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Surgical Procedures Requiring Authorization
08/2010
CODE PROCEDURE
10040 ACNE SURGERY
11920 TATTOOING 6.0 SQ CM OR LESS
11921 CORRECT COLOR DEFECTS OF SKN 6.1-20.0 SQ CM-11921
11922 CORRECT SKIN COLOR DEFECTS EA.ADDL 20 SQ CM
11960 INSERT TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INC SUBSEQ EXPANSION
11970 REPLACE EXPANDER W/PROSTHESIS
11971 REMOVAL TISSUE EXPANDER W/O INSERTION OF PROSTHESIS
11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION
11981 INSERT NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
11982 REMOVE NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
11983 REMOVE W/REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT
17999 UNLISTED PROC SKIN MUCOUS MEMB
19105 ABLATION CRYOSURG FIBROADENOMA W/ US GID EA FIBROADENOMA
19296 PLACE RADIOTHERAPY AFTERLOAD EXPANDABLE CATHETER INTO BREAST
19297 PLACE RADIOTHERAPY AFTERLOAD EXPANDABLE CATH W/PART MASTECTOMY
19298 AFTERLOAD BRACHYTHERAPY CATHETER PLACEMENT IN BREAST
19340 IMMED INSERTION BREAST PROTHES
19342 DELAYED INSERT BREAST PROSTHESIS FOLLOW MASTOPEXY,MASTECTOMY OR IN RECONSTRUCT
19350 RECONSTRUC NIPPLE/AREOLAR UNIL
19355 CORRECT INVERTED NIPPLES
19357 BREAST RECONSTRUCT IMM/DELAYED
19361 BREAST RECONSTRUCT W/LATISSIMUS DORSI FLAP W/O PROSTHETIC IMPLANT
19364 BREAST RECONSTRUCITON WITH FREE FLAP
19366 BREAST RECONSTRUCT OTHR TECHNI
19367 BREAST RECONST W/MYOCUT FLAP,SINGLE PEDICLE W/CLOSE DONOR SITE
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
19368 BREAST RECONST. WITH MICROVASCULAR ANASTOMOSIS
19369 BREAST RECONSTR. W/TRAM W/DOUBLE PEDICLE FLAP
19370 OPEN PERIPROSTHETIC CAPSULOTOMY OF BREAST
19371 PERIPROSTHETIC CAPSULECTOMY OF BREAST
19380 REVISION RECONSTRUCTED BREAST
19499 UNLISTED PROCEDURE BREAST
20696 EXTERNAL FIXJ W/STEREOTACTIC ADJUSTMENT 1ST&SUBQ
20697 EXTERNAL FIXJ W/STRTCTC ADJUSTMENT EXCHANGE STRUT
20930 ALLOGRAFT FOR SPINE SURGERY ONLY, MORSELIZED
20931 ALLOGRAFT FOR SPINE SURGERY, STRUCTURAL
20936 AUTOGRAFT SPINE SURGERY ONLY, LOCAL OBTAINED FROM SAME INCISION
20937 AUTOGRAFT SPINE SURGERY ONLY, MORSELIZED THRU SEPARATE INCISION
20938 AUTOGRAFT SPINE SURGERY ONLY, STRUCTURAL BI OR TRICORTICAL THRU SEPARATE INCIS
20975 ELECTRIC STIM TO AID BONE HEALING, INVASIVE
20999 UNLISTED PROC MUSCULOSKELETAL SYSTEM,GENERAL
21010 ARTHROTOMY,TEMPOROMANDIBULAR JOINT
21031 EXCISION OF TORUS MANDIBULARIS
21032 EXCISION OF MAXILLARY TORUS PALATINUS
21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT
21060 MENISCECTOMY, PART OR COMPLETE, TEMPORO JNT
21070 CORONOIDECTOMY UNILATERAL
21076 PREPARATION OBTURATOR PROTHESIS
21077 PREPARATION ORBITAL PROSTHESIS
21079 PREPARATION OBTURATOR PROSTHES
21080 DEFINITIVE OBTURATOR PROSTHESI
21081 MANDIBUBLAR RESECTION PROSTHES
21082 PALATAL AUGMENTATION PROSTHESI
21084 SPEECH AID PROSTHESIS
21085 PREPARE FACE/ORAL SURGICAL SPLINT
21086 AURICAL PROSTHESIS
21088 FACIAL PROSTHESIS
21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE
21100 APPLICATION HALO APPLIANCE, MAXILLOFACIAL FIX W/REMOVAL
21110 APPLY INTERDENTAL FIX FOR OTHER THAN FRACTURE/DISLOCATION INCLUDES REMOVAL
21141 RECON MIDFACE LEFORT 1 SINGLE W/O BONE GRAFT
21142 RECON MIDFACE LEFORT 1-2 PCS SEGMT MOVE ANY DIRECT W/O BONE GRAFT
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requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
21143 RECON MIDFACE LEFORT I 3 PLUS PCS, W/O BONE GRAFT
21181 RECONSTRUCT CONTOURING BENIGN TUMOR OF CRANIAL BONES, EXTRACRANIAL
21210 GRAFT BONE NASAL/MAXILLA/MALAR
21215 GRAFT BONE MANDIBLE
21230 GRAF CART/RIB TO FACE ADNEXA
21235 GRAFT, EAR CARTILAGE, AUTOGENOUS, NOSE TO EAR
21240 ARTHROPLASTY TMJ JOINT W/WO GR
21244 RECONSTRUCT MANDIBLE,EXTRAORAL W/TRANSOSTEAL BONE PLATE
21245 RECONSTRUCT MANDIBLE/MAXILLA, SUBPERIOSTEAL IMPLANT PARTIAL
21246 RECONSTRUCT MANDIBLE/MAXILLA,SUBPERIOSTEAL IMPLANT,COMPLETE
21248 RECONSTRUCT JAW,ENDOSTEAL IMPLANT - PARTIAL
21249 RECONSTRUCT MANDIBLE/MAXILLA ENDOSTEAL IMPLANT,COMPLETE
21260 PERIORBITAL OSTEOTOMIES HYPERTELORISM W/BONE GRAFTS EXTRACRANIAL
21261 PERIORBITAL OSTEOTOMIES HYPERTELORISM W/BONE GRAFTS, EXTRACRANIAL APPROACH
21263 REP ORB HYPERTELORISM W FOREHD
21267 ORBIT REPOSITION, UNILATERAL W/BONE GRAFTS, EXTRACRANIAL
21268 ORBIT REPOSITION, UNILATERAL W/BONE GRAFTS, COMBINED INTRA/EXTRACRANIAL
21275 SECONDARY REVISION OF ORBITOCRANIOFACIA
21295 REDUCE MASSETER MUSCLE AND BONE, EXTRAORAL APPROACH
21296 REDUCE MASSETER MUSCLE AND BONE, INTRAORAL APPROACH
21299 UNLISTED CRANIOFRACIAL AND MAXILLOFACIAL PROC
21431 TREAT CRANIOFACIAL FRACTURE
21432 RED FX OPEN-LEFORT 3 TYPE
21433 RED FX OPEN-LEFORT 3 COMP
21435 RED FX OPEN-LEFORT 3 COMP PLUS FIX
21436 OPEN TX CRANIOFACIAL FX,COMPL
21499 UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD
21740 RECONSTRUCT PECTUS ETUM OR CARINATUM, OPEN
21742 RECONSTRUCTVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM MINIMALLY INVAS
21743 RECON REPAIR OF PECTUS EXCAVATUM OR CARINATUM MINIMALLY INVASIVE APP
21750 CLOSURE MEDI STERNOTOMY SEP W/WO DEBRI
21899 UNLISTED PROCEDURE, NECK OR THORAX
22110 EXC VERTEBRA PART CERVICAL
22112 EXC VERTEBRA PART THORACIC
22114 EXC VERTEBRA PART LUMBAR
22116 EXC VERTEB PART, EA SEGMENT
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
22206 OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC
22207 OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR
22208 OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM
22210 OSTEOTOMY OF SPINE - CERVICAL
22212 OSTEOTOMY OF SPINE, THORACIC
22214 OSTEOTOMY OF SPINE, LUMBAR
22216 SPINE OSTEOTOMY,POST/POSTEROLAT,EA ADD SEGMENT
22220 OSTEOTOMY OF SPINE,INCL DISKECTOMY - CERVICAL
22222 OSTEOTOMY/SPINE, INCL DISKECTOMY THORACIC
22224 OSTEOTOMY/SPINE, INCL DISKECTOMY LUMBAR
22226 OSTEOTOMY OF SPINE,INCL DISKECTOMY, EA.ADDL VERT
22520 PERCUTANEOUS VERTEBROPLAST, 1 VERTEBRAL BDY UNILATRL OR BILATRL INJ.THORACIC
22521 PERCUTANEOUS VERTEBROPLAST, 1 VERTEBRAL BDY UNILATRL OR BILATRL INJ.LUMBAR
22522 PERCUTANEOUS VERTEBROPLASTY EACH ADD'L THORACIC OR LUMBAR VERTEBRAL BODY
22523 PERCUT VERT AUGMENT MECH DEVICE ONE VERT BODY THORACIC
22524 PERCUT VERT AUGMENT MECH DEVICE ONE VERT BODY LUMBAR
22525 PERCUT VERT AUGMENT MECH DEVICE ONE VERT BODY THORACIC OR LUMBAR
22532 LAT EXTRA CAVITARY ARTHRODESIS W MIN DISKECTOMY THORACIC
22533 LAT EXTRA CAVITARY ARTHRODESIS W MIN DISKECTOMY LUMBAR
22534 LAT EXTRA CAVITARY ARTHRODESIS W MIN DISKECTOMY THOR LUMB EA ADDL
22548 ARTHRODESIS, CLIVUS-C1-C2 W OR W/O EXCISION
22554 ARTHRODESIS, ANTERIOR INTERBODY TECH CERV BELOW C2
22556 ARTHRODESIS, ANTERIOR INTERBODY TECH THORACIC
22558 ARTHRODESIS, ANTERIOR INTERBODY TECH LUMBAR
22585 ARTHRODESIS,ANTERIOR TECH, EA. ADDL.
22590 ARTHRODESIS, POST TECH CRANIOCERVICAL
22595 ARTHRODESIS, POST TECH, ATLAS-AXIS C1-C2
22600 ARTHRODESIS, POST TECH, SINGLE CERV BELOW C2
22610 THORAX SPINE FUSION 1
22612 ARTHRODESIS, POST TECH SINGLE LUMBAR
22614 ARTHRODESIS, EA. ADDL. VERTEBRAL SEGMENT
22630 ARTHRODESIS,POST INTERBODY TECH,SINGLE INTERSPACE - LUMBAR
22632 POST INTERBODY ARTHRODESIS - EA AD SPC
22800 ARTHRODESIS, POSTERIOR W OR W/O CAST UP TO 6 VERTEBRAL SEGMENTS
22802 ARTHRODESIS, POSTERIOR 7 TO 12 VERT SEG
22804 ARTHRODESIS POSTERIOR 13 OR MORE
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
22808 ARTHRODESIS, ANTERIOR W OR W/O CAST 2-3 VERT SEG
22810 ARTHRODESIS, ANTERIOR 4 TO 7 VERT SEG
22812 ANT ARTHRODESIS W/WO/CAST - 8 OR MORE VERTEBRAL SEG
22818 KYPHECTOMY EXPOSURE SPINE AND RESECTION SINGLE OR 2 SEGMENTS
22819 KYPHECTOMY EXPOSURE SPINE AND RESECTION 3 OR MORE SEGMENTS
22830 EXPLORATION OF SPINAL FUSION
22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION
22841 INTERNAL SPIINAL FIXATION BY WIRING SPINOUS PROCESSES
22842 POSTERIOR SEGMENT INSTRUMENTATION 3 TO 6 SEGMENTS
22843 POSTERIOR SEGMENT INSTRUMENTATION 7-12 SEGMENTS
22844 POSTERIOR SEGMENT INSTRUMENTATION 13 OR MORE
22845 ANTERIOR INSTRUMENTATION 2-3 VERT SEGMENTS
22846 ANTERIOR INSTRUMENTATION 4-7 SEGMENTS
22847 ANTERIOR INSTRUMENTATION 8 OR MORE SEGMENTS
22848 PELVIC FIXATION, NO SACRUM
22849 REINSERT SPINAL FIXATION
22850 REMOVE POSTERIOR NONSEGMENT INSTRUMENT (HARRINGTON ROD)
22851 APPL INTERVERTEBRAL BIOMECH DEV TO VERTEBRAL DEFECT/INTERSPACE
22852 REMOVE POSTERIOR SEGMENTAL INSTRUMENTATION
22855 REMOVAL OF ANTERIOR INSTRUMENTATION
22857 TOT DISC ARTHRP ARTIF DISC ANTERIOR APPROX 1 INTERSPACE LUMBAR
22862 REV W/RPLCMT DISC ARTHROPLASTY ANTERIOR SINGLE INTERSPACE, LUMBAR
22865 REMOVAL DISC ARTHROPLASTY ANT SINGLE INTERSPACE , LUMBAR
22899 UNLISTED PROCEDURE SPINE
22999 UNLIST PROCEDURE ABD MUSC-SKEL
23220 RADICAL RESECTION TUMOR PROMAL/HUMERUS
23929 UNLISTED PROCEDURE, SHOULDER
24999 UNLISTED PROCED HUMERUS/ELBOW
25999 UNLIST PROCEDURE FOREARM/WRIST
26989 UNLISTED PROC FOR HANDS OR FINGERS
27027 DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNILATERAL
27057 DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNILATERAL
27299 UNLISTED PROCEDURE PELVIS/HIP
27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE
27415 OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN
27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
27599 UNLISTED PROCEDURE FEMUR OR KNEE
27700 ARTHROPLASTY ANKLE
27702 ARTHROPLASTY, ANKLE W/IMPLANT
27703 ARTHROPLASTY, ANKLE,REVISION, TOTAL
27704 REMOVAL OF ANKLE IMPLANT
27899 UNLISTED PROCEDURE LEG/ANKLE
28360 RECONSTRUCT CLEFT FOOT
28446 OPEN OSTEOCHONDRAL AUTOGRAFT TALUS
28890 EXTRACORP HIGH ENERGY PFRMD PHYS W/ANES INCL ULTRA SOUND INVL. PLNTAR FASCIA
28899 UNLISTED PROCEDURE, FOOT OR TOES
29799 UNLISTED PROCEDURE CASTING OR STRAPPING
29800 ARTHROSCOPY, TMJ, DIAGNOSTIC, W OR W/O SYNOVIAL BIOPSY
29804 ARTHROSCOPY TMJ SURGICAL
29862 HIP ARTHROSCOPY/DEBRIDEMENT/SHAVING/PLASTY
29866 ARTHROSCOPY, KNEE, SURGICAL, OSTEOCHONDRAL AUTOGRAFTS
29867 ARTHROSCOPY, KNEE,SURGICAL OSTEOCHONDRAL ALLOGRAFT
29868 MENISCAL TRANSPLANTATION W/ARTHROTOMY FOR MENISCAL INSERTION
29999 UNLISTED ARTHROSCOPY
30120 EXC/PLANE SKIN NASAL RHINOPHYM
30210 DISPLACEMENT THERAPY PROETZ TY
30465 REPAIR OF NASAL VESTIBULAR STENOSIS
30520 SEPTOPLASTY OR SUBMUCOUS RESECT W OR W/O SCORING,CONTOUR OR REPLACEMENT GRAFT
30540 REPR CHOANAL ATRESIA INTRANASA
30545 REPR CHOANAL ATRESIA TRANSPLNT
30560 LYSIS INTRANASAL SYNECHIA
30620 SEPTAL OR OTHER INTRANASAL DERMATOPLASTY
30630 REPAIR NASAL SEPTAL PERFORATIONS
30999 UNLISTED PROCEDURE NOSE
31299 UNLISTED PROCEDURE, ACCESSORY SINUSES
31599 UNLISTED PROCEDURE LARYNX
31611 CONSTRUCT TRACHEO FISTULA/INSERT SPEECH PROSTHESIS
31899 UNLISTED PROCED TRACHEA BRONCH
32850 DONOR PNEUMONECTOMY,CADAVER
32851 LUNG TRANSPLANT, SINGLE
32852 LUNG TRANSPLANT W/BYPASS
32853 LUNG TRANSPLANT, DOUBLE
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
32854 TRANSPLANT,LUNG(2)W/BYPASS
32999 UNLISTED PROCEDURE, LUNGS AND PLEURA
33140 TRANSMYOCARDIAL LASER REVASCULARIZATION
33254 OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED
33255 OPER TISSUE ABLATION AND RECONSTR ATRIA, EXTENSIVE W/O C-P BYPASS
33256 OPER TISSUE ABLATION AND RECONSTR ATRIA, EXTENSIVE WITH C-P BYPASS
33265 ENDOSCOPY,SURG OPER TISS ABLATION RECON ATRIA LTD W/O C-P BYPASS
33266 ENDOSCOPY,SURG OPER TISS ABLATION RECON ATRIA EXT W/O C-P BYPASS
33864 ASCENDING AORTA GRF VALVE SPARE ANNULUS REMODEL
33880 ENDOVASC REPAIR DESC THORACIC AORTA INV LT SUBCLAV ARTERY ORGIN
33881 ENDOVASC REPAIR DESC THORACIC AORTA NOT INV LT SUBCLAV ARTERY ORGIN
33883 PLACEMENT PROX EXT PROSTH EVASC REPAIR OF DESC AORTA 1ST EXTENSION
33884 PLACEMENT PROX EXT PROSTH EVASC REPAIR OF DESC AORTA EA ADDITIONAL
33886 PLACEMENT DISTAL EXT PROSTH DELAYED AFTER ENDOVAS REP OF DESC THOR AORTA
33889 OPEN SUBCLAV CARTD ARTRY TRANPOS W ENDOVAS REP OF DESC THOR BY NECK UNILAT
33891 BYPASS GRAFT W OTHER THAN VEIN ENDOVAS REP OF DESC THORAC BY NECK INCIS
33930 REMOVAL OF DONOR HEART/LUNG
33935 HEART-LUNG TRANSPLANT W/RECIPIENT CARDIECTOMY-PNEUMONECTOMY
33940 REMOVAL OF DONOR HEART
33945 HEART TRANSPLANT W OR W/O RECIPIENT CARDIECTOMY
33999 UNLISTED PROCEDURE, CARDIAC SURGERY
35523 BYPASS GRAFT W/VEIN, BRACHIAL-ULNAR OR RADIAL
35535 BYPASS GRAFT WITH VEIN HEPATORENAL
35570 BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRUNK-TIBIAL
35632 BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC
35633 BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC
35634 BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL
36299 UNLISTED PROCEDURE, VASCULAR INJECTION
36475 ENDOVENOUS ABLATION INCOMP VEIN EXTREM,INCLUSIVE IMAGING 1ST VEIN TREATED
36476 ENDOVENOUS ABLATION INCOMP VEIN EXTREM,INCLU IMAGE 2ND AND SUBSEQ VEINS
36478 ENOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 1ST VEIN
36479 ENOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY SEPARATE
36522 PHOTOPHERESIS, EXTRACORPOREAL
37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE
37650 LIGATION OF FEMORAL VEIN
37660 LIGATION OF COMMON ILIAC VEIN
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
37700 LIGATION/DIVISION VEIN AT JUNCTION OR DISTAL INTERRUPT
37718 LIGATION DIVISION AND STRIPPING SHORT SAPHENOUS VEIN
37722 LIGATION DIVISION AND STRIPPING LONG SAPHENOUS VEINS FROM KNEE OR BELOW
37735 LIGATION/DIVISION STRIPPING VEINS/EXC ULCER , GRAFT W/EXCISION
37760 LIGATION VEINS, SUBFACIAL,RADICAL SKIN GRAFT, OPEN
37761 LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG
37765 STAB PHLEBECTOMY VARICOSE VEINS 1 EXTREMITY LESS THAN 20 INCISIONS
37766 STAB PHLEBECTOMY VARICOSE VEINS 1 EXTREMITYGREATER THAN 20 INCISIONS
37780 LIGAT/DIV SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION
37785 LIGATION,DIVISION, EXCISION VARICOSE VEIN CLUSTER, ONE LEG
37788 PENILE REVASCULARIZATION, ARTERY, W OR W/O GRAFT
37790 PENILE VENOUS OCCLUSIVE PROC
37799 UNLISTED PROCEDURE, VASCULAR SURGERY
38129 UNLISTED LAPAROSCOPY PROCEDURE SPLEEN
38204 MANAGMNT OF RECIPIENT HEMATOPOIETIC PROGENITOR CELL DONOR SEARCH
38205 BLOOD DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANT
38206 BLOOD DERIVED HEMATOP PROGENITOR CELL HARVESTING FOR TRANSPLANT
38207 TRANSPLANT PREP OF HEMAT PROGENITOR CELLS CRYOPRES
38208 TRANSPLNT PREP OF HEMATOPOIETIC PROGENITOR CELLS THAWING OF PREV
38209 TRANSPLANT PREPRATION HEMATOPOIETIC PROGENITOR CELLS WASH OF HARV
38210 TRANSPLANT PREP HEMAT PROGEN CELLS SPEC CELL DEPLET WIN HARV CELL DEPL
38211 TRANSPLANT PREPAR HEMATOPOIETIC PROGENITOR CELLS TUMOR CELL DEPLETION
38212 TRANSPLNT PREPARATION HEMATOPOIETIC PROGENITOR CELLS RED BLOOD REMOV
38213 TRANSPLANT PREP OF HEMATOPOIETIC PROGENITOR CELLS PLATELET DEPLETION
38214 TRANSPLNT PREP HEMATOPOIETIC PROGENITOR CELLS PLASMA VOLUME DEPLETION
38215 TRANSPLANT PREPARATION HEMATOPOIETIC PROGENITOR CELLS CELL CONC
38230 BONE MARROW HARVESTING FOR TRANSPLANTATION
38240 BONE MARROW TRANSPLANTATION, ALLOGENIC
38241 BONE MARROW TRANSPLANTATION, AUTOLOGOUS
38242 BONE MARROW OR BLOOD DERIVED PERIPHERAL STEM CELL TRANSPLANT ALLOG
38589 UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM
38999 UNLISTED PROC.HEMIC OR LYMPHATIC SYS
39499 UNLISTED PROCEDURE, MEDIASTINUM
39599 UNLISTED PROC DIAPHRAGM
40799 UNLISTED PROCEDURE LIPS
41512 TONGUE BASE SUSPENSION PERMANENT SUTURE TECHNIQUE
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
41599 UNLISTED PROC, TONGUE, FLOOR OF MOUTH
41899 UNLISTED PROCED DENTOALVEOLAR
42140 UVULECTOMY, EXCISION OF UVULA
42145 REPAIR,PALATE,PHARYNX/UVULA
42299 UNLISTED PROCEDURE PALATE UVUL
42699 UNLISTED PROCEDURE, SALIVARY GLANDS OR DUCTS
42820 TONSILLECTOMY AND ADENOIDECTOMY, UNDER AGE 12
42821 T&A, AGE 12 OR OVER
42825 TONSILLECTOMY, PRIMARY OR SECONDARY, UNDER AGE 12
42826 TONSILLECTOMY, PRIMARY OR SECONDARY,OVER AGE 12
42830 ADENOIDECTOMY, PRIMARY UNDER AGE 12
42831 ADENOIDECTOMY,PRIMARY AGE 12 AND OVER
42835 ADENOIDECTOMY, SECONDARY, UNDER AGE 12
42836 ADENOIDECTOMY,SECONDARY, OVER AGE 12
42842 RAD RESECT TONSIL,TONSILLAR PILLARS AND/OR RETROMOLAR TRIGONE, W/O CLOSURE
42999 UNLISTED PROCEDURE, PHARYNX,ADENOIDS OR TONSILS
43257 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH
43279 LAPAROSCOPY, SURG ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED
43281 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH
43282 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH
43289 UNLISTED LAP PROCEDURE, ESOPHAGUS
43499 UNLISTED PROCEDURE ESOPHAGUS
43621 GASTRECTOMY - ROUX-EN Y RECON
43632 GASTRECTOMY,PART,DISTAL W/GASTROJEJUNOSTOMY
43633 GASTRECTOMY, PART,DISTAL W/ROUX-EN-Y RECONSTRUCTION
43634 GASTRECTOMY,PART,DISTAL W/FORMATION OF INTESTINAL POUCH
43651 LAPAROSCOPY SURGICAL TANSECTION OF VAGUS VERVES TRUNCAL
43652 LAPAROSCOPY SURGICAL TRANSECTION OF VAGUS NERVES, SELECTIVE OR HIGHLY SE
43659 UNLISTED LAPAROSCOPY, STOMACH
43810 GASTRODUODENOSTOMY
43820 GASTROJEJUNOSTOMY W/O VAGATOMY
43825 GASTROJEJUNOSTOMY W/VAGOTOMY, ANY TYPE
43850 REVISE GASTRODUODENAL ANASTOMOSIS W/RECONSTRUCT W/O VAGOTOMY
43855 REVISE GASTRODUODENAL ANASTOMOSIS W/RECONSTRUCT W/VAGOTOMY
43860 REV GASTROJEJUNOST ANAST. W/O VAGOTOMY
43865 REV GASTROJEJUNOST W VAGOTOMY
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
43999 UNLISTED PROCEDURE, STOMACH
44238 UNLISTED LAPAROSCOPY PROCEDURE INTESTINE EXCEPT RECTUM
44799 UNLISTED PROCEDURE, INTESTINE
44899 UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM/MESENTERY
44979 UNLISTED LAP PROCEDURE APPENDIX
45499 UNLISTED LAPAROSCOPY PROCEDURE RECTUM
45999 UNLISTED PROCEDURE, RECTUM
46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER
46706 REPAIR OF ANAL FISTULA WITH FIBRIN GLUE
46999 UNLISTED PROCEDURE ANUS
47133 DONOR HEPATECTOMY FROM CADAVER DONOR
47380 OPEN RADIOFREQUENCY ABLLATION OF LIVER TUMOR
47381 OPEN CRYOSURGICAL ABLATION OF LIVER TUMOR
47579 UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT
47600 CHOLECYSTECTOMY
47605 CHOLECYSTECT W CHOLANGIOGRAPHY
47610 CHOLECYSTECTOMY W/EXPLORE OF COMMON DUCT
47612 CHOLECYSTECTOMY W/CHOLEDOCHOENTEROSTOMY
47620 CHOLECYSTECTOMY W/EXPL COMMON DUCT,W/TRANSDUODENAL W OR W/O CHOLANGIOGRAPHY
47999 UNLISTED PROCEDURE, BILIARY TRACT
48160 PANCREATECTOMY,TOTAL OR SUBTOTAL W/TRANSPLANTATION
49323 LAP SURG PERITONEOSCOPY WITH DRAINAGE OF LYMPHOCELE TO PERITONEAL
49329 UNLISTED LAP PROCEDURE ABDOMEN, PERITONEUM OMENTUM
49560 REP INITIAL INCISIONAL OR VENTRAL HERNIA, REDUCIBLE
49565 REP RECURRENT INCISIONAL/VENTRAL HERNIA, REDUCIBLE
49580 REPAIR UMBILICAL HERNIA,UNDER AGE 5,REDUCIBLE
49582 REPAIR UMBILICAL HERNIA,UNDER AGE 5, INCARCERATED OR STRANGULATED
49659 UNLIST LAP PROCEDURE HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY
49999 UNLISTED PROC ABDOMEN, PERITONEUM, OMENTUM
50250 ABLATION OPEN 1 OR MORE RENAL MASS LESION CRYOSURG W INTRAOPER ULTRASOUND
50300 DONOR NEPHRECTOMY CADAVER DONOR, UNI OR BILATERAL
50320 DONOR NEPHRECTOMY OPEN FROM LIVING DONOR
50340 NEPHRECTOMY RECIPIENT UNILATER
50360 RENAL ALLOTRANSPLANTATION,GRAFT IMPLANT W/O RECIPIENT NEPHRECTOMY
50365 RENAL ALLOTRANSPLANTATION,GRAFT IMPLANT W/RECIPIENT NEPHRECTOMY
50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
50380 RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY
50549 UNLISTED LAP PROCEDURE RENAL
50593 ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY
50949 UNLISTED LAPAROSCOPY PROCEDURE,URETER
51999 UNLISTED LAPAROSCOPY PROCEDURE BLADDER
52402 CYSTOURETHROSCOPY W/TRANSURETHRAL RESECTION/INCISION EJACULATORY
52649 LASER ENUCLEATION PROSTATE WITH MORCELLATION
53852 TRANSURETHRAL DESTRUCT OF PROSTATE TISSUE BY RADIOFREQUENCY THERMOTHERAPY
53899 UNLISTED PROCED URINARY SYSTEM
54120 AMPUTATION OF PENIS, PARTIAL
54125 AMPUTATION PENIS COMPLETE
54231 DYNAMIC CAVERNOSOMETRY, INC INJ OF VASOACTIVE DRUGS
54235 INJ CORPORA CAVERNOSA W/PHARMACOLOGIC AGENT(S)
54240 PLETHYSMOGRAPHY PENIS
54250 NOCTURAL PENILE TUMESCENCE AND/OR RIGIDITY TEST
54400 INSERT PENILE PROSTH NON-INFL
54401 INSERT PENILE PROSTH.INFLATABLE
54405 INSERT INFLAT PROSTHESIS PENIS, PLACE PUMP, CYL, RESERVOIR
54406 REMOVE ALL INFLATABLE PENILE PROSTHESIS W/O REPLACEMENT
54408 REPAIR MULTI-COMPONENT,INFLATABLE PENILE PROSTHESIS
54410 REMOVE/REPLACE PENILE PROSTHESIS AT SAME OPERATIVE SESSION
54411 REMOVE/REPLACE PENILE PROSTHESIS THRU INFECT FIELD INCL I&D INFECTED TISSUE
54415 REMOVAL OF PENILE PROSTHESIS
54416 REMOVE/REPLACE PENILE PROSTHESIS AT SAME OP SESSION
54417 REMOVE/REPLACE PENILE PROSTHESIS AT SAME OP SESSION INC I&D OF TISSUE
54680 TRANSPLANT TESTIS TO THIGH
54699 UNLISTED LAP PROCEDUR TESTIS
55559 UNLISTED LAP PROCEDURE SPERMATIC CORD
55899 UNLIST PROC MALE GENITAL SYSTE
56805 CLITOROPLASTY FOR INTERSEX STATE
57285 PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH
57291 CONST ARTIFICIAL VAGINA WO GRF
57292 CONSTRUCT VAGINA WITH GRAFT
57335 VAGINOPLASTY FOR INTERSEX STATE
57423 PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH
57425 LAPAROSCOPY SURGICAL COLPOPEXY
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
57426 REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC
58150 TOTAL AB HYSTERECTOMY, W OR W/O TUBE REMOVAL, W OR W/O OVARY REMOVAL
58152 TOTAL AB HYSTERECTOMY,W WO TUBE OR OVARY REMOVAL, W/COLPO-URETHROCYSTOPEXY
58180 SUPRACERVICAL AB HYSTERECTOMY W OR W/O TUBE REMOVE W OR W/O OVARY REMOVAL
58200 HYSTERECTOMY,TOTAL ABDOMIN INCLPART VAGINECTOMY W WO TUBE OR OVARY REMOVAL
58210 HYSTERECTOMY RADICAL, ABDOM INCL BILAT LYMPHADEN W WO TUBE OR OVARY REMOVA
58240 PELVIC EXENTER MALIG TOT ABDOM HYSTERECT/CERVICECT W WO TUBE OR OVARY REMOVE
58260 VAGINAL HYSTERECTOMY FOR UTERUS 250 GRAMS OR LESS
58262 VAGINAL HYSTERECTOMY UTERS 250 GR OR LESS W/TUBE OVARY REMOVAL
58263 VAGINAL HYSTERECTOMY UTERUS W/TUBE/OVARY REMOVAL W/REPAIR ENTEROCELE
58267 VAGINAL HYSTERECTOMY W/COLPO-URETHROCYSTOPEXY W OR W/O ENDO CONTROL
58270 HYSTERECT VAG W REP ENTEROCELE
58275 HYSTERECTOMY VAG W TOTAL OR PARTIAL VAGINECTOMY
58280 HYSTER VAG W COLPECT REP ENTER
58285 HYSTERECTOMY VAGINAL RADICAL
58290 VAGINAL HYSTERECTMY FOR UTERUS GREATER THAN 250 GRAMS
58291 VAG HYSTERECTOMY FOR UTERUS GREATER THAN 250 GRAMS WITH REMOV OF TUBES
58292 VAGINL HYSTERCTMY UTERUS GREATER THAN 250 GRAMS REMOVAL OF TUBES
58293 VAGINAL HYST FOR UTERUS GREATER THAN 250 GRAMS WITH COLPO URETHROCYST
58294 VAGINAL HYSTERECTOMY FOR UTERUS GREATER THAN 250 GRAMS REPAIR OF ENTER
58321 ARTIFICIAL INSEM - INTRA CERV
58322 ARTIFICIAL INSEM - INTRAUTERINE
58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION
58340 CATH FOR SALINE INFUSION SONOHYSTEROGRAPHY OR HYSTEROSALPINGOGRAPHY
58345 TRANSCERVICAL FALLOPIAN CATH FOR DX PATENCY W OR W/O HYSTEROSALPINGOGRAPHY
58346 INSERTIO OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY
58350 CHROMOTUBATION OVIDUCT INCL MATERIALS
58353 ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE
58356 ENDOMETRIAL CRYOABLATION W/US, W/ENDOMETRIAL CURETTAGE,
58541 LAPAROSCOPY SUPRACRV HYSTERECTOMY 250 GRAMS OR LESS
58542 LAPAROSCOPY SUPRACRV HYST 250 GRAM OR LESS W/RMVL TUBE/OVARY
58543 LAPAROSCOPY SUPRACRV HYSTECTOMY GRTR THAN 250 GRAM
58544 LAPAROSCOPY SUPRACRV HYST GRTR THAN 250 G W/RMVL TUBE/OVARY
58548 LAPAROSCOPY W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY
58550 LAPAROSCOPY SURGICAL W VAGINAL HYSTERECTOMY W OR W/O REMOVAL OF TUBES
58552 LAPARSCPY SURG W VAG HYSTERECT FOR UTER 250 GRAMS LESS REMOV OF TUBES
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
58553 LAPAROSCPY SURG W VAG HYSTERECTOMY FOR UTER GREAT THAN 250 GRAMS
58554 LAPARO SURGICAL W VAGINAL HYSTERECTOMY FOR UTERUS GREAT THAN 250 GRAMS
58560 HYSTEROSCOPY W DIVISION OR REPECTION OF INTRAUTERINE SEPTUM ANY METHOD
58561 HYSTEROSCOPY W REMOVAL OF LEIOMYOMATA
58562 HYSTEROSCOPY W REMOVAL OF IMPACTED FOREIGN BODY
58563 HYSTEROSCOPY W/ENDOMETRIAL ABLATION (ANY METHOD)
58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 G OR LESS
58571 LAPS,SURG W/TOTAL HYSTERECTOMY UTERUS LESS 250 G W/REMOVE TUBE/OVARY
58572 LAPAROSCOPY,SURG W/TOTAL HYSTERECTOMY UTERUS GRTR THAN 250 G
58573 LAPAROSCOPY TOT HYSTERECTOMY GRTR THAN 250 G W TUBE/OVARY
58578 UNLISTED LAP PROCEDURE UTERUS
58579 UNLISTED HYSTEROSCOPY PROCEDURE UTERUS
58672 LAPAROSCOPY FIMBRIOPLASTY
58673 LAPAROSCOPY SALPINOSTOMY
58679 LAPAROSCOPY UNLISTED OVIDUCT/OVARY PROCEDURE
58740 LYSIS OF ADHESIONS (TUBES, OVARIES)
58760 FIMBRIOPLASTY
58770 SALPINGOSTOMY
58953 HYSTERECTOMY/REMOVAL OF TUBES/OVARIES W/RADICAL DISSECTION
58954 HYSTERECTOMY /REMOVAL OF TUBES/OVARIES W/RADICAL DISSECTION/LYMPHADENECTOMY
58960 LAPAROTOMY OVARIAN, TUBAL OR MALIG W OR W/O EXCISION, WASHING,BIOPSY ASSESSMENT
58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD
58974 EMBRYO TRANSFER, INTRAUTERINE
58976 GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY METHOD
58999 UNLISTED PROC FEMALE GENITAL SYSTEM
59070 TRANSABDOMINAL AMNIOINFUSION W US GUIDANCE
59072 FE TAL UMBILICAL CORD OCCLUSION W US GUIDANCE
59074 FETAL FLUID DRAINAGE W US GUIDANCE
59076 FET AL SHUNT PLACEMENT W US GUIDANCE
59325 CERCLAGE OF CERVIX DURING PREGNANCY ABDOMINAL
59840 INDUCED ABORTION BY DILATION AND CURETTAGE
59841 INDUCED ABORTION BY DILATION AND EVACUATION
59850 INDUCED ABORTION BY INJECTION(S) INCL HOSP DELIVERY, FETUS AND SECUNDINES
59851 ABORTION LEGAL INJECT W D&C AND/OR EVACUATION
59852 ABORT LEGAL INJECT W HYSTEROTO
59855 ABORTION, INDUCED
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
59856 ABORTION, INDUCED W/D&C
59857 INDUCED ABORTION W/HYSTEROTOMY
59897 UNLISTED FETAL INVASIVE PROCEDURE W US GUIDANCE WHEN PERFOMRED
59899 UNLST PROC MATERNITY & DELIVER
60659 UNLISTED LAPAROSCOPY PROCEDURE, ENDOCRINE SYSTEM
60699 UNLISTED PROCEDURE, ENDOCRINE SYSTEM
61795 INTRA/EXTRACRANIAL OR SPINA STEREOSTATIC COMPUTER ASSISTED PROC
61796 STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LESION
61797 STRTCTC RADIOSURGERY EA ADDL CRANIAL LESION SIMPLE
61798 STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LESION
61799 STRTCTC RADIOSURGERY EA ADDL CRANIAL LESION COMPLEX
61850 IMPL NEUROSTIMUL CORTICAL-DRIL
61860 IMPL NEUROSTIM CORTICAL-CRANIE
61863 STEREOT IMPLT NEUROS ELECTRODE ARRAY SUBCORT SITE WO INTRAOP MER 1ST ARRAY
61864 STER EOTACTIC IMPL NEUROSTIM ELEC ARRAY SUBCORT SITE WO INTRAOP MER EA ADDL
61867 STEREOTACTIC IMPLT NEURO ELECT ARRAY SUBCORT SITE W INTRAOP MER 1ST ARRAY
61868 STEREOTAC IMPLT NEUROS ELECTROD ARRAY SUBCORT SITE W INTRAOP MER EA ADDL
61870 IMPL NEUROSTIM CEREBELL CORTIC
61875 IMPL NEUROSTIM CEREBELL SUBCOR
61880 REV INTRACRAN NEUROSTIM ELECTR
61885 IMPLANT NEUROSTIMULATOR W/SINGLE ELECTRODE ARRAY
61886 PLACEMENT OF CRANIAL NEUROSTINULATOR DEVICE W CONNECTION TO 2 OR MORE
61888 REVISE/REMOVE NEUROSTIMULAR PULSE GENERATOR OR RECEIVER
62267 PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISSUE
62287 DECOMPRESS PERCUTANEOUS DISC SINGLE/MULT LUMBAR
62294 INJECTION INTO SPINAL ARTERY
63001 LAMINECTOMY W EXPLORATION
63003 LAMINECTOMY W/EXPLORATION/DECOMPRESSSION THORACIC
63005 LAMINECTOMY LUMBAR,EXCEPT FOR SPONDYLOLISTHESIS
63011 LAMINECTOMY SACRAL
63012 LAMINECTOMY GILL TYPE PROCEDUR
63015 LAMINECTOMY W/EXPLOR,DECOMPRESSION SPINAL CORD 2 OR MORE VERTEBRA
63016 LAMINECTOMY W/EXPLORATION,DECOMPRESS SPINAL CORD, THORACIC
63017 LAMINECTOMY W/EXPLORATION,DECOMPRESS SPINAL CORD, LUMBAR
63020 LAMINOTOMY W/DECOMPRESS NERVE ROOT, ONE INTERSPACE, CERVICAL
63030 LAMINOTOMY W/DECOMPRESS NERVE ROOT, ONE INTERSPACE, LUMBAR
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
63035 LAMINOTOMY W/DECOMPRESS NERVE ROOT EA.ADDL CERVICAL OR LUMBAR
63040 LAMINOTOMY W/DECOMPRESS ROOT, SINGLE INTERSPACE,CERVICAL
63042 LAMINOTOMY W/DECOMPRESS ROOT, SINGLE INTERSPACE, LUMBAR
63043 CERVICAL LAMINOTOMY EACH ADDITIONAL CERVICAL SPACE
63044 LUMBAR LAMINOTOMY EACH ADDITIONAL LUMBAR INTERSPACE
63045 LAMINECTOMY,FACETECTOMY & FORAMINOTOMY, SINGLE, CERVICAL
63046 LAMINECTOMY,FACETECTOMY & FORAMINOTOMY THORACIC
63047 LAMINECTOMY FACETECTOMY, FORAMINOTOMY LUMBAR
63048 LAMINECTOMY,FACETECTOMY,FORAMINOTOMY EA AD SEGMENT CERVICAL,THORACIC,LUMBR
63050 LAMINOPLASTY, CERVICAL, W/SPINAL CORD DECOMPRESSION, 2 VERTEBRA
63051 LAMINOPLASTY, CERVICAL, W/SPINAL CORD DECOMPRESS, 2 VERT SEGMENTS
63055 DECOMPRESS SPINAL CORD SINGLE SEGMENT THORACIC
63056 DECOMPRESS SPINAL CORD LUMBAR
63057 DECOMPRESS SPINAL CORD EA ADDL THORACIC OR LUMBAR
63064 DECOMPRESS SPINAL CORD THORACIC SINGLE
63066 DECOMPRESS SPINAL CORD EA ADDL
63075 EXC IV DISK CERVAL ANT 1 SPACE
63076 EXC IV DISK CERVL ANT GT 1 SPACE
63077 DISKECTOMY THORACIC SINGLE INTERSPACE
63078 DISKECTOMY THORACIC EA ADDL INTERSPACE
63081 VERTEBRAL CORPECTOMY SINGLE SEGMENT
63082 VERTEBRAL CORPECTOMY CERVICAL, EACH ADDITIONAL SEGMENT
63085 REM VERTEBRAL BODY PART/COMPL
63086 VERTEBRAL CORPECTOMY THORACIC EACH ADDITIONAL SEGMENT
63087 VERTEBRAL CORPECTOMY PARTIAL
63088 VERTEBRAL CORPECTOMY EACH ADDITIONAL SEGMENT
63090 VERTEBRAL REMOVAL PARTIAL OR COMPLETE THORACIC LUMBAR OR SACRAL SINGLE
63091 VERTEBRAL REMOVAL EACH ADDITIONAL
63101 VERTEBRAL CORPECTOMY LAT EXTRACAV W DECOMPRESS THORACIC SINGLE SEGM
63102 VERTE BRAL CORPECT LAT EXTRACAVITARY W DECOMPRESS LUMBAR SINGLE SEGMENT
63103 VER TEBRAL CORPEC LAT EXTRACAVIT W DECOMPRESS THORACIC LUMBAR EA ADDL
63170 LAMINECTOMY W/MYELOTOMY CERVICAL THORACIC OR THORACOLUMBAR
63172 LAMINECTOMY W/DRAINAGE OF CYST
63173 LAMINECTOMY W/DRAINAGE CYST PERITONEAL OR PLEURAL SPACE
63180 LAMINECTOMY LIGAMENTS W/OR W/O DURAL GRAFT CERVICAL ONE OR TWO SEGMENTS
63182 LAMINECTOMY LIGAMENTS MORE THAN 2 SEGMENTS
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
63185 LAMINECTOMY W/RHIZOTOMY, ONE OR MORE SEGMENTS
63190 LAMINECTOMY W/RHIZOTOMY, MORE THAN 2 SEGMENTS
63191 LAMIN SPINAL ASSORY/NERVE
63194 LAMIN CORDOTOMY 1 STAGE CERVIC
63195 CORDOTOMY UNILAT 1 STAGE THOR
63196 CORDOTOMY ONE STAGE CERVICAL
63197 CORDOTOMY BILAT 1 STAGE THOR
63198 LAMINECTOMY W/CORDOTOMY W/TRACT SECTIONS 2 STAGES W/IN 14 DAYS,CERVICAL
63199 LAMINECTOMY W/CORDOTOMY W/TRACT SECTIONS 2 STAGES W/IN 14 DAYS,THORACIC
63200 LAMINECTOMY W/RELEASE SPINAL CORD LUMBAR
63250 LAMINECTOMY EXC OR OCCL ARTERIOVENOUS MALFORM SPINAL CORD,CERVICAL
63251 LAMINECTOMY EXC OR OCCL ARTERIOVENOUS MALFORM SPINAL CORD, THORACIC
63252 LAMINECTOMY EXC OR OCCL ARTERIOVENOUS MALFORM SPINAL CORD, THORACOLUMBAR
63265 LAMINECTOMY EXCISION INTRASPINAL CERVICAL
63266 LAMINECTOMY EXCISION INTRASPINAL THORACIC
63267 LAMINECTOMY EXCISION INTRASPINAL LUMBAR
63268 LAMINECTOMY EXCISION INTRASPINAL SACRAL
63270 LAMINECTOMY EXCISION LESION INTRADURAL CERVICAL
63271 LAMINECTOMY EXCISION LESION INTRADURAL THORACIC
63272 LAMINECTOMY EXCISION LESION INTRADURAL LUMBAR
63273 LAMINECTOMY EXCISION LESION INTRADURAL SACRAL
63275 LAMINECTOMY BIOPSY/EXCISION EXTRADURAL CERVICAL
63276 LAMINECTOMY BIOPSY/EXCISION EXTRADURAL THORACIC
63277 LAMINECTOMY BIOPSY/EXCISION EXTRADURAL LUMBAR
63278 LAMINECTOMY BIOPSY/EXCISION EXTRADURAL SACRAL
63280 LAMINECTOMY INTRADURAL EXTRAMEDULLARY CERVICAL
63281 LAMINECTOMY INTRADURAL EXTRAMEDULLARY THORACIC
63282 LAMINECTOMY INTRADURAL EXTRAMEDULLARY LUMBAR
63283 LAMINECTOMY BIOPSY/EXCISION INTRA DURAL SACRAL
63285 LAMINECTOMY BX/EXC INTRADURAL,INTRAMEDULLARY,CERVICAL
63286 LAMINECTOMY BX/EXC INTRADURAL,INTRAMEDULLARY THORACIC
63287 LAMINECTOMY BX/EXC INTRADURAL,INTRAMEDULLARY THORACOLUMBAR
63290 LAMINECTOMY BX/EXC COMBINED EXTRADURAL INTRADURAL LESION ANY LEVEL
63295 OSTEOPLASTIC DORSAL SPINAL ELEMENTS RECONSTRUCTION, FOLLOWING PRIMARY
63300 VERTEBRAL REMOVE PART/COMPLETE EX INTRASPINAL SINGLE EXTRADURAL CERVICAL
63301 VERTEBRAL REMOVE PART/COMPLETE EX INTRASPINAL SINGLE EXDUR BY TRANSTHORACIC
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
63302 VERTEBRAL REMOVE PART/COMPLETE EX INTRASPINAL SINGLE EXDUR BY THORACOLUMBAR
63303 VERTEBRAL REMOVE PART/COMPLETE EX INTRASPINL LUMBAR BY TRANS OR RETROPERITONEAL
63304 VERTEBRAL REMOVE PART/COMPLETE INTRADURAL CERVICAL
63305 VERTEBRAL REMOVE PART/COMPLETE INTRADURAL THORACIC BY TRANSTHORACIC APPR
63306 VERTEBRAL REMOVE PART/COMPLETE INTRADURAL THORACIC BY THORACOLUMBAR APP
63307 VERTEBRAL REMOVE PART/COMPL INTRADURAL LUMBAR BY TRANS OR RETROPERITONEAL APPR
63308 VERTEBRAL REMOVE PART COMPL INTRADURAL LUMBAR EA ADDL
63600 CREATE LESION SPINAL CORD STEREOTACTIC, PERCUTANEOUS, ANY MODALITY
63610 STEREOTACTIC STIM SP CORD, PERCUT, SEPARATE PX NOT FOLLOW BY OTHER SURGERY
63615 STEREOSTATIC BIOPSY ASPIRATION OR EXCISION LESION SPINAL CORD
63620 STEREOTACTIC RADIOSURGERY 1 SPINAL LESION
63621 STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION
63655 LAMINECTOMY IMPLANT NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL
63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR
63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR
63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR
63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR
64416 INJECTION, ANESTHETIC AGENT, BRACHIAL PLEXUS CONTINU INFUSE BY CATHETER
64446 INJECTION, ANESTHETIC AGENT, SCIATIC NERVE, CONTINU INFUSE BY CATHETER
64447 INJECT ANEST AGENT FEMORAL NERVE SINGLE
64448 INJECTION, ANESTHETIC AGENT,FEMORAL NERVE, CONTINU INFUSE BY CATHETER
64449 INJECTION, ANESTHETIC AGNT, LUMBAR PLEXUS POSTER, CONTINU INFUSE BY CATH
64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL
64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL
64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3 OR GRTR LEVEL
64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL
64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL
64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3 OR GRTR LEVEL
64517 INJEC ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS
64553 IMPL NEUROSTIM CRANIAL-PERCUT
64555 IMPL NEUROSTIM PERIPHERAL-PERC
64560 IMPL NEUROSTIM, AUTONOMIC NERVE
64561 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES
64565 IMPL NEUROSTIM NEUROMUSC-PERCU
64573 IMPLANT NEUROELECTRODES CRANIAL NERVE
64575 IMPL NEUROSTIM PERIPHERAL-INCI
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
64577 IMPL NEUROSTIM AUTONOMIC NERVE
64580 IMPL NEUROSTIM NEUROMUSCULAR
64581 INCISION FOR NEUROSTIMULATOR ELECTRODE IMPLANT
64585 REV PERIPHERAL NEUROSTIM ELECT
64590 INSERT/REPLACE PN/GASTRIC NEUROSTIMULATOR
64595 REVISE/REMOVE PERIPHERAL OR GASTRIC NEUROSTIM PULSE GENERATOR OR RECEIVER
64650 CHEMODENERVATION OF ECCRINE GLANDS BOTH AXILLAE
64653 CHEMODENERVATION OF ECCRINE GLANDS OTHER AREAS SCALP FACE NECK PER DAY
64802 SYMPATHECTOMY, CERVICAL
64804 SYMPATHECTOMY, CERVICOTHORACIC
64809 SYMPATHECTOMY THORACOLUMBAR UN
64818 SYMPATHECTOMY LUMBAR UNILAT
64820 SYMPATHECTOMY, DIGITAL ARTERIES W/MAGNIFICATION
64821 SYMPHATHECTOMY RADIAL ARTERY
64822 SYMPHATHECTOMY ULNAR ARTERY
64823 SYMPHATHECTOMY
64999 UNLIST PROCEDURE NERVOUS SYSTE
65710 KERATOPLASTY CORNEAL TRANSPLANT, ANTERIOR LAMELLAR
65730 KERATOPLASTY CORNEAL TRANSPLANT, PENETRATING
65750 KERATOPLASTY PENETRATING IN APHAKIA
65755 KERATOPLASTY (PSEUDOPHAKIA)
65767 EPIKERATOPLASTY
65770 KERATOPROSTHESIS
65772 CORNEAL INCISION TO CORRECT ASTIGMATISM
65775 CORNEAL WEDGE RESECTION TO CORRECT ASTIGMATISM
65780 OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE TRANSPLANTATION
65781 OC ULAR SURFACE RECONSTRUCTION LIMBAL STEM CELL ALLOGRAFT
65782 OCU LAR SURFACE RECONSTRUCTION LIMBAL CONJUNCTIVAL AUTOGRAFT
66999 UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE
67299 UNLISTED PROCEDURE POSTERIOR SEGMENT
67311 OP FOR STRABISMUS 1 HORIZ MUS
67312 STRABISMUS SURG, RECESS/RESECT 2 HORIZONTAL MUSCLES
67314 STRABISMUS SURG, RECESS/RESECT,1 VERTICAL MUSCLE
67316 STRABISMUS SURG, RECESS/RESECT 2 OR MORE VERTICAL MUSCLES
67318 STRABISMUS SURG, ANY PROC, SUPERIOR OBLIQUE
67320 TRANSPOSE EXTRAOCULAR MUSCLE(S
This list is intended to provide assistance regarding services that require authorization. It is subject to change without notice. Contact Customer Service to verify authorization
requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
67331 STRABISMUS SURG W/PREV NOT INV EXTRAOCULAR MUSCLES
67332 STRABISMUS SURG W/SCARRING OF EXTRAOC MUSCLE
67334 STRABISMUS SURG POST FIX SUTURE TECH W OR W/O RECESSION
67335 ADJ SUTURE PLACE DURING STRABISMUS SURG INC POSTOP
67340 STRABISMUS SURG EXPLOR/REPAIR
67399 UNLISTED PROCEDURE, OCULAR MUSCLE
67599 UNLIST PROCEDURE ORBIT
67902 REP BLEPHAROPTOSIS FRONTALIS MUSCLE TECH W/FASCIAL SLING
67912 CORRECTION LAGOPHTHALMOS W IMPLANT UPPER EYELID LID LOAD
67914 REP ECTROPION W SUTURE
67915 REP ECTROPION W THERMOCAUTERY
67916 REPAIR ECTROPION,TARSAL WEDGE EXCISION
67917 REP ECTROPION EXTENSIVE
67921 REP ENTROPION W SUTURE
67922 REP ENTROPION W THERMOCAUTERY
67923 REPAIR ENTROPION TARSAL WEDGE EXCISION
67924 REPAIR ENTROPION, EXTENSIVE
67961 EXC/REPAIR EYELID INVL LID W/PREP SKIN GRFT OR PEDICLE FLAP UP TO 1/4 MARGIN
67966 EXC/REPAIR EYELID INVL LID W/PREP SKIN GRFT OR PEDICLE FLAP OVER 1/4 MARGIN
67971 RECONSTRUCT EYELID, FULL FROM OPPOSING EYELID UP TO 2/3, 1 OR 1ST STAGE
67973 RECONSTRUCT EYELID, FULL FROM OPPOSING EYELID TOTAL LOWER 1ST OR 1ST STAGE
67974 RECONSTRUCT EYELID, FULL FROM OPPOSING EYELID TOTAL UPPER 1 STAGE OR 1ST STAGE
67975 RECONSTRUCT EYELID, FULL FROM OPPOSING EYELID, SECOND STAGE
67999 UNLISTED PROCEDURE EYELIDS
68371 HARVESTING CONJUNCTIVAL ALLOGRAFT LIVING DONOR
68399 UNLISTED PROCEDURE CONJUNCTIVA
68899 UNLISTED PROC LACRIMAL SYSTEM
69399 UNLISTED PROCEDURE EXTERNAL EAR
69710 IMPLANT/REPLACE E-M BONE CONDUCTIN HEAR DEVICE IN TEMPORAL BONE
69711 REMOVE/REPAIR E-M BONE CONDUCTION HEAR DEVICE IN TEMPORAL BONE
69714 IMPLANTATION, OSSEOINTEGRATED IMPLANT TEMPORAL BONE W/O MASTOIDECTOMY
69715 IMPLANTATION OSSEOINTEGRATED IMPLANT TEMPORAL BONE W MASTOIDECTOMY
69717 REPLACEMENT OSSEOINTEGRATED IMPLANT W/O MASTOIDECTOMY
69718 REPLACEMENT, OSSEOINTEGRATED IMPLANT W MASTOIDECTOMY
69799 UNLISTED PROCEDURE, MIDDLE EAR
69949 UNLISTED PROCEDURE INNER EAR
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CODE PROCEDURE
69979 UNLISTED PROC, TEMPORAL BONE, MIDDLE FOSSA
91110 GI TRACT IMAGING INTRALUMINAL EG CAPSULE ENDOSCOPY W INTERP AND REPORT
91111 GI TRACT IMAGING INTRALUMINAL ESOPHAGUS W/PHY I&R
97597 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), SELECTIVE DEBRIDEMENT
97598 REMOVAL DEVITALIZED TISSUE, DEBRIDEMENT GREATER THAN 20 SQ CENT
97602 REMOVE OF DEVITALIZED TISSUE FROM WOUND NON SELECTIVE DEBRIDEMENT
97605 NEGATIVE PRESSURE WOUND THERAPY VACUUM ASSIST DRAINAGE COLLECTION
97606 NEGATIVE PRESSURE WOUND THERAPY (VACUUM ASSISTED DRAINAGE COLLECT
0099T IMPLANTATION OF INTRASTOMAL CORNEAL RING SEGMENTS
0184T EXCISION RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURG APPROACH
0192T INSERT ANT SEGMENT DRAIN DEVICE, EXTERNAL APPROACH
0213T US FACET JT INJ CER/T 1 LEV
0214T US FACET JT INJ CERT/T 2 LEV
0215T US FACET JT INJ CERT/T 3 LEV
0216T US FACET JT INJ IS 1 LEVEL
0217T US FACET JT INJ IS 2 LEVEL
0218T US FACET JT INJ IS 3 LEVEL
0219T FUSE SPINE FACET JT CERVICAL
0220T FUSE SPINE FACET JT THORACIC
0221T FUSE SPINE FACET JT LUMBAR
0222T FUSE SPINE FACET JT ADD SEGMENT
C1762 CONNECTIVE TISSUE, HUMAN (INCLUDES FASCIA LATA)
C1763 CONNECTIVE TISSUE,NON-HUMAN (INCLUDES SYNTHETIC)
C9716 CREATIONS OF THERMAL ANAL LESIONS BY RADIOFREQUENCY ENERGY
C9724 ENDOSCOPIC FULL THICKNESS IN GASTRIC CARDIA (EPS)
G0251 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY 5 SESSIONS
G0339 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURG
G0340 IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR BASED STEREOTACTIC RADIO SURG 2-5 SESS
G0412 OPEN TX OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACT
G0413 PERCUTANEOUS SKELETAL FIXATION OF POST PELVIC BONE FX AND/OR DISLO
G0414 OPEN TX ANTERIOR PELVIC BONE FX AND/OR DISLOCATION FOR FRACTURE
G0415 OPEN TX POSTERIOR PELVIC BONE FX AND/OR DISLOCATION, FOR FRACTURE
J7330 AUTOLOGOUS CULTURED CHONDROCYTES IMPLANT
M0301 FABRIC WRAPPING OF ABDOMINAL ANEURYSM
Q1003 NEW TECH INTRAOCULAR LENS CATEGORY 3(REDUCED SPHERICAL ABERRATION)
Q1004 NEW TECHNOLOGY INTRAOCULAR LENS CAT 4 AS DEFINED IN FEDERAL REGISTER
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requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
CODE PROCEDURE
Q1005 NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 5 AS DEFINED IN FEDERAL REGISTER
S2066 BREAST GAP FLAP RECONSTRUCTION, UNILATERAL
S2067 BREAST RECONSTRUCTION WITH STACKED DIE/GAP, UNILATERAL
S2068 BREAST RECON W/DIEP OR SIEA FLAP W/HARVEST,TRANSFER,CLOSURE, UNILATERAL
S2080 LASER-ASSISTED UVULOPALATOPLASTY (LAUP)
S2095 TRANSCATHETER OCCLUSION/EMBOLIZATION FOR TUMOR DESTRUCTION,PERCUTANEOUS
S2115 OSTEOTOMY,PERIACETABULAR,WITH INTERNAL FIXATION
S2117 ARTHROEREISIS SUBTALAR
S2118 TOTAL HIP RESURFACING
S2205 MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY SINGLE CORONARY
S2206 MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURG, 2 ARTERIAL GRAFTS
S2207 SINGLE CORONARY VENOUS GRAFT MINIMALLY INVASIVE DIRECT CORONARY ARTERY
S2208 MINIMAL INVASIVE DIRECT CORONARY ART BYPASS SURG,SINGLE ARTERIAL/VENOUS GR
S2209 TWO ARTERIAL GRAFTS/SINGLE VENOUS GRAFT MINIMALLY INVASIVE DIRECT CORONA
S2225 MYRINGOTOMY, LASER-ASSISTED
S2325 HIP CORE COMPRESSION
S2340 CHEMODENERVATION OF ABDUCTOR MUSCLE(S) OF VOCAL CORD
S2341 CHEMODENERV ADDUCT VOCAL
S2342 NASAL ENDOSCOPY FOR POST-OP DEBRIDEMENT FOLLOWING ENDOSCOPIC SINUS SURGERY
S2348 DECOMPRESSION PROC PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERT
S2350 DISKECTOMY ANTERIOR W/DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT
S2351 DISKETOMY, ANT W/DECOMPRESSION OF SPINAL CORD AND/OR ROOT EA ADDTL INTERSP
S2360 PERCUTANEOUS VERTEBROPLASTY,1 VERTEBRAL BODY,UNILATERAL/BILATERAL INJEC
S2361 PERCUTANEOUS VERTEBROPLASTY,EA ADDITIONAL CERVICAL VERTEBRAL BODY
S2411 FETOSCOPIC LASER THERAPY FOR TREATMENT OF TWIN TO TWIN TRANSFUSION SYND
S2900 SURG TECH REQD USE OF ROBOTIC SURG SYS SEPARATE FROM PRIMARY PROC
S9034 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR GALLSTONES
U790 EXTRAC ORPOREAL SHOCK WAVE THERAPY GENERAL
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requirements. Authorization is a review of the medical necessity of proposed treatment and is not a guarantee of payment.
