q0491 EMR PWR SOURCE COMBO VAD REP Q0495 CHARGER ELEC/COMBO VAD, REP Q0496 BATTERY ELEC/COMBO VAD, REP Q0502 MOBILITY CART PNEUM VAD, REP Q0503 BATTERY PNEUM VAD REPLACEMNT Q0504 PWR ADPT PNEUM VAD, REP VEH Q0506 LITH-ION BATT ELEC/PNEUM Q1003 NTIOL CATEGORY 3 Q4100 Q4114 Q4118 S1040 SKIN SUBSTITUTE, NOS INTEGRA FLOWABLE WOUND MA MATRISTEM MICROMATRIX CRANIAL REMOLDING ORTHOSIS 12