Prior Authorization Updates

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, 2014. 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 1-866-912-4245. The fax authorization form can be found on our website at mhsindiana.com. You may call MHS Medical Management at 1-877-647-4848. 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 1-877-647-4848 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

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, 2013. Non-highlighted codes are codes that will require prior authorization as of July 1, 2014. 1. Quantitative Testing for Drugs of Abuse & Genetic/Molecular Diagnostic Testing Quantitative Testing for Drugs of Abuse CPT CODE DESCRIPTION 80154 DRUG SCREEN QUANTITATIVE BENZODIAZEPINES 80184 DRUG SCREEN QUANTITATIVE PHENOBARBITAL 82145 AMPHETAMINE OR METHAMPHETAMINE, CHEMICAL, QUANTITATIVE 82205 BARBITURATES; QUANTITATIVE 82520 COCAINE, QUANTITATIVE 82646 DIHYDROCODEINONE 82649 DIHYDROMORPHINONE, QUANTITATIVE 83805 MEPROBAMATE, BLOOD OR URINE 83840 METHADONE 83887 NICOTINE 83925 ASSAY OF OPIATES 83992 PHENCYCLIDINE (PCP) CPT CODE DESCRIPTION Genetic/Molecular Diagnostic Testing 81161 DMD DUPLICATION/DELETION ANALYSIS 81200 ASPA GENE 81201 APC GENE ANALYSIS FULL GENE SEQUENCE 81202 APC GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81203 APC GENE ANALYSIS DUPLICATION/DELETION VARIANTS 81205 BCKDHB GENE 81206 BCR/ABL1 GENE MAJOR BP 81207 BCR/ABL1 GENE MINOR BP 81208 BCR/ABL1 GENE OTHER BP 81209 BLM GENE 81210 BRAF GENE 81211 BRCA1&2 SEQ & COM DUP/DEL 81212 BRCA1&2 185&5385&6174 VAR 81213 BRCA1&2 UNCOM DUP/DEL VAR 81214 BRCA1 FULL SEQ & COM DUP/DEL 81215 BRCA1 GENE KNOWN FAM VARIANT 81216 BRCA2 GENE FULL SEQUENCE 2

Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION 81217 BRCA2 GENE KNOWN FAM VARIANT 81220 CFTR GENE COM VARIANTS 81221 CFTR GENE KNOWN FAM VARIANTS 81222 CFTR GENE DUP/DELET VARIANTS 81223 CFTR GENE FULL SEQUENCE 81224 CFTR GENE INTRON POLY T 81225 CYP2C19 GENE COM VARIANTS 81226 CYP2D6 GENE COM VARIANTS 81227 CYP2C9 GENE COM VARIANTS 81228 CYTOGEN MICRARRAY COPY NMBR 81229 CYTOGEN M ARRAY COPY NO&SNP 81235 EGFR GENE ANALYSIS COMMON VARIANTS 81240 F2 GENE 81241 F5 GENE 81242 FANCC GENE 81243 FMR1 GENE DETECTION 81244 FMR1 GENE CHARACTERIZATION 81245 FLT3 GENE 81250 G6PC GENE 81251 GBA GENE 81252 GJB2 GENE ANALYSIS FULL GENE SEQUENCE 81253 GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81254 GJB6 GENE ANALYSIS COMMON VARIANTS 81255 HEXA GENE 81256 HFE GENE 81257 HBA1/HBA2 GENE 81260 IKBKAP GENE 81261 IGH GENE REARRANGE AMP METH 81262 IGH GENE REARRANG DIR PROBE 81263 IGH VARI REGIONAL MUTATION 81264 IGK REARRANGEABN CLONAL POP 81265 STR MARKERS SPECIMEN ANAL 81266 STR MARKERS SPEC ANAL ADDL 81267 CHIMERISM ANAL NO CELL SELEC 81268 CHIMERISM ANAL W/CELL SELECT 81270 JAK2 GENE 3

CPT CODE DESCRIPTION 81275 KRAS GENE 81280 LONG QT SYND GENE FULL SEQ 81281 LONG QT SYND KNOWN FAM VAR 81282 LONG QT SYN GENE DUP/DLT VAR Genetic/Molecular Diagnostic Testing 81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis 81290 MCOLN1 GENE 81291 MTHFR GENE 81292 MLH1 GENE FULL SEQ 81293 MLH1 GENE KNOWN VARIANTS 81294 MLH1 GENE DUP/DELETE VARIANT 81295 MSH2 GENE FULL SEQ 81296 MSH2 GENE KNOWN VARIANTS 81297 MSH2 GENE DUP/DELETE VARIANT 81298 MSH6 GENE FULL SEQ 81299 MSH6 GENE KNOWN VARIANTS 81300 MSH6 GENE DUP/DELETE VARIANT 81301 MICROSATELLITE INSTABILITY 81302 MECP2 GENE FULL SEQ 81303 MECP2 GENE KNOWN VARIANT 81304 MECP2 GENE DUP/DELET VARIANT 81310 NPM1 GENE 81315 PML/RARALPHA COM BREAKPOINTS 81316 PML/RARALPHA 1 BREAKPOINT 81317 PMS2 GENE FULL SEQ ANALYSIS 81318 PMS2 KNOWN FAMILIAL VARIANTS 81319 PMS2 GENE DUP/DELET VARIANTS 81321 PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS 81322 PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT 81323 PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT 81324 PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS 81325 PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS 81326 PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT 81330 SMPD1 GENE COMMON VARIANTS 81331 SNRPN/UBE3A GENE 81332 SERPINA1 GENE 81340 TRB@ GENE REARRANGE AMPLIFY 4

CPT CODE DESCRIPTION 81341 TRB@ GENE REARRANGE DIRPROBE 81342 TRG GENE REARRANGEMENT ANAL 81350 UGT1A1 GENE 81355 VKORC1 GENE 81370 HLA I & II TYPING LR 81371 HLA I & II TYPE VERIFY LR 81372 HLA I TYPING COMPLETE LR 81373 HLA I TYPING 1 LOCUS LR 81374 HLA I TYPING 1 ANTIGEN LR 81375 HLA II TYPING AG EQUIV LR 81376 HLA II TYPING 1 LOCUS LR 81377 HLA II TYPE 1 AG EQUIV LR 81378 HLA I & II TYPING HR 81379 HLA I TYPING COMPLETE HR 81380 HLA I TYPING 1 LOCUS HR 81381 HLA I TYPING 1 ALLELE HR 81382 HLA II TYPING 1 LOC HR 81383 HLA II TYPING 1 ALLELE HR 81400 MOPATH PROCEDURE LEVEL 1 81401 MOPATH PROCEDURE LEVEL 2 81402 MOPATH PROCEDURE LEVEL 3 81403 MOPATH PROCEDURE LEVEL 4 81404 MOPATH PROCEDURE LEVEL 5 81405 MOPATH PROCEDURE LEVEL 6 81406 MOPATH PROCEDURE LEVEL 7 81407 MOPATH PROCEDURE LEVEL 8 81408 MOPATH PROCEDURE LEVEL 9 Genetic/Molecular Diagnostic Testing 81479 UNLISTED MOLELCULAR PATHOLOGY PROCEDURE 81500 ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS 81503 ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS 81504 ONCOLOGY (TISSUE OF ORIGIN), MICROARRAY GENE EXPRESSION PROFILING OF > 2000 GENES, UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS TISSUE SIMILARITY SCORES 81506 ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL FETAL ANEUPLOIDY (TRISOMY 21, 18, AND 13) DNA SEQUENCE ANALYSIS OF SELECTED 81507 REGIONS USING MATERNAL PLASMA, ALGORITHM REPORTED AS A RISK SCORE FOR EACH TRISOMY 81508 FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS 5

Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION 81509 FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS 81510 FETAL CONGENITAL ABNOR ASSAY THREE ANAL 81511 FETAL CONGENITAL ABNOR ASSAY FOUR ANAL 81512 FETAL CONGENITAL ABNOR ASSAY FIVE ANAL 81599 UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS 83890 MOLECULE ISOLATE 83891 MOLECULE ISOLATE NUCLEIC 83892 MOLECULAR DIAGNOSTICS 83893 MOLECULE DOT/SLOT/BLOT 83894 MOLECULE GEL ELECTROPHOR 83896 MOLECULAR DX; NUCLEIC ACID PROBE EA 83897 MOLECULE NUCLEIC TRANSFER 83898 MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE 83900 MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ 83901 MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ 83902 MOLECULAR DX; REVERSE TRANSCRIPTION 83903 MOLEC DX; MUTATION SCAN BY PHYS PROP-1 SEGMT EA 83904 MOLEC DX; MUTATION ID-SEQUENCING-1 SGMT EA 83905 MOLEC DX; MUTATION ID-ALLELE SPEC TRANSCRIP-1-EA 83906 MOLEC DX; MUTATION ID-ALLELE SPEC TRANSLAT-1-EA 83907 LYSE CELLS FOR NUCLEIC EXT 83908 MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE 83909 NUCLEIC ACID HIGH RESOLUTE 83912 MOLECULAR DX; INTERPT & REPORT 83913 RNA STABILIZATION 83914 MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA 83915 NUCLEOTIDASE 5'- 86812 TISSUE TYPING; HLA TYPING, A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN 86813 TISSUE TYPING; HLA TYPING, A, B, AND/OR C (EG, A10, B7, B27), MULTIPLE A 86816 TISSUE TYPING; HLA TYPING, DR/DQ, SINGLE ANTIGEN 86817 TISSUE TYPING; HLA TYPING, DR/DQ, MULTIPLE ANTIGENS 86821 TISSUE TYPING; LYMPHOCYTE CULTURE, MIXED(MLC) 86822 TISSUE TYPING; LYMPHOCYTE CULTURE, PRIMED(PLC) 86825 HLA X-MATCH, NON-CYTOTOXIC 86826 HLA X-MATCH, NON-CYT ADD-ON 86828 HLA CLASS I&II ANTIBODY QUAL 6

Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION 86829 HLA CLASS I/II ANTIBODY QUAL 86830 HLA CLASS I PHENOTYPE QUAL 86831 HLA CLASS II PHENOTYPE QUAL 86832 HLA CLASS I HIGH DEFIN QUAL 86833 HLA CLASS II HIGH DEFIN QUAL 86834 HLA CLASS I SEMIQUANT PANEL 86835 HLA CLASS II SEMIQUANT PANEL 88230 TISS CULTURE NON-NEOPLAS DISORD; LYMPHOCYTE 88233 TISS CULTURE NON-NEOPLAS DISORD; SKIN/SOLID TISS 88235 TISS CULTURE NON-NEOPLAS DISORD; AMNIOTIC FLUID 88237 TISS CULTURE NEOPLAS DISORD; MARROW/BLD CELLS 88239 TISS CULTURE NEOPLAS DISORD; SOLID TUMOR 88240 CRYOPRESERV-FREEZE & STORE CELLS EA CELL LINE 88241 THAWING & EXPANSION FROZEN CELLS EA ALIQUOT 88245 CHROMOSOME ANALY BREAK SYNDROM; SCE 20-25 CELLS 88248 CHROMOSOME ANALY; BASELINE BREAKAGE 88249 CHROMOSOME ANALY BREAK SYNDROM; CLASTOGEN STRESS 88261 CHROMO ANALY; CT 5 CELLS 1 KARYOTYPE W/BANDING 88262 CHROMO ANALY; CT 15-20 CELLS 2 KARYOTYPES W/BAND 88263 CHROMO ANALY; CT 45 CEL MOSAICISM 2 KARYO W/BAND 88264 CHROMOSOME ANALY; ANALY 20-25 CELLS 88267 CHROMO ANALY AMNIO FLUID CT 15 CELLS 1 KARYOTYPE 88269 CHROMO ANALY AMNIO FLUID CELLS CT 6-12 COLONIES 88271 MOLEC CYTOGEN; DNA PROBE EA 88272 MOLEC CYTOGEN; CHROMOSOM IN SITU HYBRID 3-5 CELL 88273 MOLEC CYTOGEN; CHROMOSOM HYBRID 10-30 CELLS 88274 MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID 25-99 88275 MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID 100-300 88280 CHROMOSOME ANALY; ADD KARYOTYPES EA STUDY 88283 CHROMOSOME ANALY; ADD SPECIALIZED BANDING TECH 88285 CHROMOSOME ANALY; ADD CELLS COUNTED EA STUDY 88289 CHROMOSOME ANALY; ADD HIGH RESOLUTION STUDY 88291 CYTOGEN & MOLEC CYTOGEN INTERPT & REPORT 88299 UNLISTED CYTOGENETIC STUDY 88384 RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS 88385 RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS 7

Genetic/Molecular Diagnostic Testing CPT CODE DESCRIPTION 88386 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 S3823 3-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

2. Specialized Radiation Therapy CPT CODE 61796 CODE DESCRIPTION Specialized Radiation Therapy Stereotactic radiosurgery (SRS) (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion 61797 SRS; each additional cranial lesion, simple 61798 SRS; 1 complex cranial lesion 61799 SRS; each additional cranial lesion, complex 63620 SRS; 1 spinal lesion 63621 SRS; each additional spinal lesion 77301 Intensity modulated radiotherapy (IMRT) plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77338 Multi-leaf collimator (MLC) device(s) for IMRT, design and construction per IMRT plan 77371 Radiation treatment delivery, SRS, complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source cobalt 60 based 77372 77373 77418 77422 77423 77432 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) 77435 SBRT, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions 77520 Proton treatment; simple, without compensation 77522 Proton treatment delivery; simple, with compensation 77523 Proton treatment delivery; intermediate 77525 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

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

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

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