Provider Manual Section 5.0

Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria/Standards for Review 5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication 5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials Page 1 of 39

5.0 Utilization Management 5.1 Utilization Management Utilization Management (UM) is the process of influencing the continuum of care by evaluating the necessity and efficiency of health care services and affecting patient care decisions through assessments of the appropriateness of care. The UM department helps to assure prompt delivery of medicallyappropriate health care services to Passport Health Plan members and subsequently monitors the quality of care. Medically Necessary or Medical Necessity means Covered Services which are medically necessary as defined under 907 KAR 3:130 or other applicable Kentucky law or regulation, and provided in accordance with 42 CFR 440.230, including children s services pursuant to 42 U.S.C. 1396d(r). All Passport Health Plan participating providers are required to obtain prior authorization from the Plan s UM department for inpatient services and specified outpatient services listed in Section 5.3, Authorization Requirements. Failure to submit an authorization or failure to submit an authorization in a timely manner may result in a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be verified for every request of service. The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except holidays. All requests for authorization of services may be received during these hours of operation by calling or faxing: Department Phone Number Fax Number General Number (800) 578-0636 (502) 585-7989 Concurrent Review (502) 585-2023 (502) 585-7989 Retrospective Review (502) 585-7972 (502) 585-8207 Home Health (502) 585-7320 (502) 585-8204 DME (502) 585-7310 (502) 585-7990 Therapies/Pain Management (502) 585-6055 (502) 585-8205 Cosmetics (502) 585-7069 Request can be sent via confidential email to: PassportUMCosmetics @Passporthealthplan.com Appeals (502) 585-7307 (502) 585-8461 High Dollar Radiology Administered by MedSolutions 1-877-791-4099 1-888-693-3210 or on-line authorization at www.medsolutionsonline.com After business hours or on holidays, a provider can leave a message and a representative will return the call the next business day. Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical Page 2 of 39

Director, to ask questions about a utilization management issue, or to seek information from the nurse reviewer about the Utilization Management process and the authorization of care by calling Utilization Management at (800) 578-0636. Because of frequent changes in member eligibility for Medicaid coverage, providers should verify continued eligibility via the Plan s web site, www.passporthealthplan.com, or by calling the IVR or Provider Services at (800) 578-0775. 5.2 Review Criteria/Standards for Review Passport Health Plan s Utilization Management (UM) department is charged with ensuring that the Plan s members use their benefits appropriately. Passport s UM Department uses InterQual Criteria during the review process. In the event InterQual Criteria is not available for a specific request, the reviewer may use internal medical policies which are reviewed and approved by actively practicing practitioners in the community. The Partnership Council approves both the use of InterQual Criteria and Medical Polices. Criteria are only made available to participating and non-participating providers as allowed under copyright limitations and trademark considerations. At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will provide a copy of up to three (3) InterQual Criteria guidelines. If the guidelines are not available for distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to request the guideline be read over the telephone, or review the guideline at Passport Health Plan. Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any time from the Passport UM Department or the Chief Medical Officer. Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are shared with providers upon request. These requests may be made by contacting the UM Department or the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid practitioner numbers issued by state and federal entities. 5.3 Authorization Requirements The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The general UM department phone number is: (800) 578-0636. The general UM department fax number is (502) 585-7989. The following table lists procedures and/or services that require authorization from Passport Health Plan s Utilization Management (UM) department. Services Requiring Authorization Page 3 of 39

All Inpatient Admissions / Hospitalizations Maternity Code Range: 644.XX through 665.XX --- If stay is less than or equal to 3 days with the above codes, no authorization is required AUTHORIZATION IS REQUIRED FOR: All Cesarean Sections All Scheduled inductions All Non-par providers, regardless of delivery type Rehabilitation Pain Management (i.e. Epidural Blocks Trigger Point Injections) Stem Cell/Progenitor Cell Retrieval Cosmetic Procedures Neuropsychological Testing Therapy Services 23 Hour Observation greater than one (1) overnight stay Home Hospice Investigational/Experimental Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne) Diabetic Education Chiropractic Services No authorization for the first 12 visits in a calendar year Services beyond 12 visits require authorization Benefit limit = total of 26 chiropractic visits within a calendar period Specified Outpatient Surgical Procedures: PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging Authorization administered by MSI Adenoidectomy - Cardiac Catheterization - EGD DME > $500 rental or purchase Enteral Products Ostomy Supplies Home Infusion IV Therapy (IVT) All DME with E1399 Codes Select Orthotics / Prosthetics Home Health / Skilled Nursing / Private Duty Nursing High Cost Medication > $400 Authorization for IVT will be administered by PBM Synagis Injections Synagis Injections Authorizations administered by PBM Nonparticipating Provider Services Page 4 of 39

Select EPSDT Special Services Family Planning Terminations To determine if a service or supply, such as cosmetic procedures, is considered benefit exclusion, please contact the Passport Utilization Management (UM) department. The assigned authorization number must be submitted on the claim form. Policy for Newborns: An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If an infant born via NVD stays <= 3 days, authorization is not required. An infant born by C-Section does not require authorization until day six (6). If an infant born via C- Section stays <= 5 days, authorization is not required. Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual cases. To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion, please contact the Passport Utilization Management (UM) department. The assigned authorization number must be submitted on the claim form. 5.4 Online Authorization Passport Health Plan s Utilization Management Department utilizes an online authorization system via NaviNet. The online authorization system is a web-based auto-review system for providers to obtain authorization for services. For questions regarding the online authorization, contact NaviNet or your Provider Network Account Manager. The online authorization system also allows you, the provider, to search for authorizations by member, authorization number, date of service and/or physician. View the following information online for each authorization: Member identification number, coverage dates, and PCP Authorization number Service requested Primary diagnosis Treatment dates Status of the authorization The use of the online authorization system via NaviNet for select services is highly encouraged. Page 5 of 39

5.5 Inpatient Admissions UM reviews all requests for inpatient admissions utilizing InterQual criteria and internal medical policies. For those requests meeting the established medical necessity criteria, an inpatient will be authorized. Requests not meeting the established medical necessity criteria will be referred to Passport s Medical Director for further review and evaluation. When requesting a review, at a minimum, documentation must include: The member s name and Passport Health Plan ID number. The diagnosis for which the treatment or testing procedure is being sought. Other treatment or testing methods that have been tried, their duration, and any outcomes. Additional clinical information as applicable to the requested service. Applicable sections of the medical record. Some authorization requests may require a physician s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. To receive authorization for an admission, contact Passport Health Plan s Utilization Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. 5.5.1 Inpatient Admissions and Observation Requirements All inpatient admissions require an authorization. If a member is discharged from an inpatient level of care and subsequently re-admitted to the same hospital within 24 hours, the UM Department continues the member's inpatient stay under the same case reference number. Requests for prior authorization of elective inpatient services should be received prior to the date the requested service will be performed. Passport Health Plan will accept the hospital s or the attending physician s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. For an urgent or emergent admission, the facility must notify the plan within one business day of the admission. For weekend admissions to a hospital or for services delivered on the weekend or after normal business hours, authorization must be obtained within one business day of the admission or service being provided. If the member s condition or results of evaluation and testing meet inpatient criteria after the 23-hour observation period, the stay will be converted to inpatient beginning with the observation stay admission date. All claims for this type of stay should be submitted with the entire length of stay as an Page 6 of 39

inpatient. To receive authorization for an inpatient admission, contact Passport Health Plan s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. To receive authorization for an inpatient admission, contact Passport Health Plan s Utilization Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. Failure to obtain authorization of an admission will result in an administrative denial of the admission (see Section 2.11). Denied authorization requests may be appealed (see Section 2.11). Inpatient Only Codes: In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select surgical procedures must be performed in the inpatient setting. A detailed list of codes may be obtained at the following CMS website: http://www.cms.gov/medicare/medicare-fee-for-service- Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf If a provider performs one of the listed procedures in an outpatient setting and the claim is denied, they may submit supporting medical records documentation for review through the claims appeals process. 5.5.2 Inpatient Admissions to Non-Participating Facilities Requests for admission to non-participating facilities should be submitted to the Passport Health Plan UM department for review. To receive authorization for admission to a non-participating facility, contact Passport Health Plan s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. 5.5.3 Elective Participating-Hospital Transfer Policy Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient clinical information will be required to complete the authorization process, approve the transfer, and determine prospective length of stay. Either the transferring or receiving facility may initiate the prior authorization; however, the transferring facility will be able to provide the most accurate required clinical information. If a hospital transfer request is made by another Passport Health Plan facility, the receiving facility may request that the transferring facility obtain the authorization before the case will be accepted at the receiving facility. Page 7 of 39

The receiving facility should contact Passport Health Plan to confirm the authorization. In cases deemed emergent, notification of the admission is required within one business day after the transfer. To assist with transfers, contact Passport Health Plan s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. 5.5.4 Inpatient Rehabilitation Admissions If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan s Utilization Management via phone (800) 578-0636 or fax (502) 585-7989. Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient Pulmonary Rehab. If the member is to be directly admitted from home or any other sub-acute facility, contact Passport Health Plan s Case Management department at (800) 578-0636 ext. 2024. 5.5.5 Inpatient Skilled-Nursing Facility Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport Health Plan is responsible for costs of professional services, such as physician or therapist services that are not part of the routine facility service. After a member is in a nursing facility for 31 days, the disenrollment process begins for that member. Passport Health Plan s responsibility for those nonfacility services continues for any of its members while they are still enrolled with the Plan. After the Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the DMS-contracted review entity. 5.6 Outpatient Services For authorization of select outpatient services listed in Section 5.3, Authorization Requirements, the PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for payment. When requesting a review, at a minimum, documentation submitted must include: The member s name and Passport Health Plan ID number. The diagnosis for which the treatment or testing procedure is being sought. Other treatment or testing methods that have been tried, their duration, and any outcomes. Page 8 of 39

Additional clinical information as applicable to the requested service. Applicable sections of the medical record. Some authorization requests may require a physician s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. Requests for prior authorization of elective services should be received prior to the date the requested service will be performed. Requests for authorization of urgent and emergent services must be submitted to UM within one business day of the procedure being performed. Passport Health Plan will accept the hospital s or the attending physician s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. Failure to obtain prior authorization for an elective procedure / service or failure to request authorization of an urgent or emergent procedure / service within one business day of the procedure/ service being performed or rendered will result in an administrative denial of the service (see Section 5.10.2). Denied requests may be appealed (see Section 2.11). The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm authorization, they may verify online via the online authorization system. 5.6.1 Outpatient Procedures / Diagnostics / Services Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from the Plan s Utilization Management Department. See Table in section 5.3 for outpatient list. For authorization of select outpatient services listed in Section 5.3, Authorization Requirements, the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The general UM department phone number is: (800) 578-0636. The general UM department fax number is (502) 585-7989. For Outpatient Imaging Services requiring authorization, see section 5.6.2. 5.6.2 Outpatient Radiology Services Providers are required to obtain authorization for select radiological services through the high dollar radiology program for advanced diagnostic imaging services. This program is administered in partnership with MedSolutions (MSI). Authorizations are required for select diagnostic imaging services performed in an outpatient setting. Advanced diagnostic imaging includes: Page 9 of 39

Computed Tomography (CT); Computed Tomographic Angiogram (CTA) Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA) Positron Emissions Tomography (PET) Nuclear Cardiac Imaging (NCM) Authorizations are performed at MSI using their own internal criteria and medical management system. MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is required for advanced diagnostic imaging services performed in any outpatient setting. Authorization is NOT required if the imaging service is performed in: Emergency rooms Inpatient settings 23-hour observations Service performed in observation do not require an authorization. There are three (3) ways to request an authorization: 1. Internet: www.medsolutionsonline.com - Available 24/7 2. Phone: (877) 791-4099 Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free 3. Fax: 1-888-693-3210 Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer Service at (877) 791-4099 Only MedSolutions fax forms are accepted Available 24/7 See Appendix A for a list of codes that require an authorization. 5.6.3 Durable Medical Equipment The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan follows Medicare guidelines. DME PURCHASE DME items with billable charges greater than $500 require an authorization. Requests for authorization of purchase MUST be received PRIOR to the end of the rental period. DME RENTAL Authorization requirements of rentals are determined by the billable price of the item being rented. Rental charges will be applied to purchase price. If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the rental is greater than $500, authorization is required. All items requiring customization or accessories require prior authorization. Page 10 of 39

All mini-nebulizers will be a purchase only item and do not require prior authorization. Authorization requirements for DME purchases are based on total monthly cost or monthly quantity of items purchased. The following is a list of purchases with authorization requirements by quantity: Name Brand Diapers Generic Diapers Underpads (Chux) Ostomy Supplies Bedside Drainage Bags Syringes G-Tube Compression Stockings Item m Quantity Limitations Regardless of quantity, all requests for name brand diapers require authorization 180 per month require authorization 180 per month require authorization 2 boxes per month require authorization 4 per month require authorization 100 per month require authorization 1 per month requires authorization 6 pair per year require authorization * Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM department.* Enteral Products Enteral products with allowable amounts greater than $500 for a month s supply require an authorization. These services should be billed according to the fee schedule in your Provider Contract (Allowable Charges). For authorization of DME, the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number is: (502) 585-7990. For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A. For a list of Ostomy supplies that require an Authorization, see Appendix B. 5.6.4 Home Health Services When medically appropriate, home health, private duty nursing, or home infusion may be a good alternative to hospitalization. Prior authorization of all home health / private duty nursing / hospice / home infusion services is required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse reviewer, the request may be given directly to the on-site review nurse. Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be obtained under EPSDT Special Services. A request for prior authorization must be received prior to the delivery of the service for a non-urgent request and within one business day of the service being performed for an urgent or emergent service. Page 11 of 39

For authorization of Home Health Services, including home health care, private duty nursing and home hospice, the provider notifies Passport Health Plan through the online authorization system, telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax number is: (502) 585-8204. For authorization of home infusion, the provider should submit the infusion therapy authorization form to Magellan via fax at (800) 229-3928. The authorization form can be found at http://www.passporthealthplan.com/pharmacy. 5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services Providers are required to obtain prior authorization for physical, occupational, aquatic and speech therapy for acute and chronic conditions and chiropractic services. Therapy Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. Review is required for the initial therapy visit and all subsequent visits. Requests for continuation of a service that is ongoing should be sent to the therapy department seven days prior to the end of the authorization period. Please fax request together with progress notes and current plan of care to (502) 585-8204. For authorization of therapy requests, providers must notify Passport Health Plan through the online authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The therapy fax number is (502) 585-8205. Chiropractic Services Authorization requests for chiropractic services are required after the 12 th visit. No authorization is required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic visits within a 12-month calendar period. Outpatient Rehab Services Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. For authorization of chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically at (502) 585-6055 or via fax at (502) 585-8205. 5.7 High-Cost Medications Providers are required to obtain prior authorization for High-Cost Medications greater than $400 billable amount per dose from the Utilization Management Department. This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This Page 12 of 39

does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy. Authorizations for Synagis must be requested from Passport s Pharmacy Benefits Manager. See section 14 for prior authorizations related to pharmacy. For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or fax the request to (502) 585-7989. 5.8 Prior Authorization for Members with Medicare Prior authorization is not required for services listed on the prior authorization list when the member has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization requirements apply for both outpatient and inpatient services. For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior authorization of inpatient services must be obtained. If a member s lifetime reserve days are exhausted during an inpatient hospitalization, notification to Passport Health Plan must be made within one business day of the notification to the facility of the exhaustion of benefits by Medicare. 5.9 Retrospective Authorization Retrospective review of inpatient services is performed when the patient was not a member of Passport Health Plan prior to or at the time of the service. Outpatient services do not require retrospective review by Utilization Management for members whose eligibility is determined retrospectively. Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit medical records for review and utilization management authorization request. If the practitioner does not provide documentation, the card issue date, segment date, and claims history are used. A decision and written notification is provided within ten (10) business days of receipt of the medical information for the retrospective review request. An administrative denial is issued for retrospective requests when the provider fails to request a utilization management review of the medical record within the timeframe specified. The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written notification is provided. Requests received beyond 60 days from the card issue date or from the provider s documentation of the date when they were aware of the member s eligibility will be administratively denied. Send requests for retrospective review to: Utilization Management Retrospective Review 5100 Commerce Crossings Drive Louisville, KY 40229 Page 13 of 39

The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart review, please send records via mail). 5.10 Denials An authorization request for a service may be denied for failure to meet guidelines, protocols, medical policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider Manual. Members may not be billed by participating providers for deductibles, copays, and coinsurance except those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members must be held harmless for denied services. To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact Utilization Management at (800) 578-0636. 5.10.1 Medical Necessity Denials Utilization Management utilizes InterQual Guidelines, medical policies and protocols to render review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical Director for clinical review. A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a denial is issued, Utilization Management provides the name, telephone number, title, and office hours of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is available to discuss any decision rendered with the attending practitioner. 5.10.2 Administrative Denials An administrative denial is issued for those services for which the provider has not followed the requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may also be issued for failure to notify Utilization Management within one business day of an emergency service, procedure, or admission. A provider may appeal an administrative denial by submitting the appeal request in writing to: Clinical Appeals Department 5100 Commerce Crossings Drive Louisville, KY 40229 Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions CPT CPT Code CPT Description MRI TMJ Category 70336 MRI Temporomandibular Joint (s) CT 70450 CT Head without contrast Page 14 of 39

CPT CPT Code CPT Description CT Category 70460 CT Head with contrast CT 70470 CT Head with & without contrast CT 70480 CT Orbit, et al without contrast CT 70481 CT Orbit, et al with contrast CT 70482 CT Orbit, et al W & W/O CT 70486 CT Maxillofacial area, (sinus) without contrast CT 70487 CT Maxillofacial area, (sinus) with contrast CT 70488 CT Maxillofacial area, (sinus) W & W/O CT 70490 CT Soft-tissue Neck without contrast CT 70491 CT Soft-tissue Neck with contrast CT 70492 CT Soft-tissue Neck with & without contrast W & W/O CT Angiography (CTA) 70496 CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing CT Angiography (CTA) 70498 CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing MRI 70540 MRI Orbit, Face and/or Neck without contrast MRI 70542 MRI Orbit, Face and/or Neck with contrast MRI 70543 MRI Orbit, Face and/or Neck W & W/O MRA 70544 MR Angiography (MRA) Head without contrast MRA 70545 MR Angiography (MRA) Head with contrast MRA 70546 MR Angiography (MRA) Head with and without contrast W & W/O MRA 70547 MR Angiography (MRA) Neck without contrast MRA 70548 MR Angiography (MRA) Neck with contrast MRA 70549 MR Angiography (MRA) Neck with and without contrast W & W/O MRI 70551 MRI Brain (Head) without contrast MRI 70552 MRI Brain (Head) with contrast MRI 70553 MRI Brain (Head) with and without contrast W & W/O Functional MRI (fmri) 70554 MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Functional MRI (fmri) 70555 MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing CT 71250 CT Chest without contrast CT 71260 CT Chest with contrast CT 71270 CT Chest with and without contrast W & W/O CT Angiography (CTA) 71275 CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing MRI 71550 MRI Chest without contrast MRI 71551 MRI Chest with contrast MRI 71552 MRI Chest with and without contrast W & W/O MRA 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O CT 72125 CT Cervical Spine without contrast CT 72126 CT Cervical Spine with contrast Page 15 of 39

CPT CPT Code CPT Description CT Category 72127 CT Cervical Spine with and without contrast W & W/O CT 72128 CT Thoracic Spine without contrast CT 72129 CT Thoracic Spine with contrast CT 72130 CT Thoracic Spine with and without contrast W & W/O CT 72131 CT Lumbar Spine without contrast CT 72132 CT Lumbar Spine with contrast CT 72133 CT Lumbar Spine with and without out contrast W & W/O MRI 72141 MRI Cervical Spine without contrast MRI 72142 MRI Cervical Spine with contrast MRI 72146 MRI Thoracic Spine without contrast MRI 72147 MRI Thoracic Spine with contrast MRI 72148 MRI Lumbar Spine without contrast MRI 72149 MRI Lumbar Spine with contrast MRI 72156 MRI Cervical Spine with and without contrast W & W/O MRI 72157 MRI Thoracic Spine with and without contrast W & W/O MRI 72158 MRI Lumbar Spine with and without contrast W & W/O MRA 72159 MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast CT Angiography (CTA) 72191 CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing CT 72192 CT Pelvis without contrast CT 72193 CT Pelvis with contrast CT 72194 CT Pelvis with and without contrast W & W/O MRI 72195 MRI Pelvis without contrast MRI 72196 MRI Pelvis with contrast MRI 72197 MRI Pelvis with and without contrast W & W/O MRA 72198 MR Angiography (MRA) Pelvis -with or without contrast CT 73200 CT Upper Extremity without contrast CT 73201 CT Upper Extremity with contrast CT 73202 CT Upper Extremity with and without contrast W & W/O CT Angiography (CTA) 73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI 73218 MRI Upper Extremity-other than joint-without contrast MRI 73219 MRI Upper Extremity-other than joint-with contrast MRI 73220 MRI Upper Extremity-other than joint-w & W/O MRI 73221 MRI Any Joint of Upper Extremity--without contrast MRI 73222 MRI Any Joint of Upper Extremity--with contrast MRI 73223 MRI Any Joint of Upper Extremity W & W/O MRA 73225 MR Angiography (MRA) Upper Extremity -with or without contrast CT 73700 CT Lower Extremity without contrast CT 73701 CT Lower Extremity with contrast CT 73702 CT Lower Extremity with and without contrast W & W/O CT Angiography (CTA) 73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI 73718 MRI Lower Extremity-other than joint-without contrast MRI 73719 MRI Lower Extremity-other than joint-with contrast Page 16 of 39

CPT CPT Code CPT Description MRI Category 73720 MRI Lower Extremity-other than joint- W & W/O MRI 73721 MRI Any Joint of Lower Extremity--without contrast MRI 73722 MRI Any Joint of Lower Extremity--with contrast MRI 73723 MRI Any Joint of Lower Extremity W & W/O MRA 73725 MR Angiography (MRA) Lower Extremity-with or without contrast CT 74150 CT Abdomen without contrast CT 74160 CT Abdomen with contrast CT 74170 CT Abdomen with and without contrast W & W/O CT Angiography (CTA) 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography (CTA) 74175 CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing CT 74176 CT Abdomen & Pelvis, without contrast CT 74177 CT Abdomen & Pelvis, with contrast CT 74178 CT Abdomen & Pelvis, with and without contrast MRI 74181 MRI Abdomen without contrast MRI 74182 MRI Abdomen with contrast MRI 74183 MRI Abdomen with and without contrast W & W/O MRA 74185 MR Angiography (MRA) Abdomen-with or without contrast Diagnostic CT Colonography (CTC) 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Diagnostic CT Colonography (CTC) 74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including noncontrast images, if performed 74263 Computed tomographic (CT) colonography, screening, including image postprocessing CT Colonography (CTC) for Screening Cardiac MRI 75557 Cardiac MRI for morphology and function without contrast Cardiac MRI 75559 Cardiac MRI for morphology and function without contrast material; with stress imaging Cardiac MRI 75561 Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O Cardiac MRI 75563 Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging Cardiac MRI 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Cardiac CT Calcium 75571 CT, heart, without contrast with quantitative Scoring Cardiac CT 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed) Page 17 of 39

CPT CPT Code CPT Description Cardiac CT Category 75573 CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed) CT Coronary Angiography (CTCA) 75574 CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT Angiography (CTA) 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing 3D Rendering 76376 3D Rendering with interpretation and reporting of CT, 3D Rendering 76377 3D Rendering with interpretation and reporting of CT, CT 76380 CT Limited or Localized follow-up MR Spectroscopy (MRS) 76390 MR Spectroscopy (MRS) Unlisted CT 76497 Unlisted CT procedure (eg, diagnostic, interventional) Unlisted MR 76498 Unlisted MR procedure (eg, diagnostic, interventional) CT guidance 77011 CT guidance stereotactic localization CT guidance 77012 CT guidance needle placement (eg, biopsy, aspiration, injection, localization device) CT guidance 77013 CT Guidance for, and monitoring of, parenchymal tissue MR Guidance 77021 MR guidance for needle placement (eg, for biopsy, MR Guidance 77022 MR guidance for, and monitoring of, parenchymal tissue Breast MRI 77058 MRI BREAST, without and/or with contrast UNILATERAL Breast MRI 77059 MRI BREAST, without and/or with contrast BILATERAL CT Bone Density 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial MRI Bone Marrow 77084 skeleton MRI Bone Marrow blood supply Nuclear Cardiac Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Nuclear Cardiac Imaging 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Page 18 of 39

CPT CPT Code CPT Description Nuclear Category Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Cardiac PET 78459 PET Cardiac (myocardial imaging) metabolic evaluation Nuclear Cardiac Imaging 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative Nuclear Cardiac Imaging 78468 Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique Nuclear Cardiac Imaging 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT Nuclear Cardiac Imaging 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Nuclear Cardiac Imaging 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress Nuclear Cardiac Imaging 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Nuclear Cardiac Imaging 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction Cardiac PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress Cardiac PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress Nuclear Cardiac Imaging 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT Nuclear Cardiac Imaging 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass Unlisted Nuclear 78499 Unlisted Nuclear Cardiology diagnostic nuclear Cardiology Non-Cardiac PET 78608 PET Brain metabolic evaluation Non-Cardiac PET 78609 PET Brain perfusion evaluation Non-Cardiac PET 78811 PET imaging; limited area (eg, chest, head/neck) Non-Cardiac PET 78812 PET imaging; skull base to mid-thigh Non-Cardiac PET 78813 PET imaging; whole body Non-Cardiac PET 78814 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck) Non-Cardiac PET 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh Non-Cardiac PET 78816 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast Analysis CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST Magnetic Source Imaging S8035 Magnetic Source Imaging Page 19 of 39

CPT CPT Code CPT Description MRCP Category S8037 MRCP (Magnetic ResonancE) MRI Low field S8042 MRI Low field Cardiac CT Calcium Scoring S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring Page 20 of 39

Appendix B Orthotics and Prosthetics (L codes) AUTHORIZATION REQUIRED HCPCS Description HCPC Description L0113 Cranial cervical orthosis, torticollis type, S L5460 Postop app non-wgt bear dsg w/wo joint, w/o soft interface, prefab. Incl. fitting & adj. L0130 Flex thermoplastic collar molded to L5500 Init bk ptb plaster direct patient L0170 Cervical collar molded to pt L5505 Init ak ischal plstr direct L0220 Thor rib belt custom fabrica L5510 Prep BK ptb plaster molded L0430 Spinal orthosis, Dewall posture protector L5520 Perp BK ptb thermopls direct L0452 TLSO flexible, provides trunk support, L5530 Prep BK ptb thermopls molded upper thoracic region, customized L0456 TLSO, flexible thoracic region, prefab L5535 Prep BK ptb open end socket L0460 TLSO, triplanar control prefab L5540 Prep BK ptb laminated socket L0462 TLSO, triplanar control, prefab L5560 Prep AK ischial plast molded L0464 TLSO, triplanar control 4 piece rigid L5570 Prep AK ischial direct form plastic with interface, prefab L0480 TLSO, triplanar control, one piece rigid L5580 Prep AK ischial thermo mold plastic shell L0482 TLSO, triplanor, custom fabricated, one L5585 Prep AK ischial open end piece rigid plastic shell, each L0484 TLSO, triplanor control, two piece L5590 Prep AK ischial laminated L0486 TLSO, triplanor control 2 piece rigid L5595 Hip disartic sach thermopls plastic with interface, custom L0488 TLSO triplanor, one piece, prefab L5600 Hip disart sach laminat mold L0491 TLSO 2 rigid plastic shells, pre fab L5610 Above knee hydracadence L0622 Sacroiliac orthosis, flexible, custom L5611 Ak 4 bar link w/fric swing L0623 Sacroiliac orthosis, rigid or semi-rigid, L5613 Ak 4 bar ling w/hydraul swig pre fab L0624 Sacroiliac orthosis, rigid or semi-rigid, L5614 4-bar link above knee w/swng custom L0629 Lumbar-sacral orthosis, flexible, custom L5616 Ak univ multiplex sys frict L0631 Lumbar-sacral orthosis, sagittal control, L5639 Below knee wood socket pre fab L0632 Lumbar-sacral orthosis, sag. Control, L5643 Hip flex inner socket ext fr rigid ant./post. Custom L0634 Lumbar-sacral orthosis, sag. Control, rigid post., custom L5645 Ak flexibl inner socket ext Page 21 of 39

L0635 L0636 L0637 L0638 L0639 L0640 Lumbar-sacral orthosis, sag-coronal control, prefab Lumbar-sacral orthosis, sag-coronal control, custom Lumbar-sacral orthosis, sag-coronal control, rigid ant/post., prefab Lumbar-sacral orth, sag-coronal control, rigid ant./post., custom Lumbar-sacral orthosis, sag.-coronal control, rigid post. Prefab Lumbar-sacral orthosis, sag-coronal control, rigid post., custom L5647 L5648 L5649 L5651 L5670 L5673 Below knee suction socket Above knee air cushion socket Isch containmt/narrow m-l so Ak flex inner socket ext fra Bk molded supracondylar susp below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom L0700 Ctlso a-p-l control molded L5679 below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom L0710 Ctlso a-p-l control w/ inter L5681 below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical L0810 Halo cervical into jckt vest L5682 Bk thigh lacer glut/ischia molded L0820 Halo cervical into body jack L5683 below knee/above knee, custom fab, socket inset, initial only not cong.or atypical L0830 Halo cerv into milwaukee typ L5700 Replace socket below knee L0999 Addition to spinal orthosis, NOS L5701 Replace socket above knee L1000 Ctlso milwauke initial model L5702 Replace socket hip L1001 Cervical TLSO, infant, prefab L5704 Custom shape covr below knee L1200 Furnsh initial orthosis only L5705 Custom shape cover above knee L1300 Body jacket mold to patient L5706 Custom shape cvr knee disart L1310 Post-operative body jacket L5707 Custom shape cover hip disart L1499 Spinal orthosis NOS L5716 Knee-shin exo mech stance ph L1500 Thkao mobility frame L5718 Knee-shin exo frct swg & sta L1510 Thkao standing frame L5722 Knee-shin pneum swg frct exo L1520 Thkao swivel walker L5724 Knee-shin exo fluid swing ph L1680 Pelvic & hip control thigh c L5726 Knee-shin ext jnts fld swg e L1685 Post-op hip abduct custom fa L5728 Knee-shin fluid swg & stance L1686 HO post-op hip abduction L5780 Knee-shin pneum/hydra pneum L1690 Combination bilateral LS/hip/femur L5781 Addt. to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system L1700 Legg perthes orth toronto typ L5782 Addt. To lower leg prosth. Vacuum L1710 Legg perthes orth newington L5790 Exoskeletal ak ultra-light m L1720 Legg perthes orthosis trilat L5795 Exoskel hip ultra-light mate Page 22 of 39

L1730 Legg perthes orth scottish L5811 Endo knee-shin mnl lck ultra L1755 Legg perthes patten bottom L5814 Endo knee-shin hydral swg ph L1832 KO adj jnt pos rigid support L5816 Endo knee-shin polyc mch sta L1834 KO w/0 joint rigid molded to L5818 Endo knee-shin frct swg & st L1840 KO derot ant cruciate custom L5822 Endo knee-shin pneum swg frc L1843 KO single upright thigh & calf- L5824 Endo knee-shin fluid swing p prefabricated, each L1844 KO w/adj jt rot cntrl molded L5826 Miniature knee joint L1845 KO w/ adj flex/ext rotat cus L5828 Endo knee-shin fluid swg/sta L1846 KO w adj flex/ext rotat mold L5830 Endo knee-shin pneum/swg pha L1860 KO supracondylar socket mold L5840 Multi-axial knee/shin system L1904 AFO molded ankle gauntlet L5845 Knee-shin sys stance flexion L1907 supramalleolar w/straps w/wo interface/pads, custom fabricated L5848 Knee-shin system dampening feature L1932 AFO, rigid anterior tibial section,pre fab, incl. Fitting & adj. L5856 Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type L1940 AFO, plastic or other material custom L5857 Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor, any type L1945 AFO molded plas rig ant tib L5858 Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens, stance phase L1950 AFO spiral molded to pt plas L5930 High activity knee frame L1951 spiral, IRM type, plastic or other L5950 Endo ak ultra-light material material prefab, incl. Fitting and adj. L1960 AFO pos solid ank plastic mo; custom L5960 Endo hip ultra-light materia L1970 AFO plastic molded w/ankle j L5964 addt. Endoskeleton above knee, flexible protective outer surface L1980 AFO sing solid stirrup calf custom L5966 Hip flexible cover system L1990 AFO doub solid stirrup calf; custom L5968 Multiaxial ankle w dorsiflex L2000 KAFO using fre stirr thi/calf; custom L5973 Endoskeletal ankle foot system, microprocessor, incl. power source L2005 KAFO any material, single or dbl. Upright L5976 Energy storing foot includes ankle joint custom fabricated L2010 KAFO single upright, free ankle, solid L5979 Multi-axial ankle/ft prosth stirrup L2020 KAFO dbl solid stirrup band/ L5980 Flex foot system L2030 KAFO dbl solid stirrup w/o j L5981 Flex-walk sys low ext prosth L2034 KAFO full plastic, single upright, w/wo L5987 Shank ft w vert load pylon free motion knee,custom fabricated L2036 KAFO plas doub free knee mol L5988 Vertical shock reducing pylo L2037 KAFO plas sing free knee mol L5990 addt. To lower ext. user adj. ht L2038 KAFO w/o joint multi-axis an L5999 Lower extremity prosthesis, NOC L2050 Hkafo torsion cable hip pelv; custom L6000 Par hand robin-aids thum rem Page 23 of 39