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Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
Modifier Unusual Procedural N N N/A Modifier Submit documentation
-22 Services to support the modifier.
A0080 Noninterest escort in N N N/A Edit Removed Not considered a
non emergency room 03-2003 payable benefit of any
(ER) member policies.
A0090 Interest escort in non N N N/A Edit Removed Not considered a
ER 03-2003 payable benefit of any
member policies.
A0100 Nonemergency N N N/A Edit Removed Not considered a
transport taxi 03-2003 payable benefit of any
member policies.
A0110 Nonemergency N N N/A Edit Removed Not considered a
transport bus 03-2003 payable benefit of any
member policies.
A0120 Non-ER transport mini- N N N/A Edit Removed Not considered a
bus 03-2003 payable benefit of any
member policies.
A0130 Non-ER transport N N N/A N/A N/A
wheelch van
A0140 Nonemergency N N N/A N/A N/A
transport air
A0160 Non-ER transport case N N N/A Edit Removed Not considered a
worker 03-2003 payable benefit of any
member policies.
A0170 Non-ER transport N N N/A Edit Removed Not considered a
parking fees 03-2003 payable benefit of any
member policies.
A0180 Non-ER transport N N N/A Edit Removed Not considered a
lodgng recip 03-2003 payable benefit of any
member policies.
A0190 Non-ER transport meals N N N/A Edit Removed Not considered a
recip 03-2003 payable benefit of any
member policies.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 1 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A0200 Non-ER transport N N N/A Edit Removed Not considered a
lodgng escrt 03-2003 payable benefit of any
member policies.
A0210 Non-ER transport meals N N N/A Edit Removed Not considered a
escort 03-2003 payable benefit of any
member policies.
A0430 Fixed wing air transport N N N/A N/A N/A
A0431 Rotary wing air transport N N N/A N/A N/A
A0432 PI volunteer ambulance N N N/A Edit Removed Not considered a
co 03-2003 payable benefit of any
member policies.
A0435 Fixed wing air mileage N N N/A N/A Verify medical necessity,
if unsure refer to Medical
Services.
A0436 Rotary wing air mileage N N N/A N/A Verify medical necessity,
if unsure refer to Medical
Services.
A0888 Noncovered ambulance N N N/A Edit Removed Not considered a
mileage 03-2003 payable benefit of any
member policies.
A0999 Unlisted ambulance N Review Member Services N/A Procedural report is
procedure Required Fax 1-888-606-6658 required.
A4206 1 CC sterile syringe & N Review Member Services N/A May not be a covered
needle Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis and treatment
plan for review.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 2 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4207 2 CC sterile syringe & N Review Member Services N/A May not be a covered
needle Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis and treatment
plan for review.
A4208 3 CC sterile syringe & N Review Member Services N/A May not be a covered
needle Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis and treatment
plan for review.
A4209 5+ CC sterile syringe & N Review Member Services N/A May not be a covered
needle Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis and treatment
plan for review.
A4210 Needle free injection N Review Medical Services Benefit May not be a covered DME20
device Required Fax 1-800-453-4341 benefit. Need clinical (07-2006)
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
A4215 Sterile needle N Review Member Services N/A May not be a covered
Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis and treatment
plan for review.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 3 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4220 Infusion pump refill kit N N N/A N/A N/A SUR18
A4221 Maint drug infus cath N N N/A N/A N/A SUR18
per wk
A4222 Drug infusion pump N N N/A N/A N/A SUR18
supplies
A4244 Alcohol or peroxide per N Review Member Services N/A Documentation
pint Required Fax 1-888-606-6658 requested: clinical
records specific to
diagnosis and treatment
plan.
A4245 Alcohol wipes per box N Review Member Services N/A Documentation
Required Fax 1-888-606-6658 requested: clinical
records specific to
diagnosis and treatment
plan.
A4255 Glucose monitor N N N/A N/A N/A
platforms
A4257 Replace Lensshield N N N/A Edit Removed Call Customer Service
Cartridge 01-2005 to verify benefits at 1-
866-699-8170
A4261 Cervical cap N N N/A Edit Removed Call Customer Service
contraceptive 01-2005 to verify benefits at 1-
866-699-8170
A4262 Temporary tear duct N N N/A Regence Status B; Considered DME15
plug Invalid incidental to other (08-2001)
billable services, not
payable.
A4263 Permanent tear duct N N N/A Regence Status B; Considered DME15
plug Invalid incidental to other (08-2001)
billable services, not
payable.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 4 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4270 Disposable endoscope N N N/A Regence Status B; Considered DME15
sheath Invalid incidental to other (08-2001)
billable services, not
payable.
A4290 Sacral nerve stim test N N N/A N/A N/A SUR134 DME53
lead (06-2004)
A4300 Implantable access N N N/A Regence Status B; Considered DME15
catheter Invalid incidental to other (08-2001)
billable services, not
payable.
A4306 Drug delivery system <5 N N N/A N/A N/A
MI
A4335 Incontinence supply N Review Member Services N/A May not be a benefit of
Required Fax 1-888-606-6658 the member's contract.
A4421 Ostomy supply misc. N Review Member Services N/A N/A
Required Fax 1-888-606-6658
A4520 Incontinence garment N N N/A N/A May not be a benefit of
any type the member's contract.
A4534 Youth diaper N N N/A N/A May not be a benefit of
the member's contract.
A4550 Surgical trays N N N/A Regence Status B; Considered
Invalid incidental to other
billable services, not
payable.
A4554 Disposable underpads N N N/A Edit Removed Not considered a
06-2003 payable benefit of any
member policies.
A4556 Electrodes, pair N N N/A N/A N/A DME3, MED64
MED10 (07-2004)
A4557 Lead wires, pair N N N/A N/A N/A DME3
A4558 Conductive paste or gel N N N/A N/A N/A
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 5 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4575 Hyperbaric oxygen N N N/A Investigational Considered MED14
therapy Denial investigational;
investigational services
are not covered.
A4595 Electrical stimulator N N N/A N/A N/A DME11
supplies
A4604 Tubing with intergrated N N N/A N/A N/A DME8
heating element for the
use with postive airway
pressure device
A4606 Oxygen probe for use N N N/A N/A N/A DME49
with oximeter device (09-2008)
A4615 Cannula, nasal N N N/A N/A N/A DME22
(08-2008)
A4616 Tubing, (oxygen), per N N N/A N/A N/A DME22
foot (08-2008)
A4617 Mouth piece N N N/A N/A N/A DME22
(08-2008)
A4618 Breathing circuits N N N/A N/A N/A DME22
(08-2008)
A4619 Face tent N N N/A N/A N/A DME22
(08-2008)
A4620 Variable concentration N N N/A N/A N/A DME22
mask (08-2008)
A4623 Tracheostomy, inner N N N/A N/A N/A DME22
cannula (08-2008)
A4624 Tracheal suction N N N/A N/A N/A DME22
catheter, any type other (08-2008)
than closed system,
each
A4625 Tracheostomy care kit N N N/A N/A N/A DME22
for new tracheostomy (08-2008)
A4626 Tracheostomy cleaning N N N/A N/A N/A DME22
brush, each (08-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 6 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4630 Replacement batteries N N N/A N/A N/A DME11
for medically necessary
transcutaneous
electrical stimulator
(TENS) owned by
patient
A4634 Replacement bulb for N N N/A Benefit Call Customer Service
therapeutic light box, to verify benefit
tabletop model information at 1-866-699-
8170
A4638 Replacement battery for N N N/A Investigational Considered DME64
ear pulse generator Denial investigational;
investigational services
are not covered.
A4639 Infrared ht system N N N/A Investigational Considered DME63
replacement pad Denial investigational;
investigational services
are not covered.
A4640 Replacement pad for N N N/A N/A N/A DME1
use with medically
necessary alternating
pressure pad owned by
patient
A4641 Diagnostic imaging N Review Member Services N/A Invoice needed. RAD15 RAD1
agent Required Fax 1-888-606-6658 (07-2006),
RAD11
(07-2006)
A4642 Satumomab pendetide N Review Member Services N/A Invoice needed. RAD11
per dose Required Fax 1-888-606-6658 (07-2006)
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 7 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4648 Tissue marker, N N N/A N/A N/A MED58
implantable, any type,
each
A4649 Surgical supplies N Review Member Services N/A N/A
Required Fax 1-888-606-6658
A4650 Implantable radiation N Review Member Services N/A Invoice needed. MED58
dosimeter, each Required Fax 1-888-606-6658
A4651 Calibrated microcap N N N/A N/A N/A MED126
tube
A4652 Microcapillary tube N N N/A N/A N/A MED126
sealant
A4653 PD catheter anchor belt N N N/A N/A N/A MED126
A4657 Syringe w/wo needle N N N/A N/A N/A MED126
A4660 Sphyg/bp app w cuff N N N/A N/A N/A MED126
and stet
A4663 Dialysis blood pressure N N N/A N/A N/A MED126
cuff
A4670 Automatic bp monitor, N N N/A N/A N/A MED126
dial
A4671 Disposable cycler set N N N/A N/A N/A MED126
A4672 Drainage ext line, N N N/A N/A N/A MED126
dialysis
A4673 Ext line w easy lock N N N/A N/A N/A MED126
connect
A4674 Chem/antisept solution, N N N/A N/A N/A MED126
8oz
A4680 Activated carbon filter, N N N/A N/A N/A MED126
ea
A4690 Dialyzer, each N N N/A N/A N/A MED126
A4706 Bicarbonate conc sol N N N/A N/A N/A MED126
per gal
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 8 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4707 Bicarbonate conc pow N N N/A N/A N/A MED126
per pac
A4708 Acetate conc sol per N N N/A N/A N/A MED126
gallon
A4709 Acid conc sol per gallon N N N/A N/A N/A MED126
A4726 Dialys sol fld vol > N N N/A N/A N/A MED126
5999cc
A4728 Dialysate solution, non- N N N/A N/A N/A MED126
dex
A4730 Fistula cannulation set, N N N/A N/A N/A MED126
ea
A4736 Topical anesthetic, per N N N/A N/A N/A MED126
gram
A4737 Inj anesthetic per 10 ml N N N/A N/A N/A MED126
A4740 Shunt accessory N N N/A N/A N/A MED126
A4750 Art or venous blood N N N/A N/A N/A MED126
tubing
A4755 Comb art/venous blood N N N/A N/A N/A MED126
tubing
A4760 Dialysate sol test kit, N N N/A N/A N/A MED126
each
A4765 Dialysate conc pow per N N N/A N/A N/A MED126
pack
A4766 Dialysate conc sol add N N N/A N/A N/A MED126
10 ml
A4770 Blood collection N N N/A N/A N/A MED126
tube/vacuum
A4771 Serum clotting time tube N N N/A N/A N/A MED126
A4772 Blood glucose test strips N N N/A N/A N/A MED126
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 9 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A4773 Occult blood test strips N N N/A N/A N/A MED126
A4774 Ammonia test strips N N N/A N/A N/A MED126
A4802 Protamine sulfate per 50 N N N/A N/A N/A MED126
mg
A4860 Disposable catheter tips N N N/A N/A N/A MED126
A4870 Plumb/elec wk hm hemo N N N/A N/A N/A MED126
equip
A4890 Repair/maint cont hemo N N N/A N/A N/A MED126
equip
A4911 Drain bag/bottle N N N/A N/A N/A MED126
A4913 Misc dialysis supplies N N N/A N/A Procedural report is MED126 DME15
noc required. (08-2002)
A4918 Venous pressure clamp N N N/A N/A N/A MED126
A4927 Non-sterile gloves N N N/A N/A Not considered a
payable benefit of any
member policies.
A4929 Tourniquet for dialysis, N N N/A N/A N/A MED126
ea
A4930 Sterile gloves N N N/A Edit Removed Call Customer Service
01-2005 to verify benefit
information at 1-866-699-
8170
A4931 Reusable oral N N N/A Edit Removed Not considered a
thermometer 01-2005 payable benefit of any
member policies.
A4932 Reusable rectal N N N/A Edit Removed Not considered a
thermometer 01-2005 payable benefit of any
member policies.
A5500 Diabetic shoe for density N N N/A N/A N/A DME28
insert (07-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 10 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A5501 Diabetic custom molded N N N/A N/A N/A DME28
shoe (07-2008)
A5503 Diabetic shoe with roller N N N/A N/A N/A DME28
with rocker (07-2008)
A5504 Diabetic shoe with N N N/A N/A N/A DME28
wedge (07-2008)
A5505 Diabetic shoe with N N N/A N/A N/A DME28
metatarsal bar (07-2008)
A5506 Diabetic shoe with /off N N N/A N/A N/A DME28
set heel (07-2008)
A5507 Modification diabetic N N N/A N/A N/A DME28
shoe (07-2008)
A5508 Diabetic deluxe shoe N N N/A N/A N/A DME28
(07-2008)
A5510 Compression form shoe N N N/A Edit Removed May not be a covered DME28
insert 01-2005 benefit. Need clinical (07-2008)
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
A5512 For diabetics only, N N N/A Edit Removed May not be a covered DME28
multiple density insert, 07-2008 benefit. Need clinical (07-2008)
direct formed, molded to records pertinent to
foot after external heat diagnosis, treatment
sourse of 230 degrees plan and planned
fahrenheit or higher duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 11 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A5513 For diabetics only, N N N/A Edit Removed May not be a covered DME28
multiple density insert, 07-2008 benefit. Need clinical (07-2008)
custom molded from records pertinent to
model of patient's foot diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
A6000 Non-contact warming N N N/A Investigational Considered MED92
wound cover Denial investigational;
investigational services
are not covered.
A6020 Collagen wound N N N/A N/A N/A
dressing
A6021 Collagen dressing <=16 N N N/A N/A N/A
sq in
A6022 Collagen N N N/A N/A N/A
dressing>6<=48 sq in
A6023 Collagen dressing >48 N N N/A N/A N/A
sq in
A6024 Collagen dressing N N N/A N/A N/A
wound filler
A6025 Silicone gel sheet, each N N N/A N/A N/A
A6216 Non-sterile gauze <=16 N N N/A N/A N/A
sq in
A6217 Non-sterile gauze N N N/A N/A N/A
>16<=48 sq
A6218 Non-sterile gauze > 48 N N N/A N/A N/A
sq in
A6219 Gauze <= 16 sq in N N N/A N/A N/A
w/border
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 12 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A6220 Gauze >16 <=48 sq in N N N/A N/A N/A
w/bordr
A6221 Gauze > 48 sq in N N N/A N/A N/A
w/border
A6222 Gauze <=16 in no w/sal N N N/A N/A N/A
w/o b
A6223 Gauze >16<=48 no N N N/A N/A N/A
w/sal w/o b
A6224 Gauze > 48 in no w/sal N N N/A N/A N/A
w/o b
A6228 Gauze <= 16 sq in N N N/A N/A N/A
water/sal
A6229 Gauze >16<=48 sq in N N N/A N/A N/A
watr/sal
A6230 Gauze > 48 sq in N N N/A N/A N/A
water/saline
A6261 Wound filler gel/paste N N N/A N/A N/A
/oz
A6262 Wound filler dry form / N N N/A N/A N/A
gram
A6266 Impreg gauze no N N N/A N/A N/A
H20/sal/yard
A6402 Sterile gauze <= 16 sq N N N/A N/A N/A
in
A6403 Sterile gauze>16 <= 48 N N N/A N/A N/A
sq in
A6404 Sterile gauze > 48 sq in N N N/A N/A N/A
A6549 Gradient compression N Review Member Services N/A Procedural report is
stocking, not otherwise Required Fax 1-888-606-6658 required.
specified
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 13 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A6550 Dressing set wound N N N/A Edit Removed Documentation DME42
therapy electrical pump 09-2008 requested: Need (09-2008)
medical records
pertinent to diagnosis,
treatment plan for
review.
A7025 High frequency chest N Review Medical Services Potential Documentation DME45
wall oscillation system Required Fax 1-800-453-4341 Investigational requested: Operative
vest report and copies of the
member's prior
treatment plan.
A7026 High frequency chest N Review Medical Services Potential Documentation DME45
wall oscillation system Required Fax 1-800-453-4341 Investigational requested: Operative
hose report and copies of the
member's prior
treatment plan.
A7027 Combination oral/nasal N N N/A N/A N/A DME8
mask, used with
continuous positive
airway pressure device,
each
A7028 Oral cushion for N N N/A N/A N/A DME8
combination oral/nasal
mask, replacement only,
each
A7029 Nasal pillows for N N N/A N/A N/A DME8
combination oral/nasal
mask, replacement only,
pair
A7030 Full face mask used N N N/A N/A N/A DME8
with positive airway
pressure device, each
A7031 Face mask interface, N N N/A N/A N/A DME8
replacement
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 14 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A7032 Replacement cushion N N N/A N/A N/A DME8
for nasal application
device
A7033 Replacement pillows for N N N/A N/A N/A DME8
nasal application device
A7034 Nasal interface (mask or N N N/A N/A N/A DME8
cannula type)
A7035 Headgear used with N N N/A N/A N/A DME8
positive airway pressure
device
A7036 Chinstrap use with N N N/A N/A N/A DME8
positive airway pressure
device
A7037 Tubing used with N N N/A N/A N/A DME8
positive airway pressure
device
A7038 Filter, disposable, used N N N/A N/A N/A DME8
with positive airway
pressure device
A7039 Filter, non disposable, N N N/A N/A N/A DME8
used with positive
airway pressure device
A7044 Oral interface used with N N N/A N/A N/A DME8
positive airway pressure
device, each
A8000 Helmet, protective, soft, N N N/A N/A N/A DME17
prefabricated, includes
all components and
accessories
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 15 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A8001 Helmet, protective, hard, N N N/A N/A N/A DME17
prefabricated, includes
all components and
accessories
A8002 Helmet, protective, soft, N N N/A N/A N/A DME17
custom fabricated,
includes all components
and accessories
A8003 Helmet, protective, hard, N N N/A N/A N/A DME17
custom fabricated,
includes all components
and accessories
A9150 Misc/exper non- N N N/A Edit Removed Not considered a
prescription drug 01-2005 payable benefit of any
member policies.
A9155 Artificial saliva, 30 ml N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9270 Non-covered item or N N N/A Edit Removed Not considered a DME1
service 01-2005 payable benefit of any
member policies.
A9274 External ambulatory Preauth Review Medical Services Potential Possibly investigational,
insulin delivery system, Required Required Fax 1-800-453-4341 Investigational documentation required.
disposable, each, Submit the medical and
includes all supplies and treatment history for the
accessories service and/or diagnosis
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 16 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9276 Sensor; invasive (e.g. N N N/A Investigational Considered MED83
subcutaneous), Denial investigational;
disposable, for use with investigational services
interstitial continuous are not covered.
glucose monitoring
system, one unit = 1 day
A9277 Transmitter; external, for N N N/A Investigational Considered MED83
use with interstitial Denial investigational;
continuous glucose investigational services
monitoring system are not covered.
A9278 Receiver (monitor); N N N/A Investigational Considered MED83
external, for use with Denial investigational;
interstitial continuous investigational services
glucose monitoring are not covered.
system
A9280 Alert or alarm device, N Review Member Services Unlisted Call Customer Service
NOC Required Fax 1-888-606-6658 Code to verify benefit
information at 1-866-699-
8170
A9300 Exercise equipment N N N/A N/A May not be a benefit of
the member's contract.
A9500 Technetium TC 99m N Review Member Services N/A N/A RAD15
sestamibi Required Fax 1-888-606-6658
for HS65
Only
A9501 Technetium TC-99m N Review Member Services N/A Invoice needed.
teboroxime, diagnostic, Required Fax 1-888-606-6658
per study dose
A9502 Technetium TC 99m N Review Member Services N/A N/A
tetrofosmin Required Fax 1-888-606-6658
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 17 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9503 Technetium TC 99m N Review Member Services N/A N/A
medronate Required Fax 1-888-606-6658
for HS65
Only
A9505 Thallous chloride TI N Review Member Services N/A N/A
201/Mci Required Fax 1-888-606-6658
for HS65
Only
A9507 Indium/111 Capromab N Review Member Services N/A N/A
Pendetid Required Fax 1-888-606-6658
for HS65
Only
A9508 Iobenguane Sulfate I- N Review Member Services N/A N/A
131 Required Fax 1-888-606-6658
for HS65
Only
A9509 Iodine I-123 sodium N Review Member Services N/A Invoice needed.
iodide, diagnostic, per Required Fax 1-888-606-6658
millicurie
A9510 Technetium TC 99m N Review Member Services N/A N/A
Disofenin Required Fax 1-888-606-6658
for HS65
Only
A9512 Technetiumtc 99m N Review Member Services N/A N/A
pertechnetate Required Fax 1-888-606-6658
for HS65
Only
A9516 I-123 sodium iodide N Review Member Services N/A N/A
capsule Required Fax 1-888-606-6658
for HS65
Only
A9517 Th I131 so iodide cap N Review Member Services N/A Invoice needed.
millic Required Fax 1-888-606-6658
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 18 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9521 Technetiumtc-99m N Review Member Services N/A N/A
exametazine Required Fax 1-888-606-6658
for HS65
Only
A9524 Iodinated I-131 N Review Member Services N/A Invoice needed.
serumalbumin Required Fax 1-888-606-6658
A9526 Supply of N Review Member Services N/A Invoice needed. RAD34
radiopharmaceutical Required Fax 1-888-606-6658
diagnostic imaging
agent, amonia n13
A9527 Iodine I-125, sodium N N N/A N/A N/A
iodide solution,
therapeutic, per
millicurie
A9528 Iodine I-131 iodide cap, N Review Member Services N/A Invoice needed.
dx Required Fax 1-888-606-6658
for HS65
Only
A9529 I131 iodide sol, dx N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9530 I131 iodide sol, rx N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9531 I131 max 100uCi N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9532 I125 serum albumin, dx N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9535 Injection, methylene N Review Member Services N/A Invoice needed.
blue Required Fax 1-888-606-6658
A9536 Tc99m depreotide N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 19 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9537 Tc99m mebrofenin N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9538 Tc99m pyrophosphate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9539 Tc99m pentetate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9540 Tc99m MAA N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9541 Tc99m sulfur colloid N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9542 In111 ibritumomab, dx N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9543 Y90 ibritumomab, rx N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9544 I131 tositumomab, dx N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9545 I131 tositumomab, rx N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 20 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9546 Co57/58 N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9547 In111 oxyquinoline N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9548 In111 pentetate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9550 Tc99m gluceptate N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9551 Tc99m succimer N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9552 Fluorodexyglucose F-18 N Review Member Services N/A Invoice needed. RAD33,
FDG, diagnostic, per Required Fax 1-888-606-6658 RAD34
study dose, up to 45
millicuries
A9553 Cr51 chromate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9554 I125 iothalamate, dx N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9555 Rb82 rubidium N Review Member Services N/A Invoice needed. RAD34
Required Fax 1-888-606-6658
A9556 Ga67 gallium N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 21 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9557 Tc99m bicisate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9558 Xe133 xenon 10mci N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9559 Co57 cyano N Review Member Services N/A Invoice needed.
Required Fax 1-888-606-6658
A9560 Tc99m labeled rbc N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9561 Tc99m oxidronate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9562 Tc99m mertiatide N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9563 P32 Na phosphate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9564 P32 chromic phosphate N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 22 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9565 In111 pentetreotide N N N/A N/A N/A
Code
deleted
12/31/20
07
See
A9572
A9566 Tc99m fanolesomab N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9567 Technetium TC-99m N Review Member Services N/A Invoice needed.
aerosol Required Fax 1-888-606-6658
A9569 Technetium TC-99m N Review Member Services N/A Invoice needed.
exametazime labeled Required Fax 1-888-606-6658
autologous white blood
cells, diagnostic, per
study dose
A9570 Indium In-111 labeled N Review Member Services N/A Invoice needed.
autologous white blood Required Fax 1-888-606-6658
cells, diagnostic, per
study dose
A9571 Indium In-111 labeled N Review Member Services N/A Invoice needed.
autologous platelets, Required Fax 1-888-606-6658
diagnostic, per study
dose
A9572 Indium In-111 N Review Member Services N/A Invoice needed.
penetetreotide, Required Fax 1-888-606-6658
diagnostic, per sutdy
dose, up to 6 millicuries
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 23 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
A9600 Strontium-89 chloride N Review Member Services N/A N/A
Required Fax 1-888-606-6658
for HS65
Only
A9603 Radiopharmaceutical N N N/A N/A N/A
therapeutic agent
A9605 Samarium sm 153 N Review Member Services N/A N/A
lexidronamm Required Fax 1-888-606-6658
for HS65
Only
A9698 Non-rad contrast N Review Member Services N/A N/A
material NOC Required Fax 1-888-606-6658
for HS65
Only
A9699 Radiopharm rx agent N Review Member Services N/A Invoice needed.
noc Required Fax 1-888-606-6658
A9700 Echocardiography N Review Member Services N/A N/A
Contrast Required Fax 1-888-606-6658
for HS65
Only
A9900 Miscellaneous DME N Review Member Services N/A Description of DME DME65
supply, accessory, Required Fax 1-888-606-6658 requested on billing.
and/or service
component of another
HCPCS code
A9901 Delivery/set N N N/A Regence Not considered a
up/dispensing Invalid payable service. Will be
denied provider write-off.
A9999 Miscellaneous DME N Review Member Services N/A Description of DME
supply or accessory, not Required Fax 1-888-606-6658 requested on billing.
otherwise specified
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 24 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
B4034 Enteral feed supply kit; N N N/A N/A N/A AH5
syringe (11-2008)
B4035 Enteral feeding supply N N N/A N/A N/A AH5
kit; pump (11-2008)
B4036 Enteral fee supply kit; N N N/A N/A N/A AH5
gravity (11-2008)
B4081 Nasogastric tubing with N N N/A N/A N/A AH5
stylet (11-2008)
B4082 Nasogastric tubing N N N/A N/A N/A AH5
without stylet (11-2008)
B4083 Stomach tube; levine N N N/A N/A N/A AH5
type (11-2008)
B4086 Gastrostomy / N N N/A N/A N/A AH5
jejunostomy tube (11-2008)
B4087 Gastrostomy/jejunostom N N N/A N/A N/A AH5
y tube, standard, any (11-2008)
material, any type, each
B4088 Gastrostomy/jejunostom N N N/A N/A N/A AH5
y tube, low-profile, any (11-2008)
material, any type, each
B4100 Food thickner N N N/A N/A May not be a benefit of
the member's contract.
B4102 Enteral formula, for N N N/A N/A N/A AH5
adults, used to replace (11-2008)
fluids and electrolytes
(e.g., clear liquids), 500
ml = 1 unit
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 25 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
B4103 Enteral formula, for N N N/A N/A N/A AH5
pediatrics, used to (11-2008)
replace fluids and
electrolytes (e.g., clear
liquids), 500 ml = 1 unit
B4104 Additive for enteral N N N/A N/A N/A AH5
formula (e.g., fiber) (11-2008)
B4149 Enteral formula, N N N/A N/A N/A AH5
blenderized natural (11-2008)
foods with intact
nutrients, includes
proteins, fats,
carbohydrates, vitamins
and minerals, may
include fiber,
administration through
an enteral feeding tube,
100 calories = 1 unit
B4150 Enteral formulae; N N N/A N/A N/A AH5
category I; sem (11-2008)
B4152 Enternal formulae; N N N/A N/A N/A AH5
category II; in (11-2008)
B4153 Enteral formulae; N N N/A N/A N/A AH5
category III; H (11-2008)
B4154 Enteral formulae; N N N/A N/A N/A AH5
category IV; de (11-2008)
B4155 Enteral formulae; N N N/A N/A N/A AH5
category V; mod (11-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 26 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
B4157 Enteral formula, N N N/A N/A N/A
nutrionally complete for
special metabolic needs
for inherited disease of
metabolism
B4158 Enteral formula for N N N/A N/A N/A AH5
pediatrics, nutritionally (11-2008)
complete with intact
nutrients
B4159 Enteral formula for N N N/A N/A N/A AH5
pediatrics, nutritionally (11-2008)
complete soy based with
intact nurtrients
B4160 Enteral formula for N N N/A N/A N/A AH5
pediatrics, nutritionally (11-2008)
complete calorically
dense (equal or greater
than 0.7 Kcal/ml)
B4161 Enteral formula for N N N/A N/A N/A AH5
pediatrics, (11-2008)
hydrolyzed/amino acids
and peptide chain
proteins
B4162 Enteral formula, for N N N/A N/A N/A AH5
pediatrics, special (11-2008)
metabolic needs for
inherited disease of
metabolism
B4164 Parenteral nutrition N N N/A N/A N/A AH6
solution; C (08-2008)
B4168 Parenteral nutrition N N N/A N/A N/A AH6
solution; am (08-2008)
B4172 Parenteral nutrition N N N/A N/A N/A AH6
solution; am (08-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 27 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
B4176 Parenteral nutrition N N N/A N/A N/A AH6
solution; am (08-2008)
B4178 Parenteral nutrition N N N/A N/A N/A AH6
solution; am (08-2008)
B4180 Parenteral nutrition N N N/A N/A N/A AH6
solution; ca (08-2008)
B4189 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B4193 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B4197 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B4199 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B4216 Parenteral nutrition; N N N/A N/A N/A AH6
additives (08-2008)
B4220 Parenteral nutrition N N N/A N/A N/A AH6
supply kit (08-2008)
B4222 Parenteral nutrition N N N/A N/A N/A AH6
supply kit (08-2008)
B4224 Parenteral nutrition N N N/A N/A N/A AH6
administration (08-2008)
B5000 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B5100 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B5200 Parenteral nutrition N N N/A N/A N/A AH6
solution; co (08-2008)
B9000 Enteral nutrition infusion N N N/A N/A N/A AH5
pump (11-2008)
B9002 Enteral nutrition infusion N N N/A N/A N/A AH5
pump (11-2008)
B9004 Parenteral nutrition N N N/A N/A N/A AH6
infusion pump (08-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 28 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
B9006 Parenteral nutrition N N N/A N/A N/A AH6
infusion pump (08-2008)
B9998 NOC for enteral N Review Member Services N/A N/A AH5
supplies Required Fax 1-888-606-6658 (11-2008)
B9999 NOC for parenteral N N N/A N/A N/A AH5
supplies (11-2008)
C1300 Hyperbaric oxygen N N N/A N/A N/A
under pressure
C1360 Ocular photodynamic N N N/A Investigational Considered
therapy Denial investigational;
investigational services
are not covered.
C1754 Catheter, intradiscal N N N/A Investigational Considered SUR118
Denial investigational;
investigational services
are not covered.
C1780 Lens, intraocular (new N N N/A N/A N/A SUR39
technology)
C1818 Intergrated N N N/A Investigational Considered SUR85
keratoprosthesis Denial investigational;
investigational services
are not covered.
C1821 Interspinous process N N N/A Investigational Considered
distraction device Denial investigational;
(implantable) investigational services
are not covered.
C2614 Probe, percutaneous N Review Medical Services Potential Documentation
lumbar disectomy Required Fax 1-800-453-4341 Investigational requested: Need
operative report and
member's prior
treatment history.
C8900 Magnetic resonance N N N/A N/A N/A RAD8
angiograpy with (09-2007)
contrast, abdomen
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 29 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
C8901 Magnetic resonance N N N/A N/A N/A RAD8
angiograpy without (09-2007)
contrast, abdomen
C8902 Magnetic resonance N N N/A N/A N/A RAD8
angiograpy without (09-2007)
contrast followed by with
contrast, abdomen
C8903 Magnetic resonance N N N/A N/A N/A RAD8
imaging with contrast, (09-2007)
breast; unilateral
C8904 Magnetic resonance N N N/A N/A N/A RAD8
imaging without (09-2007)
contrast, breast;
unilateral
C8905 Magnetic resonance N N N/A N/A N/A RAD8
imaging without contrast (09-2007)
follwed by with
constrast, breast;
unilateral
C8906 Magnetic resonance N N N/A N/A N/A RAD8
imaging with contrast, (09-2007)
breast; bilateral
C8907 Magnetic resonance N N N/A N/A N/A RAD8
imaging without (09-2007)
contrast, breast; bilateral
C8908 Magnetic resonance N N N/A N/A N/A RAD8
imaging without contrast (09-2007)
followed by with
contrast, breast; bilateral
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 30 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
C8909 Magnetic resonance N N N/A N/A N/A RAD8
angiography with (09-2007)
contrast, chest
(excluding myocardium)
C8910 Magnetic resonance N N N/A N/A N/A RAD8
angiography without (09-2007)
contrast, chest
(excluding myocardium)
C8911 Magnetic resonance N N N/A N/A N/A RAD8
angiography without (09-2007)
contrast followed by with
contrast, chest
(excluding myocardium)
C8912 Magnetic resonance N N N/A N/A N/A RAD8
angiography with (09-2007)
contrast, lower extremity
C8913 Magnetic resonance N N N/A N/A N/A RAD8
angiography without (09-2007)
contrast, lower extremity
C8914 Magnetic resonance N N N/A N/A N/A RAD8
angiography without (09-2007)
contrast followed by with
contrast, lower extremity
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 31 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
C9003 Palivizamab-RSV-IgM, Preauth N Pharmacy N/A Documentation DRU029
per 50 mg Required Fax 1-800-884-4282 requested: Need clinical
records outlining
diagnosis, gestational
age, and treatment
plan.
C9716 Creation of thermal N N N/A Investigational Considered
annual lesions by Denial investigational;
radiofrequency energy investigational services
are not covered.
C9723 Dynamic infrared blood N Review Medical Services Potential Documentation
perfusion imaging Required Fax 1-800-453-4341 Investigational requested: Need
operative report and
member's prior
treatment history.
C9724 Eposcopic full-thickness N N N/A Investigational Considered SUR110
plication in the gastric Denial investigational;
cardia using endoscopic investigational services
plication system (EPS); are not covered.
includes endoscopy
C9727 Insertion of implants into N N N/A Investigational Considered SUR142
the soft palate; minimum Denial investigational;
of 3 implants investigational services
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 32 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
C9728 Placement of interstitial N Review Medical Services Potential Possibly investigational,
device(s) for radiation Required Fax 1-800-453-4341 Investigational documentation required.
therapy/surgery Submit operative report
guidance (e.g., fiducial and medical and
markers, dosimeter) treatment history for the
other than prostate (any service and/or diagnosis
approach), single or
multiple
D0320 Temporomandibular N Review Dental Benefit May not be a covered SUR122
joint arthrogram, Required Fax 208-798-2047 benefit. Refer to Dental
including injection Department.
D7940 Reshaping bone N Review Dental N/A Refer to Dental SUR137
orthognathic Required Fax 208-798-2047 Department.
D7941 Osteotomy - mandibular N N N/A N/A N/A SUR137,
rami TRG UM
Dental
Treatment
Provided
Outside the
Dentist
Office Outpt
Hospital or
Ambulatory
Surgery
Center
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 33 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
D7943 Osteotomy - mandibular N N N/A N/A N/A SUR137,
raimi with bone graft; TRG UM
includes obtaining the Dental
graft Treatment
Provided
Outside the
Dentist
Office Outpt
Hospital or
Ambulatory
Surgery
Center
D7944 Osteotomy - segmented N N N/A N/A N/A SUR137,
or subapical - per TRG UM
sextant or quadrant Dental
Treatment
Provided
Outside the
Dentist
Office Outpt
Hospital or
Ambulatory
Surgery
Center
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 34 of 908
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CPT Required Y/N Required When?
Code
D7945 Osteotomy - body of N N N/A N/A N/A SUR137,
mandible TRG UM
Dental
Treatment
Provided
Outside the
Dentist
Office Outpt
Hospital or
Ambulatory
Surgery
Center
D7946 Reconstruction maxilla N Review Dental N/A Refer to Dental SUR137
total Required Fax 208-798-2047 Department.
D7947 Reconstruct maxilla N Review Dental N/A Refer to Dental SUR137
segment Required Fax 208-798-2047 Department.
D7948 Reconstruct midface no N Review Dental N/A Refer to Dental SUR137
graft Required Fax 208-798-2047 Department.
D7949 Reconstruct midface N Review Dental N/A Refer to Dental SUR137
w/graft Required Fax 208-798-2047 Department.
D7950 Mandible graft N Review Dental N/A Refer to Dental SUR137
Required Fax 208-798-2047 Department.
D7995 Synthetic graft facial N Review Dental N/A Refer to Dental SUR137
bones Required Fax 208-798-2047 Department.
D7996 Implant mandible for N Review Dental N/A Refer to Dental SUR137
augment Required Fax 208-798-2047 Department.
D7999 Unspecified oral surgery Preauth N Dental N/A Refer to Dental SUR137
procedure, by report Required Fax 208-798-2047 Department.
D9220 Deep sedation / general Preauth N Dental N/A Refer to Dental
anesthesia - first 30 Required Fax 208-798-2047 Department
minutes
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 35 of 908
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CPT Required Y/N Required When?
Code
D9221 Deep sedation / general Preauth N Dental N/A Refer to Dental
anesthesia - each Required Fax 208-798-2047 Department.
additional 15 minutes
E0163 Commode chair, N N N/A N/A N/A DME6
stationary, with fixed (06-2008)
arms
E0165 Commode chair, N N N/A N/A N/A DME6
stationary, with (06-2008)
detachable arms
E0167 Pail or pan for use with N N N/A N/A N/A DME6
commode chair (06-2008)
E0168 Commode chair, with N N N/A N/A N/A DME6
extra wide and / or (06-2008)
heavy duty, stationary or
mobile, with or without
arms, any type, each
E0170 Commode chair with N N N/A N/A N/A DME6
integrated seat lift (06-2008)
mechanism, electric,
any type
E0171 Commode chair with N N N/A N/A N/A DME6
integrated seat lift (06-2008)
mechanism, non-
electric, any type
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 36 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0172 Seat lift mechanism N N N/A Edit Removed Documentation DME26
placed over or on top of 06-2008 requested; Need clinical (06-2008)
toilet, any type records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0175 Foot rest, for use with N N N/A N/A N/A DME6
commode chair, each (06-2008)
E0181 Pressure pad, aternating N N N/A N/A N/A DME1
w / pump
E0182 Pump for alternating N N N/A N/A N/A DME1
pressure pad
E0184 Dry pressure mattress N N N/A N/A N/A DME1
E0185 Gel pressure pad for N N N/A N/A N/A DME1
mattress
E0186 Air pressure mattress N N N/A N/A N/A DME1
E0187 Water pressure N N N/A N/A N/A DME1
mattress
E0190 Positioning N N N/A Benefit Call Customer Service
cushion/pillow/wedge, to verify benefit
any shape or size information at 1-866-699-
8170
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 37 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0193 Powered air flotation N N N/A Edit Removed May not be a covered DME1
bed (low air loss 10-2003 benefit. Need clinical
therapy) records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0194 Air fludized bed N Review Medical Services Medical Review for medical DME1,
Required Fax 1-800-453-4341 Necessity necessity, DME76
documentation required.
Submit the medical and
treatment history for the
service and/or diagnosis
E0196 Gel pressure mattress N N N/A Edit Removed May not be a covered DME1
10-2003 benefit. Need clinical
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0197 Air pressure pad for N N N/A N/A N/A DME1
mattress
E0198 Water pressure pad for N N N/A N/A N/A DME1
mattress
E0199 Dry pressure pad for N N N/A N/A N/A DME1
mattress
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 38 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0202 Phototherapy (billirubin) N N N/A N/A N/A DME58
light with photometer (06-2008)
E0203 Therapeutic lightbox, N N N/A N/A N/A DME58
minimum 10,000 lux, (06-2008)
table top model
E0218 Water circulating cold N N N/A N/A Considered not DME7
pad with pump medically necessary.
Not payable.
E0221 Infrared heating pad N N N/A Investigational Considered DME63
system Denial investigational;
investigational services
are not covered.
E0225 Hydrocollator unit, N N N/A N/A Not considered a
includes pad payable benefit of any
member policies.
E0230 Ice cap or collar N N N/A N/A Considered not
medically necessary.
Not payable.
E0231 Non-contact wound N N N/A Investigational Considered MED92
warming device Denial investigational;
investigational services
are not covered.
E0232 Warming card for use N N N/A Investigational Considered MED92
with the non-contact Denial investigational;
wound warming device investigational services
are not covered.
E0236 Pump for water N N N/A N/A Not considered a DME7
circulating pad payable benefit of any
member policies.
E0238 Nonelectric heat pad, N N N/A Edit Removed Not considered a
moist 03-2003 payable benefit of any
member policies.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 39 of 908
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CPT Required Y/N Required When?
Code
E0239 Hydrocollator unit, N N N/A N/A Considered not DME7
portable medically necessary.
Not payable.
E0240 Bath/shower chair any N N N/A N/A N/A DME27
size (06-2008)
E0243 Toilet rail, each N N N/A N/A N/A
E0245 Tub stool or bench N N N/A N/A N/A DME27
(06-2008)
E0249 Pad for water circulating N N N/A N/A Considered not
heat unit medically necessary.
Not payable.
E0250 Hospital bed, fixed N N N/A N/A N/A DME16
height, with any type (06-2008)
side rails, with mattress
E0251 Hospital bed, fixed N N N/A N/A N/A DME16
height, with any type (06-2008)
side rails, without
mattress
E0255 Hospital bed, variable N N N/A N/A N/A DME16
height, hi-lo, with any (06-2008)
type side rails, with
mattress
E0256 Hospital bed, variable N N N/A N/A N/A DME16
height, hi-lo, with any (06-2008)
type side rails, without
mattress
E0260 Hospital bed, semi- N N N/A N/A N/A DME16
electric (head and foot (06-2008)
adj.) with any type side
rails, with mattress
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 40 of 908
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CPT Required Y/N Required When?
Code
E0261 Hospital bed, semi- N N N/A N/A N/A DME16
electric (head and foot (06-2008)
adj.) with any type side
rails, without mattress
E0265 Hospital bed, total N N N/A N/A N/A DME16
electric (head, foot and (06-2008)
height adj.) with any
type side rails, with
mattress
E0266 Hospital bed, total N N N/A N/A N/A DME16
electric (head, foot and (06-2008)
height adj.) with any
type side rails, without
mattress
E0270 Hospital bed, N N N/A N/A N/A DME16
institutional type (06-2008)
includes: oscillating,
circulating and stryker
frame, with mattress
E0271 Mattress, inner spring N N N/A N/A N/A DME16
(06-2008)
E0272 Mattress, foam rubber N N N/A N/A N/A DME16
(06-2008)
E0273 Bed board N N N/A N/A N/A DME16
(06-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 41 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0274 Over-bed table N N N/A Edit Removed May not be a covered DME16
06-2008 benefit. Need clinical (06-2008)
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0277 Alternating pressure N N N/A N/A N/A DME1
mattress
E0280 Bed cradle N N N/A N/A N/A DME16
(06-2008)
E0290 Hospital bed, fixed N N N/A N/A N/A DME16
height, without side rails, (06-2008)
with mattress
E0291 Hospital bed, fixed N N N/A N/A N/A DME16
height, without side rails, (06-2008)
without mattress
E0292 Hospital bed, variable N N N/A N/A N/A DME16
height, hi-lo, without (06-2008)
side rails, with mattress
E0293 Hospital bed, varialbe N N N/A N/A N/A DME16
height, hi-lo, without (06-2008)
side rails, without
mattress
E0294 Hospital bed, semi- N N N/A N/A N/A DME16
electric (head and foot (06-2008)
adj.), without side rails,
with mattress
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 42 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0295 Hospital bed, semi- N N N/A N/A N/A DME16
electric (head and foot (06-2008)
adj.), without side rails,
without mattress
E0296 Hospital bed, total N N N/A N/A N/A DME16
electric (head, foot and (06-2008)
height adj.) without side
rails, with mattress
E0297 Hospital bed, total N N N/A N/A N/A DME16
electric (head, foot and (06-2008)
height adj.) without side
rails, without mattress
E0300 Pediatric crib, hospital N N N/A N/A N/A DME16
grade, fully enclosed (06-2008)
E0301 Hospital bed, heavy N N N/A N/A N/A DME16
duty, extra wide (06-2008)
E0302 Hospital bed, extra N N N/A N/A N/A DME16
heavy duty, extra wide (06-2008)
E0303 Hospital bed, heavy N N N/A N/A N/A DME16
duty, extra wide (06-2008)
E0304 Hospital bed, extra N H N/A N/A N/A DME16
heavy duty, extra wide (06-2008)
E0305 Bedside rails, half-length N N N/A Edit Removed May not be a covered DME16
08-2008 benefit. Need clinical (06-2008)
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 43 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0310 Bedside rails, full-length N N N/A Edit Removed May not be a covered DME16
08-2008 benefit. Need clinical (06-2008)
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0315 Bed accessory; board, N N N/A Edit Removed May not be a covered
table, or support device, 08-2008 benefit. Need clinical
any type records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0316 Saftey enclosure frame / N N N/A N/A N/A DME16
canopy for use with (06-2008)
hospital bed, any type
E0328 Hospital bed, pediatric, N N N/A N/A N/A DME16
manual, 360 degree (06-2008)
side enclosure, top of
headboard, footboard
and side rails up to 24
inches above the spring,
includes mattress
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 44 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0329 Hospital bed, pediatric, N N N/A N/A N/A DME16
electric or semi-electric, (06-2008)
360 degree side
enclosures, top of
headboard, footboard
and side rails up to 24
inches above the spring,
includes mattress
E0370 Air elevator for heel N N N/A N/A Not considered a
payable benefit of any
member policies.
E0371 Nonpowered advanced N N N/A N/A Not considered a DME1
pressure reducing payable benefit of any
overlay for mattress, member policies.
standard mattress
E0372 Powered air overlay for N N N/A N/A N/A DME1
mattress, standard
mattress
E0373 Non-powered advanced N N N/A N/A N/A DME1
pressure reducing
mattress
E0424 Stationary compressed N N N/A Edit Removed Documentation MED36
gaseous oxygen 03-2003 requested: Clinical (07-2004),
system, rental records pertinent to DME22
diagnosis, O2 saturation (08-2008)
levels, treatment plan
and planned duration of
use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 45 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0425 Stationary compressed N N N/A Edit Removed Documentation MED36
gaseous oxygen 03-2003 requested: Clinical (07-2004),
system, purchase records pertinent to DME22
diagnosis, O2 saturation (08-2008)
levels, treatment plan
and planned duration of
use.
E0430 Portable gaseous N N N/A Edit Removed Documentation DME22
oxygen stem, purchase 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0431 Portable gaseous N N N/A Edit Removed Documentation DME22
oxygen stem, rental 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0434 Portable liquid oxygen N N N/A Edit Removed Documentation DME22
sytem, rental 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 46 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0435 Portable liquid oxygen N N N/A Edit Removed Documentation DME22
sytem, purchase 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0439 Stationary liquid oxygen N N N/A Edit Removed Documentation DME22
system, rental 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0440 Stationary liquid oxygen N N N/A Edit Removed Documentation DME22
system, purchase 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0441 Oxygen contents, N N N/A Edit Removed Documentation DME22
gaseous 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 47 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0442 Oxygen contents, liquid N N N/A Edit Removed Documentation DME22
03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0443 Portable oxygen N N N/A Edit Removed Documentation DME22
contents, gaseous 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0444 Portable oxygen N N N/A Edit Removed Documentation DME22
contents, liquid 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, O2 saturation
levels, treatment plan
and planned duration of
use.
E0445 Oximeter device for N N N/A Edit Removed May not be a covered MED16 DME49
measuring blood oxygen 03-2003 benefit. Need clinical (09-2008)
levels non-invasively records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 48 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0450 Volume vent N N N/A N/A N/A
stationary/portable
E0460 Neg pressure vent N N N/A N/A N/A
portable/stationary
E0470 Respiratory assist N N N/A N/A N/A DME8
device, bi-level pressure
capability, without
backup rate feature,
used with noninvasive
interface
E0471 Respiratory assist N N N/A N/A N/A DME8
device, bi-level pressure
capability, with backup
rate feature, used with
invasive interface
E0472 Respiratory assist N N N/A N/A N/A DME8
device, bi-level pressure
capability, with backup
rate feature, used with
invasive interface
E0480 Precussor, electric or N N N/A Edit Removed May be considered not DME62
pneumatic 09-2008 medically necessary.
Need clinical records
pertinent to diagnosis
and treatment plan for
review.
E0481 Intrapulmonary N N N/A Investigational Considered DME62
percussive ventilation Denial investigational;
system investigational services
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 49 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0482 Cough stimulating N N N/A Edit Removed May be considered not DME62
device 09-2008 medically necessary.
Need clinical records
pertinent to diagnosis
and treatment plan for
review.
E0483 High frequency chest Preauth Review Medical Services Potential Possibly investigational, DME45,
wall oscillation air-pulse Required Required Fax 1-800-453-4341 Investigational documentation required. DME62
generator system Submit the medical and
treatment history for the
service and/or diagnosis
E0484 Oscillatory positive N N N/A Edit Removed May be considered not DME62
expiratory pressure 04-2004 medically necessary.
device Need clinical records
pertinent to diagnosis
and treatment plan for
review.
E0485 Oral device/appliance N N N/A N/A N/A DME8
used to reduce upper
airway collapsibilit,
adjustable or non-
adjustable, custom
fabricated, includes
fitting and adjustment
E0486 Oral device/appliance N N N/A N/A N/A DME8
used to reduce upper
airway collapsibilit,
adjustable or non-
adjustable, custom
fabricated, includes
fitting and adjustment
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 50 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0500 IPPB machine, all types, N N N/A Investigational Considered DME62
with built-in nebulization; Denial investigational;
manual or automatic investigational services
valves are not covered.
E0550 Humidifier, durable for N N N/A N/A N/A
extensive supplmental
humidification during
IPPB treatments or
oxygen delivery
E0560 Humidifier, durable for N N N/A N/A N/A
supplemental
humidification during
IPPB treatment or
oxygen delivery
E0561 Humidifier, non-heated, N N N/A N/A N/A DME8
used with positive
airway pressure device
E0562 Humidifier, heated, used N N N/A Edit Removed Documentation DME8
with positive airway 02-2004 requested: CMN and
pressure device pertinent clinical
records for the last 2
months.
E0574 Ultrasonic generator wit N N N/A N/A N/A
svneb
E0575 Nebulizer, ultrasonic, N Review Corr Pool Medical May be considered not
large volume Required Fax 1-888-606-6658 Necessity medically necessary.
Need clinical records
pertinent to diagnosis
and treatment plan for
review.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 51 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0580 Nebulizer, with N N N/A N/A N/A
compressor, durable,
glass or autoclavable
plastic, bottle type, for
use with regulator or
flowmeter
E0585 Nebulizer with N N N/A N/A N/A
compressor and heater
E0601 Continuous airway N N N/A N/A N/A DME8
pressure (CPAP) device
E0602 Breast pump, manual, N N N/A N/A N/A
any type
E0603 Breast pump, electric N N N/A N/A N/A DME5
(AC and or DC), any (07-2008)
type
E0604 Breast pump, heavy N N N/A N/A N/A DME5
duty, hospital grade, (07-2008)
piston operated
E0617 External defibrillator with N N N/A Investigational Considered DME61
integrated Denial investigational:
electrocardiogram investigational services
analysis are not covered. If
Medicare: Need clinical
records pertinent to
diagnosis and treatment
plan for review.
E0618 Apnea monitor, without N N N/A N/A N/A DME3
recording feauture
E0619 Apnea monitor, with N N N/A N/A N/A DME3
recording feature
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 52 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0620 Skin piercing device for N Review Member Services N/A May not be a covered
collection of capillary Required Fax 1-888-606-6658 benefit. Need clinical
blood, laser, each records pertinent to
diagnosis, treatment
plan and planned
duration of use.
E0621 Sling or seat, patient lift, N N N/A N/A N/A DME23
canvas or nylon (05-2008)
E0625 Patient lift, Kartop, N N N/A N/A Not considered a DME23
bathroom or toilet payable benefit of any (05-2008)
member policies.
E0627 Seat lift mechanism N N N/A N/A N/A DME26
incorporated into a (06-2008)
combination liftchair
mechanism
E0628 Separate seat lift N N N/A N/A N/A DME26
mechanism for use with (06-2008)
patient owned furniture -
electric
E0629 Separate seat lift N N N/A N/A N/A DME26
mechanism for use with (06-2008)
patient owned furniture -
nonelectric
E0630 Patient lift, hydraulic, N N N/A N/A N/A DME23
with seat or sling (05-2008)
E0635 Patient lift, electric, with N N N/A N/A Not considered a DME23
seat or sling payable benefit of any (05-2008)
member policies.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 53 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0636 Multipositional patient N N N/A Edit Removed Documentation DME71
support system, with 09-2008 requested; Need clinical
intergrated lift, patient records pertinent to
accessible controls diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0637 Combination sit to stand N Review Medical Services Medical Review for medical DME71
system, with lift seat Required Fax 1-800-453-4341 Necessity necessity,
feature documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E0638 Standing frame system, N Review Medical Services Medical Review for medical DME71
any size with or without Required Fax 1-800-453-4341 Necessity necessity,
wheels documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E0639 Patient lift, moveable N N N/A N/A N/A DME23
from room to room with (05-2008)
disassembly and
reassembly, includes all
components /
accessories
E0640 Patient lift, fixed system, N N N/A N/A N/A DME23
includes all components (05-2008)
/ accessories
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 54 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0641 Standing frame system, N N N/A Medical Review for medical DME71
multi-position Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E0642 Standing frame system, N N N/A Edit Removed May be considered DME71
mobile (dynamic 09-2008 medically necessary.
stander) Need clinical records
pertinent to diagnosis
and treatment plan. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0650 Pneumatic compressor, N N N/A N/A N/A DME19,
nonsegmental home DME50
model
E0651 Pneumatic compressor, N N N/A N/A N/A DME19,
segmental home model DME50
without calibrated
gradient pressure
E0652 Pneumatic compressor, N Review Member Services N/A N/A DME7,
segmental home model Required Fax 1-888-606-6658 DME19,
with calibrated gradient DME50
pressure
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 55 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0655 Nonsegmental N N N/A N/A N/A DME19
pneumatic appliance for
use with pneumatic
compressor, half arm
E0660 Nonsegmental N N N/A N/A N/A DME19,
pneumatic appliance for DME50
use with pneumatic
compressor, full leg
E0665 Nonsegmental N N N/A N/A N/A DME19
pneumatic appliance for
use with pneumatic
compressor, full arm
E0666 Nonsegmental N N N/A N/A N/A DME19,
pneumatic applinace for DME50
use with pneumatic
compressor, half leg
E0667 Segmental pneumatic N N N/A N/A N/A DME19,
applicance for use with DME50
pneumatic compressor,
full leg
E0668 Segmental pneumatic N N N/A N/A N/A DME19
applicance for use with
pneumatic compressor,
full arm
E0669 Segmental pneumatic N N N/A N/A N/A DME19,
applicance for use with DME50
pneumatic compressor,
half leg
E0671 Segmental gradient N N N/A N/A N/A DME19,
pressure pneumatic DME50
appliance, full leg
E0672 Segmental gradient N N N/A N/A N/A DME19,
pressure pneumatic DME50
appliance, full arm
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 56 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0673 Segmental gradient N N N/A N/A N/A DME19,
pressure pneumatic DME50
appliance, half leg
E0675 Pneumatic compression N N N/A Investigational Considered DME50
device Denial investigational;
investigational services
are not covered.
E0676 Intermittent limb N Review Member Services Medical May not be a covered DME19,
compression device Required Fax 1-888-606-6658 Necessity benefit. Need clinical DME50
(includes all records pertinent to
accessories), not diagnosis, treatment
otherwise specified plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0691 Ultraviolet light therapy N N N/A Edit Removed Documentation
system panel, includes 06-2006 requested; Need clinical
blubs/lamps, timer and records pertinent to
eye protection; diagnosis, treatment
treatment area 2 sq ft or plan and planned
less duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 57 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0692 Ultraviolet light therapy N N N/A Edit Removed Documentation
system panel, includes 06-2006 requested; Need clinical
bulbs/lamp, timer and records pertinent to
eye protection, 4 ft panel diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0693 Ultraviolet light therapy N N N/A Edit Removed Documentation
system panel, includes 06-2006 requested; Need clinical
bulbs/lamp, timer and records pertinent to
eye protection, 6 ft panel diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0694 Ultraviolet N N N/A Edit Removed Documentation
multidirectional light 06-2006 requested; Need clinical
therapy system in 6 ft records pertinent to
cabinet diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0720 TENS, two lead, N N N/A N/A N/A DME11
localized stimulation
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 58 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0730 Transcutaneous N N N/A N/A N/A DME11
electrical nerve (TENS),
four lead, larger area /
multiple nerve
stimulation
E0731 Form-fitting conductive N N N/A Edit Removed May be considered DME11
garment for delivery of 09-2008 medically necessary.
TENS or NMES Need clinical records
pertinent to diagnosis
and treatment plan for
review.
E0740 Incontinence treatment N N N/A Investigational Considered AH4
system, pelvic floor stim Denial investigational;
investigational services
are not covered.
E0744 Neuromuscular N N N/A Investigational Considered DME11
stimulator for scoliosis Denial investigational;
investigational services
are not covered.
E0745 Neuromuscular N N N/A Investigational Considered DME11, DME43
stimulator, electronic Denial investigational; DME56, (06-2002),
shock unit investigational services DME57, DME53
are not covered. SUR44, (06-2004)
SUR134
E0746 Electromyograpy N N N/A Investigational Considered AH26, AH27,
(EMG), biofeedback Denial investigational; AH28, AH29,
device investigational services AH30
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 59 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0747 Osteogenesis Preauth Review Medical Services Potential Possibly investigational, DME10
stimulator, non-invasive, Required Required Fax 1-800-453-4341 Investigational documentation required.
other than spinal Submit medical and
applications treatment history for the
service and/or diagnosis
E0748 Osteogenesis Preauth Review Medical Services Potential Possibly investigational, DME10
stimulator, noninvasive, Required Required Fax 1-800-453-4341 Investigational documentation required.
spinal applications Submit medical and
treatment history for the
service and/or diagnosis
E0749 Osteogenesis Preauth Review Medical Services Potential Possibly investigational, DME10
stimulator, surgical Required Required Fax 1-800-453-4341 Investigational documentation required.
Submit medical and
treatment history for the
service and/or diagnosis
E0760 Osteigenesis stimulator, Preauth Review Medical Services Potential Possibly investigational, DME10,
low intensity (non- Required Required Fax 1-800-453-4341 Investigational documentation required. DME40
invasive) Submit medical and
treatment history for the
service and/or diagnosis
E0761 Non-thermal pulsed high N N N/A Investigational Considered DME67
frequency radiowaves Denial investigational;
investigational services
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 60 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0762 Transcutaneous N N N/A Investigational Considered DME11,
electrical joint Denial investigational; DME70
stimulation device investigational services
system, includes all are not covered.
accessories
E0764 Functional N N N/A Investigational Considered DME11,
neuromuscular Denial investigational; DME56
stimulator, investigational services
transcutaneious are not covered.
stimulation of muscles
of ambulation with
computer control
E0765 Implantable Preauth Review Medical Services Potential Possibly investigational, SUR111
neurostimulator pulse Required Required Fax 1-800-453-4341 Investigational documentation required.
generator Submit operative report
and medical and
treatment history for the
service and/or
diagnosis.
E0769 Electrical stimulation or N N N/A Investigational Considered DME67
electromagnetic wound Denial investigational;
treatment device, not investigational services
otherwise classified are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 61 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0781 Ambulatory infusion N N N/A Edit Removed Documentation
pump 03-2006 requested: Need clinical
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0782 Infusion pump, N N N/A Edit Removed Documentation SUR18
implantable non- 05-2003 requested: Clinical
programable records pertinent to
diagnosis and treatment.
E0783 Infusion pump, system, N N N/A Edit Removed Documentation SUR18
implantable, 05-2003 requested: Clinical
programable records pertinent to
diagnosis and treatment.
E0784 External ambulatory N N N/A N/A N/A
infusion pump, insulin
E0786 Implantable N Review Member Services Potential Documentation SUR18
programmable infusion Required Fax 1-888-606-6658 Investigational requested: Clinical
pump, replacement records pertinent to
diagnosis and treatment.
E0791 Parenteral infusion N N N/A N/A N/A
pump, stationary
E0830 Ambulatory traction N Review Member Services Potential Possibly investigational. DME60
device, all types, each Required Fax 1-888-606-6658 Investigational Review may be required.
Submit appropriate
documentation.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 62 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0855 Cervical traction N Review Medical Services Medical Review for medical
equipment not requiring Required Fax 1-800-453-4341 Necessity necessity,
additional stand or documentation required.
frame Submit the medical and
treatment history for the
service and/or diagnosis
E0860 Traction equipment, N N N/A N/A N/A
overdoor, cervical
E0910 Trapeze bars, also N N N/A N/A N/A DME16
known as Patient (06-2008)
Helper, attached to bed,
with grab bar
E0911 HD trapeze bar attached N N N/A N/A N/A DME16
to bed (06-2008)
E0912 HD trapeze bar free N N N/A N/A N/A DME16
standing (06-2008)
E0935 Passive motion exercise N N N/A Edit Removed May be considered DME39
device 06-2008 investigational. Need
clinical records pertinent
to diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E0936 Continuous passive N N N/A Investigational Considered DME39
motion exercise device Denial investigational;
for use other than knee investigational services
are not covered.
E0940 Trapeze bar, N N N/A N/A N/A DME16
freestanding, complete (06-2008)
wth grab bar
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 63 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0941 Gravity assisted traction N Review Medical Services N/A May be considered
device, any type Required Fax 1-800-453-4341 investigational. Need
name of manufacturer
and model number.
E0950 Tray N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0951 Loop heel N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0952 Loop toe N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0955 Wheelchair accessory, N Review Member Services N/A Documentation DME37
headrest, cushioned, Required Fax 1-888-606-6658 requested: CMN and
any type pertinent clinical records
for the last 6 months and
planned duration of use.
E0956 Wheelchair accessory, N Review Member Services N/A Documentation DME37
lateral trunk or hip Required Fax 1-888-606-6658 requested: CMN and
support, any type pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 64 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0957 Wheelchair accessory, N Review Member Services N/A Documentation DME37
meial thigh support, any Required Fax 1-888-606-6658 requested: CMN and
type pertinent clinical records
for the last 6 months and
planned duration of use.
E0958 Wheelchair attachment N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0959 Amputee adapter N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0960 Wheelchair accessory, N Review Member Services N/A Documentation DME37
shoulder harness/straps Required Fax 1-888-606-6658 requested: CMN and
or chest strap pertinent clinical records
for the last 6 months and
planned duration of use.
E0961 Brake extension N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 65 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0966 Hook on headrest N Review Member Services N/A Documentation DME37
extension Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0967 Wheelchair hand rims N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0968 Commode seat N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0969 Narrowing device N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0970 No. 2 footplates N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 66 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0971 Anti-tipping device N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0973 Adjustable height N Review Member Services N/A Documentation DME37
detachable arms Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0974 Grade-aid N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0978 Belt, safety with airplane N Review Member Services N/A Documentation DME37
buckle Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0979 Belt, safety with velcro N Review Member Services N/A Documentation DME37
closure Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 67 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0980 Saftey vest N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0981 Wheelchair accessory, N Review Member Services N/A Documentation DME37
seat upholstery, Required Fax 1-888-606-6658 requested: CMN and
replacement only pertinent clinical records
for the last 6 months and
planned duration of use.
E0982 Wheelchair accessory, N Review Member Services N/A Documentation DME37
back upholstery, Required Fax 1-888-606-6658 requested: CMN and
replacement only pertinent clinical records
for the last 6 months and
planned duration of use.
E0985 Wheelchair accessory, N Review Member Services N/A Documentation DME37
seat lift mechanism Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0986 Manual wheelchair N N N/A N/A Considered not
accessory, push-trim medically necessary.
activated power assist, Not payable.
each
E0990 Elevating leg rest N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 68 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E0992 Solid seat insert N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0994 Armrest N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E0995 Calf rest N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1002 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
tilt only pertinent clinical records
for the last 6 months and
planned duration of use.
E1003 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
recline only pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 69 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1004 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
recline only, w/ pertinent clinical records
mechanical shear for the last 6 months and
reduction planned duration of use.
E1005 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
recline only, w/ power pertinent clinical records
shear reduction for the last 6 months and
planned duration of use.
E1006 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
recline only, w/o power pertinent clinical records
shear reduction for the last 6 months and
planned duration of use.
E1007 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
combination tilt and pertinent clinical records
recline, w/o shear for the last 6 months and
reduction planned duration of use.
E1008 Wheelchair accessory, N Review Medical Services Medical Documentation DME37
power seating system, Required Fax 1-800-453-4341 Necessity requested: CMN and
combination tilt and pertinent clinical records
recline, w/ shear for the last 6 months and
reduction planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 70 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1009 Wheelchair accessory, N Review Member Services N/A Documentation DME37
addition to power Required Fax 1-888-606-6658 requested: CMN and
seating system pertinent clinical records
for the last 6 months.
E1010 Wheelchair accessory, N Review Member Services N/A Documentation DME37
addition to power Required Fax 1-888-606-6658 requested: CMN and
seating system, power pertinent clinical records
leg elevation system for the last 6 months and
planned duration of use.
E1011 Modification to pediatric N Review Member Services N/A Documentation DME37
size wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1014 Reclining back, addition N Review Member Services N/A Documentation DME37
to pediatric wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1015 Shock absorber for N Review Member Services N/A Documentation DME37
manual wheelchair, Required Fax 1-888-606-6658 requested: CMN and
each pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 71 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1016 Shock absorber for N Review Member Services N/A Documentation DME37
power wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1017 Heavy duty shock N Review Member Services N/A Documentation DME37
absorber for heavy duty Required Fax 1-888-606-6658 requested: CMN and
or extra heavy duty pertinent clinical records
manual wheelchair, for the last 6 months and
each planned duration of use.
E1018 Heavy duty shock N Review Member Services N/A Documentation DME37
abosorber for heavy Required Fax 1-888-606-6658 requested: CMN and
duty or extra heavy duty pertinent clinical records
power wheelchair, each for the last 6 months and
planned duration of use.
E1020 Residual limb support N Review Member Services N/A Documentation DME37
system for wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1028 Wheelchair accessory, N Review Member Services N/A Documentation DME37
manual swingaway, Required Fax 1-888-606-6658 requested: CMN and
retractable or removable pertinent clinical records
mounting hardware for for the last 6 months and
joystick, other control planned duration of use.
interface or positioning
accessory
E1029 Wheelchair accessory, N N N/A N/A N/A DME37
ventilator tray, fixed
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 72 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1031 Rollabout chair N Review Corr Pool N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1035 Multi-positional patient N N N/A N/A N/A DME23
transfer system, with (05-2008)
intergrated seat,
operated by a care giver
E1037 Transport chair, N Review Medical Services Medical Documentation DME37
pediatric size Required Fax 1-800-453-4341 Necessity requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1038 Transport chair, adult N Review Medical Services Medical Documentation DME37
size, patient weight Required Fax 1-800-453-4341 Necessity requested: CMN and
capacity less than 250 pertinent clinical records
pounds for the last 6 months and
planned duration of use.
E1039 Transport chair, adult N Review Medical Services Medical Documentation DME37
size, heavy duty, patient Required Fax 1-800-453-4341 Necessity requested: CMN and
weight capacity 250 pertinent clinical records
pounds or greater for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 73 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1050 Fully reclining N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1060 Fully reclining N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1065 Wheelchair power N Review Member Services N/A Documentation DME37
attachment Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1070 Fully reclining N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1083 Hemi-wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1084 Hemi-wheelchair N N N/A N/A N/A DME37
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 74 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1085 Hemi-wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1086 Hemi-wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1087 High-strength N Review Member Services N/A Documentation DME37
lightweight wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1088 High-strength N Review Member Services N/A Documentation DME37
lightweight wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1089 High-strength N Review Member Services N/A Documentation DME37
lightweight wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 75 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1090 High-strength N Review Member Services N/A Documentation DME37
lightweight wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1091 Youth wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1092 Wide, heavy-duty N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1093 Wide, heavy-duty N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1100 Semi-reclining N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 76 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1110 Semi-reclining N Review Member Services N/A Documentation DME37
wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1130 Standard wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1140 Wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1150 Wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1160 Wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 77 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1161 Manual adult size N Review Medical Services Medical Documentation DME37
wheelchair Required Fax 1-800-453-4341 Necessity requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1170 Amputee wheelchair; N Review Member Services N/A Documentation DME37
fixed arm, leg rest Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1171 Amputee wheelchair; N Review Member Services N/A Documentation DME37
without leg rest Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1172 Amputee wheelchair; N Review Member Services N/A Documentation DME37
detach arm Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1180 Amputee wheelchair; N Review Member Services N/A Documentation DME37
with foot rest Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1190 Amputee wheelchair; N Review Member Services N/A Documentation DME37
with leg rest Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 78 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1195 Amputee wheelchair; N Review Member Services N/A Documentation DME37
heavy duty Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1200 Amputee wheelchair; N Review Member Services N/A Documentation DME37
fixed arm Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months.
E1220 Wheelchair, special size N Review Medical Services Medical Documentation DME37
Required Fax 1-800-453-4341 Necessity requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1221 Wheelchair, special size N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1222 Wheelchair, special size N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1223 Wheelchair with N Review Member Services N/A Documentation DME37
detachable arms; foot Required Fax 1-888-606-6658 requested: CMN and
rests pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 79 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1224 Wheelchair, special size N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1225 Semi-reclining back for N Review Member Services N/A Documentation DME37
custom wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1226 Ful reclining back for N Review Member Services N/A Documentation DME37
custom wheelchair Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1227 Special height arms N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1228 Special back height N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 80 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1229 Wheelchair, pediatric N Review Medical Services Unlisted Unlisted Code. Submit DME37,
size, NOS Required Fax 1-800-453-4341 Code documentation to DME73
describe service.
Unlisted codes may be
used for potentially
investigational or
potentially cosmetic
services and are subject
to review.
E1230 Power operated vehicle N Review Medical Services Medical Review for medical DME24,
Required Fax 1-800-453-4341 Necessity necessity, DME73
documentation required.
Submit the medical and
treatment history for the
service and/or diagnosis
E1231 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size 10-2008 requested: CMN and DME73
pertinent clinical records
for the last 6 months and
planned duration of use.
E1232 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size 10-2008 requested: CMN and DME73
pertinent clinical records
for the last 6 months and
planned duration of use.
E1233 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size, tilt-in-space, rigid, 10-2008 requested: CMN and DME73
adjustable, without pertinent clinical records
seating system for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 81 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1234 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size 10-2008 requested: CMN and DME73
pertinent clinical records
for the last 6 months and
planned duration of use.
E1235 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size, ridgid, adjustable, 10-2008 requested: CMN and DME73
with seating system pertinent clinical records
for the last 6 months and
planned duration of use.
E1236 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size, folding, adjustable, 10-2008 requested: CMN and DME73
with seating system pertinent clinical records
for the last 6 months and
planned duration of use.
E1237 Wheelchair, pediatric N N N/A Edit Removed Documentation DME37,
size, rigid, adjustable, 10-2008 requested: CMN and DME73
without seating system pertinent clinical records
for the last 6 months and
planned duration of use.
E1238 Wheelchair pediatric N N N/A Edit Removed Documentation DME37,
size, folding, adjustable, 10-2008 requested: CMN and DME73
without seating system pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 82 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1239 Power wheelchair, N Review Medical Services Medical Documentation DME37
pediatric size, not Required Fax 1-800-453-4341 Necessity requested: CMN and
otherwise specified pertinent clinical records
for the last 6 months and
planned duration of use.
E1240 Lightweight wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1250 Lightweight wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1260 Lightweight wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1270 Lightweight wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 83 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1280 Heavy duty wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1285 Heavy duty wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1290 Heavy durty wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1295 Heavy duty wheelchair N Review Member Services N/A Documentation DME37
Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1296 Special wheelchair seat N Review Member Services N/A Documentation DME37
height Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 84 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1297 Special wheelchair seat N Review Member Services N/A Documentation DME37
depth Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E1298 Special wheelchair seat N Review Member Services N/A Documentation DME37
depth or width by Required Fax 1-888-606-6658 requested: CMN and
construction pertinent clinical records
for the last 6 months and
planned duration of use.
E1340 Repair or nonroutine N Review Member Services Benefit Documentation
service for durable Required Fax 1-888-606-6658 requested: CMN and
medical equipment pertinent clinical records
requiring the skill of a for the last 6 months and
technician, labor planned duration of use.
component, per 15
minutes
E1353 Regulator N N N/A Edit Removed Documentation DME22
03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, including O2
saturation levels,
treatment plan and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 85 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1355 Stand / rack N N N/A Edit Removed Documentation DME22
03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, including O2
saturation levels,
treatment plan and
planned duration of use.
E1372 Immersion external N N N/A Edit Removed Documentation DME22
heater for nebulizer 03-2003 requested: Clinical (08-2008)
records pertinent to
diagnosis, including O2
saturation levels,
treatment plan and
planned duration of use.
E1390 Oxygen concentrator, N N N/A Edit Removed Documentation DME22
capable of delivering 65 03-2003 requested: Clinical (08-2008)
percent or greater records pertinent to
oxygen concentration at diagnosis, including O2
the prescribed flow rate saturation levels,
treatment plan and
planned duration of use.
E1391 Oxygen concentrator, N N N/A N/A N/A DME22
dual delivery port, (08-2008)
capable of delivering 85
percent or greater
oxygen concentration at
the prescribed flow rate
E1392 Portable oxygen N N N/A N/A N/A DME22
concentrator, rental (08-2008)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 86 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1399 Durable medical N Review Member Services Unlisted Description of DME DME1, DME53
equipment (DME), misc. Required Fax 1-888-606-6658 Code requested on billing. DME5 (06-2004),
DME37, DME59
DME65, (07-2006)
DME74,
MED79,
SUR122,
SUR134
E1405 Oxygen and water vapor N N N/A N/A N/A DME22
enriching system with (08-2008)
heated delivery
E1406 Oxygen and water vapor N N N/A N/A N/A DME22
enriching system without (08-2008)
heated delivery
E1500 Centrifuge, for dialysis N N N/A N/A N/A MED126
E1510 Kidney, dialysate N N N/A N/A N/A MED126
delivery system kidney
machine
E1520 Heparin infusion pump N N N/A N/A N/A MED126
for hemodialysis
E1530 Air bubble detector for N N N/A N/A N/A MED126
hemodialysis, each,
replacement
E1540 Pressure alarm for N N N/A N/A N/A MED126
hemodialysis, each,
replacement
E1550 Bath conductivity meter N N N/A N/A N/A MED126
for hemodialysis, each
E1560 Blood leak detector for N N N/A N/A N/A MED126
hemodialysis, each,
replacement
E1570 Adjustable chair, for N N N/A N/A N/A MED126
ESRD patients
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 87 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1575 Transducer protectors / N N N/A N/A N/A MED126
fluid barriers, for
hemodialysis, any size,
per 10
E1580 Unipuncture control N N N/A N/A N/A MED126
system for hemodialysis
E1590 Hemodialysis machine N N N/A N/A N/A MED126
E1600 Delivery osmosis water N N N/A N/A N/A MED126
purification system, for
hemodialysis
E1610 Reverse osmosis water N N N/A N/A N/A MED126
purification system, for
hemodialysis
E1620 Blood pump for N N N/A N/A N/A MED126
hemodialysis,
replacement
E1625 Water softening system, N N N/A N/A N/A MED126
for hemodialysis
E1635 Compact (portable) N N N/A N/A N/A MED126
travel hemodialyzer
system
E1636 Sorbent cartridge for N N N/A N/A N/A MED126
hemodialysis, per 10
E1637 Hemostats, each N N N/A N/A N/A MED126
E1639 Scale, each N N N/A N/A N/A MED126
E1699 Dialysis equipment, not N Review Member Services N/A Description of DME MED126
otherwise specified Required Fax 1-888-606-6658 requested on billing.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 88 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1700 Jaw motion N N N/A Edit Removed May not be a covered
rehabilitation system 09-2008 benefit. Need clinical
records pertinent to
diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E1701 Replacement cushions N N N/A Edit Removed May not be a covered
for jaw motion 09-2008 benefit. Need clinical
rehabilitation system, records pertinent to
package of six diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
E1702 Replacement measuring N N N/A Edit Removed May not be a covered
scales for jaw motion 09-2008 benefit. Need clinical
rehabilitation system, records pertinent to
package of 200 diagnosis, treatment
plan and planned
duration of use. If
HealthSense 65
member would need
Certificate of Medical
Necessity.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 89 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1800 Dynamic adjustable N N N/A Edit Removed Documentation DME9
elbow extension / flexion 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1801 Bi-directional static N N N/A Edit Removed Documentation DME9
progressive stretch 11-2008 requested: CMN (if (02-2007)
elbow HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1802 Dynamic adjustable N N N/A Edit Removed Documentation DME9
forearm pronation / 11-2008 requested: CMN (if (02-2007)
supination HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1805 Dynamic adjustable N N N/A Edit Removed Documentation DME9
wrist extension / flexion 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 90 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1806 Bi-directional static N N N/A Edit Removed Documentation DME9
progressive stretch wrist 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1810 Dynamic adjustable N N N/A Edit Removed Documentation DME9
knee extension / flexion 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1811 Bi-directional N N N/A Edit Removed Documentation DME9
progressive strech knee 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1812 Dynamic knee, N N N/A Edit Removed Documentation DME9
extension/flexion device 01-2007 requested: CMN (if (02-2007)
with active resistance HS65) and pertinent
control clinical records for the
current illness/injury and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 91 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1815 Dynamic adjustable N N N/A Edit Removed Documentation DME9
ankle extension 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1816 Bi-directional static N N N/A Edit Removed Documentation DME9
progressive stretch 11-2008 requested: CMN (if (02-2007)
ankle HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1818 Bi-directional static N N N/A Edit Removed Documentation DME9
progress. stretch 11-2008 requested: CMN (if (02-2007)
forearm HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1820 Replacement soft N N N/A Edit Removed Documentation DME9
interface material, 11-2008 requested: CMN (if (02-2007)
dynamic adjustable HS65) and pertinent
extension clinical records for the
current illness/injury and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 92 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1821 Replacement soft N N N/A Edit Removed Documentation DME9
interface material / cuffs 11-2008 requested: CMN (if (02-2007)
for bi-directional static HS65) and pertinent
progressive stretch clinical records for the
device current illness/injury and
planned duration of use.
E1825 Dynamic adjustable N N N/A Edit Removed Documentation DME9
finger extension 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1830 Dynamic adjustable toe N N N/A Edit Removed Documentation DME9
extension 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
E1840 Dynamic adjustable N N N/A Edit Removed Documentation DME9
shoulder flexion 11-2008 requested: CMN (if (02-2007)
HS65) and pertinent
clinical records for the
current illness/injury and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 93 of 908
Regence Clinical Edits by Code List
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E1841 Multi-directional static N N N/A Edit Removed Documentation DME9
progressive stretch 11-2008 requested: CMN (if (02-2007)
shoulder device, with HS65) and pertinent
range of motion clinical records for the
adjustability, includes current illness/injury and
cuffs planned duration of use.
E1902 Communication board, N Review Member Services Medical Documentation
non-electric Required Fax 1-888-606-6658 Necessity requested: CMN (if
augementative or HS65) and pertinent
alternative clinical records for the
communication device last 6 months and
planned duration of use.
E2100 Blood glucose monitor N Review Member Services N/A May not be a covered
with intergrated voice Required Fax 1-888-606-6658 benefit. Need clinical
synthesizer records pertinent to
diagnosis, treatment
plan and planned
duration of use.
E2101 Blood glucose monitor N Review Member Services N/A May not be a covered
with intergrated lancing / Required Fax 1-888-606-6658 benefit. Need clinical
blood sample records pertinent to
diagnosis, treatment
plan and planned
duration of use.
E2120 Pulse generator system N N N/A Investigational Considered DME64
Denial investigational;
investigational services
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 94 of 908
Regence Clinical Edits by Code List
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2201 Manual wheelchair (w/c) N Review Member Services N/A Documentation DME37
accessory, nonstandard Required Fax 1-888-606-6658 requested: CMN and
seat frame, width pertinent clinical records
greater than or equal to for the last 6 months and
20 inches and less than planned duration of use.
24 inches
E2202 Manual w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat frame Required Fax 1-888-606-6658 requested: CMN and
width, 24-27 inches pertinent clinical records
for the last 6 months and
planned duration of use.
E2203 Manual w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat frame Required Fax 1-888-606-6658 requested: CMN and
depth, 20 to less than 22 pertinent clinical records
inches for the last 6 months and
planned duration of use.
E2204 Manual w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat frame Required Fax 1-888-606-6658 requested: CMN and
depth, 22 to 25 inches pertinent clinical records
for the last 6 months and
planned duration of use.
E2205 Manual w/c acessory, N Review Member Services N/A Documentation DME37
heanrim without Required Fax 1-888-606-6658 requested: CMN and
projections, any type, pertinent clinical records
replacement only, each for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 95 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2206 Manual w/c accessory, N Review Member Services N/A Documentation DME37
wheel lock assembly, Required Fax 1-888-606-6658 requested: CMN and
complete, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2207 Wheelchair accessory, N N N/A N/A N/A DME37
crutch and cane holder,
each
E2208 Wheelchair accessory, N N N/A N/A N/A DME37
cylinder tank carrier,
each
E2209 Wheelchair accessory, N N N/A N/A N/A DME37
arm trough, each
E2210 Wheelchair accessory, N N N/A N/A N/A DME37
bearings, any type,
replacement only, each
E2211 Manual wheelchair N N N/A N/A N/A DME37
accessory, pneumatic
propulsion tire, any size,
each
E2212 Manual wheelchair N N N/A N/A N/A DME37
accessory, tube for
pneumatic propulsion
tire, any size, each
E2213 Manual wheelchair N N N/A N/A N/A DME37
accessory, insert for
pneumatic propulsion
tire (removable) any
type, any size, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 96 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2214 Manual wheelchair N N N/A N/A N/A DME37
accessory, pneumatic
caster tire, any size,
each
E2215 Manual wheelchair N N N/A N/A N/A DME37
accessory, tube for
pneumatic caster tire,
any size, each
E2216 Manual wheelchair N N N/A N/A N/A DME37
accessory, foam filled
propulsion tire, any size,
each
E2217 Manual wheelchair N N N/A N/A N/A DME37
accessory, foam filled
caster tire, any size,
each
E2218 Manual wheelchair N N N/A N/A N/A DME37
accessory, foam
propulsion tire, any size,
each
E2219 Manual wheelchair N N N/A N/A N/A DME37
accessory, foam caster
tire, any size, each
E2220 Manual wheelchair N N N/A N/A N/A DME37
accessory, solid
(rubber/plastic)
propulsion tire, any size,
each
E2221 Manual wheelchair N N N/A N/A N/A DME37
accessory, solid
(rubber/plastic) caster
tire (removable), any
size, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 97 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2222 Manual wheelchair N N N/A N/A N/A DME37
accessory, solid
(rubber/plastic) caster
tire with integrated
wheel, any size, each
E2223 Manual wheelchair N N N/A N/A N/A DME37
accessory, valve, any
type, replacement only,
each
E2224 Manual wheelchair N N N/A N/A N/A DME37
accessory, propulsion
wheel excludes tire, any
size, each
E2225 Manual wheelchair N N N/A N/A N/A DME37
accessory, caster wheel
excludes tire, any size,
replacement only, each
E2226 Manual wheelchair N N N/A N/A N/A DME37
accessory, caster fork,
any size, replacement
only, each
E2227 Manual wheelchair N N N/A N/A N/A DME37
accessory, gear
reduction drive wheel,
each
E2228 Manual wheelchair N N N/A N/A N/A DME37
accessory, wheel
braking system and
lock, complete, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 98 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2291 Back, planar, pediatric N Review Member Services N/A Documentation DME37
size w/c including fixed Required Fax 1-888-606-6658 requested: CMN and
attaching hardware pertinent clinical records
for the last 6 months and
planned duration of use.
E2292 Seat, planar, for N Review Member Services N/A Documentation DME37
pediatric size w/c Required Fax 1-888-606-6658 requested: CMN and
including fixed attaching pertinent clinical records
hardware for the last 6 months and
planned duration of use.
E2293 Back, contoured for N Review Member Services N/A Documentation DME37
pediatric size w/c Required Fax 1-888-606-6658 requested: CMN and
including fixed attaching pertinent clinical records
hardware for the last 6 months and
planned duration of use.
E2294 Seat, contoured for N Review Member Services N/A Documentation DME37
pediatric size w/c Required Fax 1-888-606-6658 requested: CMN and
including fixed attaching pertinent clinical records
hardware for the last 6 months and
planned duration of use.
E2300 Power w/c accessory, N N N/A N/A Considered not DME37
power seat elevation medically necessary.
system Not payable.
E2301 Power w/c accessory, N N N/A N/A Considered not DME37
power seat standing medically necessary.
system Not payable.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 99 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2310 Power w/c accessory, N Review Member Services N/A Documentation DME37
electronic connection Required Fax 1-888-606-6658 requested: CMN and
between w/c controller pertinent clinical records
and 1 or more power for the last 6 months and
seating system motors planned duration of use.
E2311 Power w/c accessory, N Review Member Services N/A Documentation DME37
electronic connection Required Fax 1-888-606-6658 requested: CMN and
between w/c controller pertinent clinical records
and 2 or more power for the last 6 months and
seating system motors planned duration of use.
E2312 Power wheelchair N N N/A N/A N/A DME37
accessory, hand or chin
control interface, mini-
proportional remote
joystick, proportional,
including fixed mounting
hardware
E2313 Power wheelchair N N N/A N/A N/A DME37
accessory, harness for
upgrade to expandable
controller including all
fasteners, connectors
and mounting hardware,
each
E2321 Power w/c accessory N Review Member Services N/A Documentation DME37
hand control interface, Required Fax 1-888-606-6658 requested: CMN and
remote joystick, pertinent clinical records
nonproportional for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 100 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2322 Power w/c accessory N Review Member Services N/A Documentation DME37
hand control interface, Required Fax 1-888-606-6658 requested: CMN and
multiple mechanical pertinent clinical records
switches, for the last 6 months and
nonproportional planned duration of use.
E2323 Power w/c accessory, N Review Member Services N/A Documentation DME37
specialty joystick handle Required Fax 1-888-606-6658 requested: CMN and
for hand control pertinent clinical records
interface, prefabricated for the last 6 months and
planned duration of use.
E2324 Power w/c accessory, N Review Member Services N/A Documentation DME37
chin cup for chin control Required Fax 1-888-606-6658 requested: CMN and
interface pertinent clinical records
for the last 6 months and
planned duration of use.
E2325 Power w/c accessory, N Review Member Services N/A Documentation DME37
sip and puff interface, Required Fax 1-888-606-6658 requested: CMN and
nonproportional pertinent clinical records
for the last 6 months and
planned duration of use.
E2326 Power w/c accessory, N Review Member Services N/A Documentation DME37
breath tube kit for sip Required Fax 1-888-606-6658 requested: CMN and
and puff interface pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 101 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2327 Power w/c accessory, N Review Member Services N/A Documentation DME37
head control interface, Required Fax 1-888-606-6658 requested: CMN and
mechanical, proportional pertinent clinical records
for the last 6 months and
planned duration of use.
E2328 Power w/c accessory, N Review Member Services N/A Documentation DME37
head control or Required Fax 1-888-606-6658 requested: CMN and
extremity control pertinent clinical records
interface for the last 6 months and
planned duration of use.
E2329 Power w/c accessory, N Review Member Services N/A Documentation DME37
head control interface, Required Fax 1-888-606-6658 requested: CMN and
contact switch pertinent clinical records
mechanism, for the last 6 months and
nonproportional planned duration of use.
E2330 Power w/c accessory, N Review Member Services N/A Documentation DME37
head control interface, Required Fax 1-888-606-6658 requested: CMN and
proximity switch pertinent clinical records
mechanism, for the last 6 months and
nonproportional planned duration of use.
E2331 Power w/c accessory, N N N/A N/A Considered not DME37
attendant control, medically necessary.
proportional Not payable.
E2340 Power w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat fram Required Fax 1-888-606-6658 requested: CMN and
width, 20-23 inches pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 102 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2341 Power w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat fram Required Fax 1-888-606-6658 requested: CMN and
width, 24-27 inches pertinent clinical records
for the last 6 months and
planned duration of use.
E2342 Power w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat fram Required Fax 1-888-606-6658 requested: CMN and
depth, 20 or 21 inches pertinent clinical records
for the last 6 months and
planned duration of use.
E2343 Power w/c accessory, N Review Member Services N/A Documentation DME37
nonstandard seat fram Required Fax 1-888-606-6658 requested: CMN and
depth, 22 or 25 inches pertinent clinical records
for the last 6 months and
planned duration of use.
E2351 Power w/c accessory, N Review Member Services N/A Documentation DME37
electronic interface to Required Fax 1-888-606-6658 requested: CMN and
operate speech pertinent clinical records
generating device using for the last 6 months and
power w/c control planned duration of use.
interface
E2360 Power w/c accessory, N Review Member Services N/A Documentation DME37
22 NF non-sealed lead Required Fax 1-888-606-6658 requested: CMN and
acid battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 103 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2361 Power w/c accessory, N Review Member Services N/A Documentation DME37
22 NF sealed lead acid Required Fax 1-888-606-6658 requested: CMN and
battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2362 Power w/c accessory, N Review Member Services N/A Documentation DME37
group 24 non-sealed Required Fax 1-888-606-6658 requested: CMN and
lead acid battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2363 Power w/c accessory, N Review Member Services N/A Documentation DME37
group 24 sealed lead Required Fax 1-888-606-6658 requested: CMN and
acid battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2364 Power w/c accessory, U- N Review Member Services N/A Documentation DME37
1 non-sealed lead acid Required Fax 1-888-606-6658 requested: CMN and
battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2365 Power w/c accessory, U- N Review Member Services N/A Documentation DME37
1 sealed lead acid Required Fax 1-888-606-6658 requested: CMN and
battery, each pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 104 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2366 Power w/c accessory, N Review Member Services N/A Documentation DME37
battery charger, single Required Fax 1-888-606-6658 requested: CMN and
mode, for use w/ only pertinent clinical records
one battery type, sealed for the last 6 months and
or non-sealed planned duration of use.
E2367 Power w/c accessory, N Review Member Services N/A Documentation DME37
battery charger, dual Required Fax 1-888-606-6658 requested: CMN and
mode, for use w/ either pertinent clinical records
battery type, sealed or for the last 6 months and
non-sealed, each planned duration of use.
E2368 Power w/c component, N Review Member Services N/A Documentation DME37
motor, replacement only Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2369 Power w/c component, N Review Member Services N/A Documentation DME37
gear box, replacement Required Fax 1-888-606-6658 requested: CMN and
only pertinent clinical records
for the last 6 months and
planned duration of use.
E2370 Power w/c component, N Review Member Services N/A Documentation DME37
motor and gear box Required Fax 1-888-606-6658 requested: CMN and
combination, pertinent clinical records
replacement only for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 105 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2371 Gr27 sealed leadacid N Review Member Services N/A Documentation DME37
battery Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2372 Gr27 non-sealed N Review Member Services N/A Documentation DME37
leadacid battery Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2373 Power wheelchair N N N/A N/A N/A DME37
accessory, hand or chin
control interface, mini-
proportional, compact,
or short throw remote
joystick or touchpad,
proportional, including
all related electronics
and fixed mounting
hardware
E2374 Power wheelchair N N N/A N/A N/A DME37
accessory, hand or chin
control interface,
standard remote joystick
(not including controller),
proportional, including
all related electronics
and fixed mounting
hardware, replacement
only
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 106 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2375 Power wheelchair N N N/A N/A N/A DME37
accessory, non-
expandable controller,
including all related
electronics and
mounting hardware,
replacement only
E2376 Power wheelchair N N N/A N/A N/A DME37
accessory, expandable
controller, including all
related electronics and
mounting hardware,
replacement only
E2377 Power wheelchair N N N/A N/A N/A DME37
accessory, expandable
controller, including all
related electronics and
mounting hardware,
upgrade provided at
initial issue
E2381 Power wheelchair N N Member Services N/A N/A DME37
accessory, pneumatic Fax 1-888-606-6658
drive wheel tire, any
size, replacement only,
each
E2382 Power wheelchair N N Member Services N/A N/A DME37
accessory, tube for Fax 1-888-606-6658
pneumatic drive wheel
tire, any size,
replacement only, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 107 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2383 Power wheelchair N N Member Services N/A N/A DME37
accessory, insert for Fax 1-888-606-6658
pneumatic drive wheel
tire (removable), any
type, any size,
replacement only, each
E2384 Power wheelchair N N Member Services N/A N/A DME37
accessory, pneumatic Fax 1-888-606-6658
caster tire, any size,
replacement only, each
E2385 Power wheelchair N N Member Services N/A N/A DME37
accessory, tube for Fax 1-888-606-6658
pneumatic caster tire,
any size, replacement
only, each
E2386 Power wheelchair N N Member Services N/A N/A DME37
accessory, foam filled Fax 1-888-606-6658
drive wheel tire, any
size, replacement only,
each
E2387 Power wheelchair N N Member Services N/A N/A DME37
accessory, foam filled Fax 1-888-606-6658
caster tire, any size,
replacement only, each
E2388 Power wheelchair N N Member Services N/A N/A DME37
accessory, foam drive Fax 1-888-606-6658
wheel tire, any size,
replacement only, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 108 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2389 Power wheelchair N N Member Services N/A N/A DME37
accessory, foam caster Fax 1-888-606-6658
tire, any size,
replacement only, each
E2390 Power wheelchair N N Member Services N/A N/A DME37
accessory, solid Fax 1-888-606-6658
(rubber/plastic) drive
wheel tire, any size,
replacement only, each
E2391 Power wheelchair N N Member Services N/A N/A DME37
accessory, solid Fax 1-888-606-6658
(rubber/plastic) caster
tire (removable), any
size, replacement only,
each
E2392 Power wheelchair N N Member Services N/A N/A DME37
accessory, solid Fax 1-888-606-6658
(rubber/plastic) caster
tire with integrated
wheel, any size,
replacement only, each
E2393 Power wheelchair N N Member Services N/A N/A DME37
accessory, valve for Fax 1-888-606-6658
pneumatic tire tube, any
type, replacement only,
each
E2394 Power wheelchair N N Member Services N/A N/A DME37
accessory, drive wheel Fax 1-888-606-6658
excludes tire, any size,
replacement only, each
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 109 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2395 Power wheelchair N N Member Services N/A N/A DME37
accessory, caster wheel Fax 1-888-606-6658
excludes tire, any size,
replacement only, each
E2396 Power wheelchair N N Member Services N/A N/A DME37
accessory, caster fork, Fax 1-888-606-6658
any size, replacement
only, each
E2397 Power wheelchair N N N/A N/A N/A DME37
accessory, lithium-
based battery, each
E2399 Power w/c accessory, N Review Member Services N/A Documentation DME37
NOC, interface Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2402 Neg pressure wound N N N/A Edit Removed Documentation DME42
therapy electric pump 09-2008 requested: Need (08-2008)
medical records
pertinent to diagnosis,
treatment plan for
review.
E2500 Speech generating N Review Medical Services Medical Review for medical DME52
device, digitized speech Required Fax 1-800-453-4341 Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 110 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2502 Speech generating N Review Medical Services Medical Review for medical DME52
device, digitized speech Required Fax 1-800-453-4341 Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2504 Speech generating N Review Medical Services Medical Review for medical DME52
device, digitized speech Required Fax 1-800-453-4341 Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2506 Speech generating N Review Medical Services Medical Review for medical DME52
device, digitized speech Required Fax 1-800-453-4341 Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2508 Speech generating N Review Medical Services Medical Review for medical DME52
device, synthesize Required Fax 1-800-453-4341 Necessity necessity,
speech documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 111 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2510 Speech generating N Review Medical Services Medical Review for medical DME52
device, synthesize Required Fax 1-800-453-4341 Necessity necessity,
speech documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2511 Speech generating N Review Medical Services Medical Review for medical DME52
software program Required Fax 1-800-453-4341 Necessity necessity,
documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2512 Mounting system N Review Medical Services Medical Review for medical DME52
accessory - speech Required Fax 1-800-453-4341 Necessity necessity,
device documentation required.
Submit the medical and
treatment history for the
service and / or
diagnosis.
E2599 Speech generating N Review Member Services Unlisted Operative report DME52
device accessory, NOC Required Fax 1-888-606-6658 Code required.
E2601 General use w/c seat N Review Member Services N/A Documentation DME37
cushion, width less than Required Fax 1-888-606-6658 requested: CMN and
22 in., any depth pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 112 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2602 General use w/c seat N Review Member Services N/A Documentation DME37
cushion, width 22 in. or Required Fax 1-888-606-6658 requested: CMN and
greater, any depth pertinent clinical records
for the last 6 months and
planned duration of use.
E2603 Skin protection w/c seat N Review Member Services N/A Documentation DME37
cushion, width less than Required Fax 1-888-606-6658 requested: CMN and
22 in., any depth pertinent clinical records
for the last 6 months and
planned duration of use.
E2604 Skin protection w/c seat N Review Member Services N/A Documentation DME37
cushion, width 22 in. or Required Fax 1-888-606-6658 requested: CMN and
greater, any depth pertinent clinical records
for the last 6 months and
planned duration of use.
E2605 Positioning w/c seat N Review Member Services N/A Documentation DME37
cushion, width less than Required Fax 1-888-606-6658 requested: CMN and
22 in. any depth pertinent clinical records
for the last 6 months and
planned duration of use.
E2606 Positioning w/c seat N Review Member Services N/A Documentation DME37
cushion, width less than Required Fax 1-888-606-6658 requested: CMN and
22 in. any depth pertinent clinical records
for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 113 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2607 Skin protection and N Review Member Services N/A Documentation DME37
positioning w/c seat Required Fax 1-888-606-6658 requested: CMN and
cushion, width less than pertinent clinical records
22 in., any depth for the last 6 months and
planned duration of use.
E2608 Skin protection and N Review Member Services N/A Documentation DME37
positioning w/c seat Required Fax 1-888-606-6658 requested: CMN and
cushion, width 22 in., or pertinent clinical records
greater, any depth for the last 6 months and
planned duration of use.
E2609 Custom fabricated w/c N Review Member Services N/A Documentation DME37
seat cushon, any size Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2610 Wheelchair seat N Review Member Services N/A Documentation DME37
cushion, powered Required Fax 1-888-606-6658 requested: CMN and
pertinent clinical records
for the last 6 months and
planned duration of use.
E2611 General use w/c back N Review Member Services N/A Documentation DME37
cushion, width less than Required Fax 1-888-606-6658 requested: CMN and
22 in., any height, pertinent clinical records
including any type for the last 6 months and
mounting hardware planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 114 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2613 General use w/c back N Review Member Services N/A Documentation DME37
cushion, width 22 in. or Required Fax 1-888-606-6658 requested: CMN and
greater, any height, pertinent clinical records
including any type for the last 6 months and
mounting hardware planned duration of use.
E2614 Positioning w/c back N Review Member Services N/A Documentation DME37
cushion, posterior, width Required Fax 1-888-606-6658 requested: CMN and
22 in. or greater, any pertinent clinical records
height, including any for the last 6 months and
type mounting hardware planned duration of use.
E2615 Positioning w/c back N Review Member Services N/A Documentation DME37
cushion, posterior- Required Fax 1-888-606-6658 requested: CMN and
lateral, width less than pertinent clinical records
22 in., any height for the last 6 months and
including any type planned duration of use.
mounting hardware
E2616 Positioning w/c back N Review Member Services N/A Documentation DME37
cushion, posterior- Required Fax 1-888-606-6658 requested: CMN and
lateral, width 22 in. or pertinent clinical records
greater, any height for the last 6 months and
including any type planned duration of use.
mounting hardware
E2617 Custom fabricated w/c N Review Member Services N/A Documentation DME37
back cushion, any size, Required Fax 1-888-606-6658 requested: CMN and
including any type pertinent clinical records
mounting hardware for the last 6 months and
planned duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 115 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E2618 Wheelchair accessory, N N N/A N/A N/A DME37
Code solid seat support base
deleted (replaces sling seat)
12/31/20
07
E2619 Repalcement cover for N Review Member Services N/A Documentation DME37
w/c seat cushion or Required Fax 1-888-606-6658 requested: CMN and
back cushion, each pertinent clinical records
for the last 6 months and
planned duration of use.
E2620 Positioning w/c back N Review Member Services N/A Documentation DME37
cushion, planar back Required Fax 1-888-606-6658 requested: CMN and
with lateral supports, pertinent clinical records
width less than 22 in., for the last 6 months and
any height, including any planned duration of use.
type mounting hardware
E2621 Positioning w/c back N Review Member Services N/A Documentation DME37
cushion, planar back Required Fax 1-888-606-6658 requested: CMN and
with lateral supports, pertinent clinical records
width 22 in. or greater, for the last 6 months and
any height, including any planned duration of use.
type mounting hardware
E8000 Gait trainer, pediatric N N N/A Edit Removed May be considered DME72
size, posterior support, 10-2008 medically necessary.
includes all accessories Need history and
and components physical pertinent to
diagnosis and treatment
plan.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 116 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
E8001 Gait trainer, pediatric N N N/A Edit Removed May be considered DME72
size, upright support, 10-2008 medically necessary.
includes all accessories Need history and
and components physical pertinent to
diagnosis and treatment
plan.
E8002 Gait trainer, pediatric N N N/A Edit Removed May be considered DME72
size, anterior support, 10-2008 medically necessary.
includes all accessories Need history and
and components physical pertinent to
diagnosis and treatment
plan.
G0008 Admin influenza virus N N N/A Edit Removed Call Customer Service
vac 01-2005 to verify benefit
information at 1-866-699-
8170
G0009 Admin pneumococcal N N N/A Edit Removed Call Customer Service
vaccine 01-2005 to verify benefit
information at 1-866-699-
8170
G0010 Admin hepatitis b N N N/A Edit Removed Call Customer Service
vaccine 01-2005 to verify benefit
information at 1-866-699-
8170
G0108 Diab manage trn per N N N/A Edit Removed May not be a covered
individual 01-2005 benefit. Refer to
benefits. May require
chart notes for program.
G0109 Diab manage trn N N N/A Edit Removed May not be a covered
ind/group 01-2005 benefit. Refer to
benefits. May require
chart notes for program.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 117 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0127 Trimming of dystophic N N N/A Edit Removed Call Customer Service SUR89
nails 01-2005 to verify benefit (10-2008)
information at 1-866-699-
8170
G0129 Occupational therapy, N N N/A N/A N/A UM04
part hosp tx program
G0130 Single energy x-ray N N N/A N/A N/A RAD2
study (11-2008)
G0151 Services of physical N N N/A N/A N/A UM04, UM06
therpist in home health
setting
G0152 Services of occupational N N N/A N/A N/A UM02, UM04
therapist in home health
setting
G0153 Services of speech and N N N/A N/A N/A UM02, UM09
language pathologist in
home health setting
G0154 Services of skilled nurse N N N/A N/A N/A UM02
in home health setting
G0155 Services of clinical N N N/A N/A N/A UM02
social worker in home
health setting
G0156 Services of home health N N N/A N/A N/A UM02
aide in home health
setting
G0166 External N N N/A Investigational Considered MED66
counterpulsation, per Denial investigational;
treatment investigational services
are not covered.
G0173 Linear acc stereo radsur N Review Medical Services Potential Review with a copy of SUR16
com Required Fax 1-800-453-4341 Investigational operative report and
prior treatment history.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 118 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0175 OPPS Service,sched N N N/A Regence Not considered a
team conf Invalid payable service. Will be
denied provider write-off.
G0176 OPPS/PHP; activity N N N/A N/A N/A
therapy
G0177 OPPS/PHP; train & N N N/A Regence Not considered a
education service Invalid payable service. Will be
denied provider write-off.
G0179 MD recertification HHA N N N/A Regence Considered an
PT Invalid administrative fee, not
payable.
G0180 MD certification HHA N N N/A Regence Considered an
patient Invalid administrative fee, not
payable.
G0181 Home health care N N N/A Regence Considered an
supervision Invalid administrative fee, not
payable.
G0182 Hospice care N N N/A Regence Not considered a
supervision Invalid payable benefit of any
member policies.
G0186 Destruction of localized N N N/A Edit Removed Documentation
lesion of choroid 06-2008 requested: Need
medical records
pertinent to diagnosis
and treatment plan.
G0202 Screening N N N/A Edit Removed Considered RAD39
mammography, 08-2003 investigational;
producing direct digital investigational services
image, bilateral, all are not covered.
views
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 119 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0204 Diagnositic N N N/A Edit Removed Considered RAD39
mammography, 08-2003 investigational;
producing direct digital investigational services
image, bilateral, all are not covered.
views
G0206 Diagnositic N N N/A Edit Removed Considered RAD39
mammography, 08-2003 investigational;
producing direct digital investigational services
image, unilateral, all are not covered.
views
G0235 PET not otherwise N Review Medical Services Potential Documentation RAD14,
specified Required Fax 1-800-453-4341 Investigational requested: Need RAD34,
medical records RAD35
pertinent to diagnosis
and x-ray report.
G0237 Therapeutic procedures N N N/A N/A N/A UM07
to increase strength or
endurance of respiratory
muscles, face-to-face,
one-on-one
G0238 Colorectal cancer N N N/A N/A N/A UM07
screening; fecal occult
blood test,
immunoassay, 1-3
simultaneous
G0239 Therapeutic N N N/A N/A N/A UM07
proceduresto improve
respiratory function or
increase strength or
endurance of respiratory
muscles, two or more
individuals
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 120 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0248 Demonstrate use home N N N/A Edit Removed Documentation DME44
inr mon 01-2007 requested: Need clinical
records pertinent to
diagnosis and treatment
plan.
G0249 Provide test material N N N/A Edit Removed Documentation DME44
equipment 01-2007 requested: Need clinical
records pertinent to
diagnosis and treatment
plan.
G0250 MD review interpret of N N N/A Edit Removed Documentation DME44
test 01-2007 requested: Need clinical
records pertinent to
diagnosis and treatment
plan.
G0251 Linear accelerator N Review Medical Services Potential Review with a copy of SUR16
based sterotactic radio Required Fax 1-800-453-4341 Investigational operative report and
prior treatment history.
G0255 Current percep N N N/A Investigational Considered MED91
threshold test Denial investigational;
investigational services
are not covered.
G0256 Prostate brachytherapy N N N/A N/A N/A MED58
using permanently
implanted Palladium
seeds
G0261 Prostate brachytherapy N N N/A N/A N/A MED58
using permanently
implanted iodine seeds
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 121 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0265 Cryopresevation N N N/A Edit Removed Documentation TRA35,
Code Freeze+stora 01-2008 requested: Need clinical TRA40
deleted records pertinent to
12/31/20 diagnosis and treatment
07 plan.
G0266 Thawing + expansion N N N/A Edit Removed Documentation TRA35,
Code frozen cell 01-2008 requested: Need clinical TRA40
deleted records pertinent to
12/31/20 diagnosis and treatment
07 plan.
G0267 Bone marrow or N N N/A Edit Removed Documentation TRA22,
Code peripheral stem cell 01-2008 requested: Need history TRA23.
deleted harvest and physical, letter of TRA24,
12/31/20 medical necessity and TRA25,
07 transplant evaluation. TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
G0268 Removal of impacted N N N/A Edit Removed Not considered a
wax md 11-2007 payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 122 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0269 Placement of occlusive N N N/A Regence Status B; Considered
device into either a Invalid incidental to other
venous or arterial billable services, not
access payable.
G0281 Electrical stimulation N N N/A Investigational Considered DME67
(unattend) for pressure Denial investigational;
investigational services
are not covered.
G0282 Electrical stimulation N N N/A Investigational Considered DME67
wound care other than Denial investigational;
described in G0281 investigational services
are not covered.
G0283 Electrical stimulation N N N/A Edit Removed Considered DME11,
other than wound 05-2003 investigational; DME66
investigational services
are not covered.
G0293 Non-cov proc, clinical N N N/A Regence Not considered a
trial Invalid payable service. Will be
denied provider write-off.
G0294 Electromagnetic therapy N N N/A Regence Not considered a
onc Invalid payable service. Will be
denied provider write-off.
G0295 Electomagnetic N N N/A Investigational Considered AH4, DME67
stimulation, to one or Denial investigational;
more areas investigational services
are not covered.
G0297 Insertion of single N N N/A N/A N/A MED75
Code chamber pacing (08-2008)
deleted cardioverter defibrillator
12/31/20 pulse generator
07
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 123 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0298 Insertion of dual N N N/A N/A N/A MED75
Code chamber pacing (08-2008)
deleted cardioverter defibrilator
12/31/20 pulse generator
07
G0299 Insertion or repositioning N N N/A N/A N/A MED75
Code of electronic lead for (08-2008)
deleted single chamber pacing
12/31/20 cardioverter defibrillator
07 and insertion of pulse
generator
G0300 Insertion or repositioning N N N/A N/A N/A MED75
Code of electronic lead(s) for (08-2008)
deleted dual chamber pacing
12/31/20 cardioverter defibrillator
07 and insertion of pulse
generator
G0302 Pre-op pulmonary N N N/A N/A N/A SUR31
surgery services; min 16 (05-2008),
days MED75
(08-2008)
G0303 Pre-op pulmonary N N N/A N/A N/A SUR31
surgery services; 10-15 (05-2008)
days
G0304 Pre-op pulmonary N N N/A N/A N/A SUR31
surgery services; 1-9 (05-2008)
days
G0305 Post-op pulmonary N N N/A N/A N/A SUR31
surgery services; min 6 (05-2008)
days
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 124 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0328 Fecal blood screening N N N/A Edit Removed Considered LAB38
immunoassay 08-2008 investigational; (08-2008)
investigational services
are not covered.
G0329 Electromagnetic N N N/A Investigational Considered DME67
therapy, to one or more Denial investigational;
arears for chronic stage investigational services
III and stage IV pressure are not covered.
ulcers, arterial ulcers,
diabetic ulcers and
venous stasis ulcers
G0339 Image-guided robotic Preauth Review Medical Services Potential Possibly investigational, SUR16
linear accelerator-based Required Required Fax 1-800-453-4341 Investigational documentation required.
stereotactic radiosurgery Submit operative report
and medical and
treatment history for the
service and/or
diagnosis.
G0340 Image-guided robotic Preauth Review Medical Services Potential Possibly investigational, SUR16
linear accelerator-based Required Required Fax 1-800-453-4341 Investigational documentation required.
sterotactic radiosurgery, Submit operative report
delivery and medical and
treatment history for the
service and/or
diagnosis.
G0341 Percutaneous islet cell Preauth N Medical Services N/A Documentation TRA13
transplant, includes Required Fax 1-800-453-4341 requested: Need history
portal vein catherization and physical, letter of
and infusion medical necessity and
transplant evaluation.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 125 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0342 Laparoscopy for islet Preauth N Medical Services N/A Documentation TRA13
cell transplant, includes Required Fax 1-800-453-4341 requested: Need history
portal vein catherization and physical, letter of
and infusion medical necessity and
transplant evaluation.
G0343 Laparotomy for islet cell Preauth N Medical Services N/A Documentation TRA13
transplant, includes Required Fax 1-800-453-4341 requested: Need history
portal vein catherization and physical, letter of
and infusion medical necessity and
transplant evaluation.
G0377 Administrative Part D N N N/A Edit Removed Not considered a
Code vaccine 07-2008 payable service. Will be
deleted denied provider write-off.
12/31/20
07
G0380 Lev 2 hosp type B ED N N N/A N/A N/A
visit
G0381 Lev 3 hosp type B ED N N N/A N/A N/A
visit
G0382 Lev 4 hosp type B ED N N N/A N/A N/A
visit
G0383 Lev 5 hosp type B ED N N N/A N/A N/A
visit
G0389 Ultrasound B-scan N Review Medical Services Potential Possibly investigational,
and/or real time with Required Fax 1-800-453-4341 Investigational documentation required.
image documentation; Submit operative report
for abdominal aortic and medical and
aneurysm (AAA) treatment history for the
screening service and/or diagnosis
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 126 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G0390 Trauma response team N N N/A N/A N/A
associated with hospital
critical care service
G0392 Transluminal balloon N N N/A N/A N/A SUR119
angioplasty,
percutaneous; for
maintenance of
hemodialysis access,
arteriovenous fistula or
graft; arterial
G0393 Transluminal balloon N N N/A N/A N/A SUR119
angioplasty,
percutaneous; for
maintenance of
hemodialysis access,
arteriovenous fistula or
graft; venous
G0396 Alcohol and/or N N N/A Regence Not considered a
substance (other than Invalid payable service. Will be
tobacco) abuse denied provider write-off.
structured assessment
(e.g., audit, dast), and
brief intervention 15 to
30 minutes
G0397 Alcohol and/or N N N/A Regence Not considered a
substance (other than Invalid payable service. Will be
tobacco) abuse denied provider write-off.
structured assessment
(e.g., audit, dast), and
intervention, greater
than 30 minutes
Effective Date: 11/1/2008
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Code
G3001 Administration and N Review Member Services N/A Call Customer Service
supply of Tositumomab, Required Fax 1-888-606-6658 to verify benefit
450 mg information at 1-866-699-
8170
G0377 Administration part D N N N/A Regence Not considered a
vaccine Invalid payable service. Will be
denied provider write-off.
G8006 Acute myocardial N N N/A Regence Not considered a
infarction: patient Invalid payable service. Will be
documented to have denied provider write-off.
received aspirin at
arrival
G8007 Acute myocardial N N N/A Regence Not considered a
infarction: patient not Invalid payable service. Will be
documented to have denied provider write-off.
received aspirin at
arrival
G8008 Clinician documented N N N/A Regence Not considered a
that acute myocardial Invalid payable service. Will be
infarction patient was denied provider write-off.
not an eligible candidate
to receive aspirin at
arrival measure
G8009 Acute myocardial N N N/A Regence Not considered a
infarction: patient Invalid payable service. Will be
documented to have denied provider write-off.
received beta-blocker at
arrival
Effective Date: 11/1/2008
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Code
G8010 Acute myocardial N N N/A Regence Not considered a
infarction: patient not Invalid payable service. Will be
documented to have denied provider write-off.
received beta-blocker at
arrival
G8011 Clinician documented N N N/A Regence Not considered a
that acute myocardial Invalid payable service. Will be
infarction patient was denied provider write-off.
not an eligible candidate
for beta-blocker at
arrival measure
G8012 Pneumonia: patient N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
received antibiotic within denied provider write-off.
4 hours of presentation
G8013 Pneumonia: patient not N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
received antibiotic within denied provider write-off.
4 hours of presentation
G8014 Clinician documented N N N/A Regence Not considered a
that pneumonia patient Invalid payable service. Will be
was not an eligible denied provider write-off.
candidate for antibiotic
within 4 hours of
presentation measure
G8015 Diabetic patient with N N N/A Regence Not considered a
most recent hemoglobin Invalid payable service. Will be
A1c level (within the last denied provider write-off.
6 months) documented
as greater than 9%
Effective Date: 11/1/2008
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Code
G8016 Diabetic patient with N N N/A Regence Not considered a
most recent hemoglobin Invalid payable service. Will be
A1c level (within the last denied provider write-off.
6 months) documented
as less than or equal to
9%
G8017 Clinician documented N N N/A Regence Not considered a
that diabetic patient was Invalid payable service. Will be
not eligible candidate for denied provider write-off.
hemoglobin A1c
measure
G8018 Clinical has not provided N N N/A Regence Not considered a
care for the diabetic Invalid payable service. Will be
patient for the required denied provider write-off.
time for hemoglobin A1c
measure (6 months)
G8019 Diabetic patient with N N N/A Regence Not considered a
most recent low-density Invalid payable service. Will be
lipoprotein (within the denied provider write-off.
last 12 months)
documented as greater
than or equal to 100
mg/dl
G8020 Diabetic patient with N N N/A Regence Not considered a
most recent low-density Invalid payable service. Will be
lipoprotein (within the denied provider write-off.
last 12 months)
documented as less
than 100 mg/dl
Effective Date: 11/1/2008
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Code
G8021 Clinician documented N N N/A Regence Not considered a
that diabetic patient was Invalid payable service. Will be
not eligible candidate for denied provider write-off.
low-density lipoprotein
measure
G8022 Clinnician has not N N N/A Regence Not considered a
provided care for the Invalid payable service. Will be
diabetic patient for the denied provider write-off.
required time for low-
density lipoprotein
measure (12 months)
G8023 Diabetic patient with N N N/A Regence Not considered a
most recent blood Invalid payable service. Will be
pressure (within the last denied provider write-off.
6 months) documented
as equal to or greater
than 140 systolic or
equal to or greate than
80 mmHg diastolic
G8024 Diabetic patient with N N N/A Regence Not considered a
most recent lood Invalid payable service. Will be
pressure (within the last denied provider write-off.
6 months) documented
less than 140 systolic
and less than 80
diastolic
G8025 Clinician documented N N N/A Regence Not considered a
that the diabetic patient Invalid payable service. Will be
was not eligible denied provider write-off.
candidate for blood
pressure measure
Effective Date: 11/1/2008
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Code
G8026 Clinician has not N N N/A Regence Not considered a
provided care for the Invalid payable service. Will be
diabetic patient for the denied provider write-off.
required time for blood
measure (within the last
6 months)
G8027 Heart failure patient with N N N/A Regence Not considered a
left ventricular systolic Invalid payable service. Will be
dysfunction (LVSD) denied provider write-off.
documented to be on
either angiotensin-
converting enzyme-
inhibitor or angiotensin-
recepor blocker (ACE-I
or ARB) therapy
G8028 Heart failure patient with N N N/A Regence Not considered a
left ventricular systolic Invalid payable service. Will be
dysfunction (LVSD) not denied provider write-off.
documented to be on
either angiotension-
converting enzyme-
inhibitor or angiotensin-
receptor blocker (ACE-I
or ARB) therapy
Effective Date: 11/1/2008
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Code
G8029 Clinician documented N N N/A Regence Not considered a
that heart failure patient Invalid payable service. Will be
was not an eligible denied provider write-off.
candidate for either
angiotensin-converting
enzyme-inhibitor or
angiotensin-receptor
blocker (ACE-I or ARB)
therapy measure
G8030 Heart failure patient with N N N/A Regence Not considered a
left ventricular systolic Invalid payable service. Will be
dysfunction (LVSD) denied provider write-off.
documented to be on
beta-blocker therapy
G8031 Heart failure patient with N N N/A Regence Not considered a
left ventricular systolic Invalid payable service. Will be
dysfunction (LVSD) not denied provider write-off.
documented to be on
beta-blocker therapy
G8032 Clinician documented N N N/A Regence Not considered a
that heart failue patient Invalid payable service. Will be
was not eligible denied provider write-off.
candidate for beta-
blocker therapy
G8033 Prior myocardial N N N/A Regence Not considered a
infarction - coronary Invalid payable service. Will be
artery disease patient denied provider write-off.
documented to be on
beta-blocker therapy
Effective Date: 11/1/2008
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Code
G8034 Prior myocardial N N N/A Regence Not considered a
infarction - coronary Invalid payable service. Will be
artery disease patient denied provider write-off.
not documented to be
on beta-blocker therapy
G8035 Clinician documented N N N/A Regence Not considered a
that prior myocardial Invalid payable service. Will be
infarction - coronary denied provider write-off.
artery disease patient
was not eligible
candidate for beta-
blocker therapy
measure
G8036 Coronary artery disease N N N/A Regence Not considered a
patient documented to Invalid payable service. Will be
be on antiplatelet denied provider write-off.
therapy
G8037 Coronary artery disease N N N/A Regence Not considered a
patient not documented Invalid payable service. Will be
to be on antiplatelet denied provider write-off.
therapy
G8038 Clinician documented N N N/A Regence Not considered a
that coronary artery Invalid payable service. Will be
disease patient was not denied provider write-off.
eligible candidate for
antiplatelet therapy
measure
G8039 Coronary artery disease - N N N/A Regence Not considered a
patient with low-density Invalid payable service. Will be
lipoprotein documented denied provider write-off.
to be greater than 100
mg/dl
Effective Date: 11/1/2008
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Code
G8040 Coronary artery disease - N N N/A Regence Not considered a
patient with low-density Invalid payable service. Will be
lipoprotein documented denied provider write-off.
to be less than or equal
to 100 mg/dl
G8041 Clinician documented N N N/A Regence Not considered a
that coronary artery Invalid payable service. Will be
disease patient was not denied provider write-off.
eligible candidate for low-
density lipoprotein
measure
G8051 Patient (female) N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
been assessed for denied provider write-off.
osteoporosis
G8052 Patient (female) not N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
been assessed for denied provider write-off.
osteoporosis
G8053 Clinician documented N N N/A Regence Not considered a
that (female) patient Invalid payable service. Will be
was not an eligible denied provider write-off.
candidate for
osteoporosis
assessment measure
G8054 Patient not documented N N N/A Regence Not considered a
for the assessment for Invalid payable service. Will be
falls within last 12 denied provider write-off.
months
G8055 Patient documented for N N N/A Regence Not considered a
the assessment for falls Invalid payable service. Will be
within last 12 months denied provider write-off.
Effective Date: 11/1/2008
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Code
G8056 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for the denied provider write-off.
falls assessment
measure within the last
12 months
G8057 Patient documented to N N N/A Regence Not considered a
have received hearing Invalid payable service. Will be
assessment denied provider write-off.
G8058 Patient not documented N N N/A Regence Not considered a
to have received hearing Invalid payable service. Will be
assessment denied provider write-off.
G8059 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
hearing assessment
measure
G8060 Patient documented for N N N/A Regence Not considered a
the assessment of Invalid payable service. Will be
urinary incontinence denied provider write-off.
G8061 Patient not documented N N N/A Regence Not considered a
for the assessment of Invalid payable service. Will be
urinary incontinence denied provider write-off.
G8062 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
urinary incontinence
assessment measure
Effective Date: 11/1/2008
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Code
G8075 End-stage renal disease N N N/A Regence Not considered a
patient with documented Invalid payable service. Will be
dialysis dose of URR denied provider write-off.
greater than or equal to
65% (Kt/V greater than
or equal to 1.2)
G8076 End-stage renal disease N N N/A Regence Not considered a
patient with documented Invalid payable service. Will be
dialysis dose of URR denied provider write-off.
less than 65% (or Kt/V
less than 1.2)
G8077 Clinician documented N N N/A Regence Not considered a
that end-stage renal Invalid payable service. Will be
disease patient was not denied provider write-off.
an eligible candidate for
UR or Kt/V measure
G8078 End-stage renal disease N N N/A Regence Not considered a
patient with documented Invalid payable service. Will be
hematocrit greater than denied provider write-off.
or equal to 33 (or
hemoglobin greater than
or equal to 11)
G8079 End-stage renal disease N N N/A Regence Not considered a
patient with documented Invalid payable service. Will be
hematocrit less than 33 denied provider write-off.
(hemoglobin less than
11)
Effective Date: 11/1/2008
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Code
G8080 Clinician documented N N N/A Regence Not considered a
that end-stage renal Invalid payable service. Will be
disease patient was not denied provider write-off.
an eligible candidate for
hematocrit (hemoglobin)
measure
G8081 End-stage renal disease N N N/A Regence Not considered a
patient requiring Invalid payable service. Will be
hemodialysis vascular denied provider write-off.
access documented to
have received
autogenous AV fistula
G8082 End-stage renal disease N N N/A Regence Not considered a
patient requiring Invalid payable service. Will be
hemodialysis denied provider write-off.
documented to have
received vascular
access other than
autogenous AV fistula
G8085 End-stage renal disease N N N/A Regence Not considered a
patient ineligible Invalid payable service. Will be
autogenous AV fistula denied provider write-off.
G8093 Newly diagnosed N N N/A Regence Not considered a
chronic obstructive Invalid payable service. Will be
pulmonary disease denied provider write-off.
(COPD) patient
documented to have
received smoking
cessation intervention,
within 3 months of
diagnosis
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8094 Newly diagnosed N N N/A Regence Not considered a
chronic obstructive Invalid payable service. Will be
pulmonary disease denied provider write-off.
(COPD) patient not
documented to have
received smoking
cessation intervention,
within 3 months of
diagnosis
G8099 Osteoporosis patient N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
prescribed calcium and denied provider write-off.
vitamin D supplements
G8100 Clinician documented N N N/A Regence Not considered a
that osteoporosis patient Invalid payable service. Will be
was not an eligible denied provider write-off.
candidate for calcium
and vitamin D
supplement measure
G8103 Newly diagnosed N N N/A Regence Not considered a
osteoporosis patients Invalid payable service. Will be
documented to have denied provider write-off.
been treated with
antiresorptive therapy
and/or parathyroid
hormone treatment
within 3 months of
diagnosis
Effective Date: 11/1/2008
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Code
G8104 Clinician documented N N N/A Regence Not considered a
that newly diagnosed Invalid payable service. Will be
osteoporosis patient denied provider write-off.
was not an eligible
candidate for
antiresorptive therapy
and/or parathyroid
hormone treatment
measure within 3
months of diagnosis
G8106 Within 6 months of N N N/A Regence Not considered a
suffering a nontraumatic Invalid payable service. Will be
fracture, female patient denied provider write-off.
65 years of age or older
documented to have
undergone bone mineral
density testing or to
have been prescribed a
drug to treat or prevent
osteoporosis
G8107 Clinician documented N N N/A Regence Not considered a
that female patient 65 Invalid payable service. Will be
years of age or older denied provider write-off.
who suffered a
nontraumatic fracture
within the last 6 months
was not an eligible
candidate for measure
to test bone mineral
density or drug to treat
or prevent osteoporosis
Effective Date: 11/1/2008
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Code
G8108 Patient documented to N N N/A Regence Not considered a
have received influenza Invalid payable service. Will be
vaccination during denied provider write-off.
influenza season
G8109 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
influenza vaccination denied provider write-off.
during influenza season
G8110 Clinician documented N N N/A Regence Not considered a
that patient was not Invalid payable service. Will be
eligible candidate for denied provider write-off.
influenza vaccination
measure
G8111 Patient (female) N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
received a mammogram denied provider write-off.
during the measurement
year or prior year to the
measurement year
G8112 Patient (female) not N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
received a mammogram denied provider write-off.
during the measurement
year or prior year to the
measurement year
G8113 Clinician documented N N N/A Regence Not considered a
that female patient was Invalid payable service. Will be
not eligible candidate for denied provider write-off.
mammography measure
Effective Date: 11/1/2008
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Code
G8114 Clinician did not provide N N N/A Regence Not considered a
care to patient for the Invalid payable service. Will be
required time of denied provider write-off.
mammography measure
(i.e., measurement year
or prior year)
G8115 Patient documented to N N N/A Regence Not considered a
have received Invalid payable service. Will be
pneumococcal denied provider write-off.
vaccination
G8116 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
pneumococcal denied provider write-off.
vaccination
G8117 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
pneumococcal
vaccination measure
G8126 Patient documented as N N N/A Regence Not considered a
being treated with Invalid payable service. Will be
antidepressant denied provider write-off.
medication during the
entire 12 week acute
treatment phase
G8127 Patient not documented N N N/A Regence Not considered a
as being treated with Invalid payable service. Will be
antidepressant denied provider write-off.
medication during the
entire 12 weeks acute
treatment phase
Effective Date: 11/1/2008
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Code
G8128 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
antidepressant
medication during the
entire 12 week acute
treatment phase
measure
G8129 Patient documented as N N N/A Regence Not considered a
being treated with Invalid payable service. Will be
antidepressant denied provider write-off.
medication for at least 6
months continuous
treatment phase
G8130 Patient not documented N N N/A Regence Not considered a
as being treated with Invalid payable service. Will be
antidepressant denied provider write-off.
medication for at least 6
months continuous
treatment phase
G8131 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
antidepressant
medication for
continuous treatment
phase
G8152 Patient documented to N N N/A Regence Not considered a
have received antibiotic Invalid payable service. Will be
prophylaxis one hour denied provider write-off.
prior to incision time
(two hours for
vancomycin)
Effective Date: 11/1/2008
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Code
G8153 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
antibiotic prophylaxis denied provider write-off.
one hour prior to incision
time (two hours for
vancomycin)
G8154 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
antibiotic prophylaxis
one hour prior to incision
time (two hours for
vancomycin) measure
G8155 Patient with documented N N N/A Regence Not considered a
receipt of Invalid payable service. Will be
thromboembolism denied provider write-off.
prophylaxis
G8156 Patient without N N N/A Regence Not considered a
documented receipt of Invalid payable service. Will be
thromboembolism denied provider write-off.
prophylaxis
G8157 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
thromboembolism
prophylaxis measure
G8159 Patient documented to N N N/A Regence Not considered a
have received coronary Invalid payable service. Will be
artery bypass graft denied provider write-off.
without use of internal
mammary artery
Effective Date: 11/1/2008
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Code
G8162 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft not documented to denied provider write-off.
have received pre-
operative beta-blockade
G8164 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft documented to denied provider write-off.
have prolonged
intubation
G8165 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft not documented to denied provider write-off.
have prolonged
intubation
G8166 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft documented to denied provider write-off.
have required surgical
re-exploration
G8167 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft did not require denied provider write-off.
surgical re-exploration
G8170 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft documented to denied provider write-off.
have been discharged
on aspirin or clopidogrel
Effective Date: 11/1/2008
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Code
G8171 Patient with isolated N N N/A Regence Not considered a
coronary artery bypass Invalid payable service. Will be
graft not documented to denied provider write-off.
have been discharged
on aspirin or clopidogrel
G8172 Clinician documented N N N/A Regence Not considered a
that patient with isolated Invalid payable service. Will be
coronary artery bypass denied provider write-off.
graft was not an eligible
candidate for antiplatelet
therapy at discharge
measure
G8182 Clinician has not N N N/A Regence Not considered a
provided care for the Invalid payable service. Will be
cardiac patient for the denied provider write-off.
required time for low-
density lipoprotein
measure (6 months)
G8183 Patient with heart failure N N N/A Regence Not considered a
and atrial fibrillation Invalid payable service. Will be
documented to be on denied provider write-off.
warfarin therapy
G8184 Clinician documented N N N/A Regence Not considered a
that patient with heart Invalid payable service. Will be
failure and atrial denied provider write-off.
fibrillation was not an
eligible candidate for
warfarin therapy
measure
Effective Date: 11/1/2008
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Code
G8185 Patient diagnosed with N N N/A Regence Not considered a
symptomatic Invalid payable service. Will be
osteoarthritis with denied provider write-off.
documented annual
assessment of function
and pain
G8186 Clinician documented N N N/A Regence Not considered a
that symptomatic Invalid payable service. Will be
osteoarthritis patient denied provider write-off.
was not eligible
candidate for annual
assessment of function
and pain measure
G8193 Clinician did not N N N/A Regence Not considered a
document that an order Invalid payable service. Will be
for prophylactic denied provider write-off.
antibiotic to be given
within one hour (if
vancomycin, two hours)
prior to surgical incision
(or start of procedure
when no incision is
required) was given
Effective Date: 11/1/2008
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Code
G8196 Clinician did not N N N/A Regence Not considered a
document a prophylactic Invalid payable service. Will be
antibiotic was denied provider write-off.
administered within one
hour (if fluoroquinolone
or vancomycin, two
hours) prior to surgical
incision (or start of
procedure when no
incision required)
G8200 Order for cefazolin or N N N/A Regence Not considered a
cefuroxime for Invalid payable service. Will be
antimicrobial prophylaxis denied provider write-off.
not documented
G8204 Clinician did not N N N/A Regence Not considered a
document an order was Invalid payable service. Will be
given to discontinue denied provider write-off.
prophylactic antibiotics
within 24 hours of
surgical end time
G8206 Clinician documented N N N/A Regence Not considered a
that prophylactic Invalid payable service. Will be
antibiotic was given denied provider write-off.
G8209 Clinician did not N N N/A Regence Not considered a
document an order was Invalid payable service. Will be
given to discontinue denied provider write-off.
prophylactic antibiotics
within 48 hours of
surgical end time
Effective Date: 11/1/2008
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Code
G8214 Clinician did not N N N/A Regence Not considered a
document an order was Invalid payable service. Will be
given for appropriate denied provider write-off.
venous
thromboembolism (VTE)
prophylaxis to be given
within 24 hrs prior to
incision time or 24 hours
after surgery end time
G8217 Patient not documented N N N/A Regence Not considered a
to have received DVT Invalid payable service. Will be
prophylaxis by end of denied provider write-off.
hospital day 2
G8219 Patient documented to N N N/A Regence Not considered a
have received DVT Invalid payable service. Will be
prophylaxis by end of denied provider write-off.
hospital day 2
G8220 Patient not documented N N N/A Regence Not considered a
to have received DVT Invalid payable service. Will be
prophylaxis by end of denied provider write-off.
hospital day 2
G8221 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
DVT prophylaxis by the
end of hospital day 2,
including physician
documentation that
patient is ambulatory
Effective Date: 11/1/2008
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Code
G8223 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
prescription for denied provider write-off.
antiplatelet therapy at
discharge
G8226 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
prescription for denied provider write-off.
anticoagulant therapy at
discharge
G8231 Patient not documented N N N/A Regence Not considered a
to have received t-PA or Invalid payable service. Will be
not documented to have denied provider write-off.
been considered a
candidate for t-PA
administration
G8234 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
dysphagia screening denied provider write-off.
G8238 Patient not documented N N N/A Regence Not considered a
to have received order Invalid payable service. Will be
for or consideration for denied provider write-off.
rehabilitation services
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8240 Internal carotid stenosis N N N/A Regence Not considered a
in the 30-99% range, Invalid payable service. Will be
and no documentation denied provider write-off.
of reference to
measurements of distal
internal carotid diameter
as the denominator for
stenosis measurement
G8243 Patient not documented N N N/A Regence Not considered a
to have received CT or Invalid payable service. Will be
MRI and the presence denied provider write-off.
or absence of
hemorrhage, mass
lesion and acute
infarction not
documented in the final
report
G8246 Patient was not an N N N/A Regence Not considered a
eligible candidate for Invalid payable service. Will be
medical history review denied provider write-off.
with assessment of new
or changing moles
G8248 Patient with at least one N N N/A Regence Not considered a
alarm symptom not Invalid payable service. Will be
documented to have denied provider write-off.
had upper endoscopy or
referral for upper
endoscopy
Effective Date: 11/1/2008
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Code
G8251 Patient not documented N N N/A Regence Not considered a
to have received an Invalid payable service. Will be
esophageal biopsy when denied provider write-off.
suspicion of Barrett's
esophagus is indicated
in the endoscopy report
G8254 Patients with no N N N/A Regence Not considered a
documentation order for Invalid payable service. Will be
barium swallow test denied provider write-off.
G8257 Medications with current N N N/A Regence Not considered a
medication list in Invalid payable service. Will be
medical record denied provider write-off.
G8260 Patient not documented N N N/A Regence Not considered a
to have surrogate Invalid payable service. Will be
decision maker or denied provider write-off.
advance care plan in
medical record
G8263 Patient not documented N N N/A Regence Not considered a
to have been assessed Invalid payable service. Will be
for presence or absence denied provider write-off.
of urinary incontinence
G8266 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
characterization of denied provider write-off.
urinary incontinence
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8268 Patient not documented N N N/A Regence Not considered a
to have received plan of Invalid payable service. Will be
care for urinary denied provider write-off.
incontinence
G8271 Patients with no N N N/A Regence Not considered a
documentation of Invalid payable service. Will be
screening for fall risks (2 denied provider write-off.
or more falls in the past
year or any fall with
injury in the past year)
G8274 Clinician has not N N N/A Regence Not considered a
documented presence Invalid payable service. Will be
or absence of alarm denied provider write-off.
symptoms
G8276 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
medical history with denied provider write-off.
assessment of new or
changing moles
G8279 Patient not documented N N N/A Regence Not considered a
to have received a Invalid payable service. Will be
complete physical skin denied provider write-off.
exam
G8282 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
counseling to perform a denied provider write-off.
self-examination
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8285 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
pharmacologic therapy denied provider write-off.
G8289 Patient with no N N N/A Regence Not considered a
documentation of Invalid payable service. Will be
calcium and vitamin D denied provider write-off.
use or counseling
regarding both calcium
and vitamin D use, or
exercise
G8293 COPD patient without N N N/A Regence Not considered a
spirometry results Invalid payable service. Will be
documented denied provider write-off.
G8296 COPD patient not N N N/A Regence Not considered a
documented to have Invalid payable service. Will be
inhaled bronchodilator denied provider write-off.
therapy prescribed
G8298 Patient documented to N N N/A Regence Not considered a
have received optic Invalid payable service. Will be
nerve head evaluation denied provider write-off.
G8299 Patient not documented N N N/A Regence Not considered a
to have received optic Invalid payable service. Will be
nerve head evaluation denied provider write-off.
G8302 Patient documented to N N N/A Regence Not considered a
have a specific target Invalid payable service. Will be
intraocular pressure denied provider write-off.
range goal
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8303 Patient not documented N N N/A Regence Not considered a
to have a specific target Invalid payable service. Will be
intraocular pressure denied provider write-off.
range goal
G8304 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for a denied provider write-off.
specific target
intraocular pressure
range goal
G8305 Clinician has not N N N/A Regence Not considered a
provided care for the Invalid payable service. Will be
primary open-angle denied provider write-off.
glaucoma patient for the
required time for
treatment range goal
documentation
measurement
G8306 Primary open-angle N N N/A Regence Not considered a
glaucoma patient with Invalid payable service. Will be
intraocular pressure denied provider write-off.
above the target range
goal documented to
have received plan of
care
G8307 Primary open-angle N N N/A Regence Not considered a
glaucoma patient with Invalid payable service. Will be
intraocular pressure at denied provider write-off.
or below goal, no plan of
care necessary
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8308 Primary open-angle N N N/A Regence Not considered a
glaucoma patient with Invalid payable service. Will be
intraocular pressure denied provider write-off.
above the target range
goal, and not
documented to have
received plan of care
during the reporting year
G8310 Patient not documented N N N/A Regence Not considered a
to have been Invalid payable service. Will be
prescribed/recommende denied provider write-off.
d Age-Related Eye
Disease Study (AREDS)
formulation
G8314 Patient not documented N N N/A Regence Not considered a
to have received Invalid payable service. Will be
macular exam with denied provider write-off.
documentation of
presence or absence of
macular thickening or
hemorrhage and no
documentation of level
of macular degeneration
severity
G8318 Patient documented not N N N/A Regence Not considered a
to have visual functional Invalid payable service. Will be
status assessed denied provider write-off.
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8322 Patient not documented N N N/A Regence Not considered a
to have had a pre- Invalid payable service. Will be
surgical axial length, denied provider write-off.
corneal power
measurement and
method of intraocular
lens power calculation
G8326 Patient not documented N N N/A Regence Not considered a
to have received fundus Invalid payable service. Will be
evaluation denied provider write-off.
G8330 Patient not documented N N N/A Regence Not considered a
to have received dilated Invalid payable service. Will be
macular or fundus exam denied provider write-off.
with level of severity of
retinopathy and the
presence or absence of
macular edema not
documented
G8334 Documentation of N N N/A Regence Not considered a
findings of macular or Invalid payable service. Will be
fundus exam not denied provider write-off.
communicated to the
physician managing the
patient's ongoing
diabetes care
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8338 Clinician has not N N N/A Regence Not considered a
documented that Invalid payable service. Will be
communication was denied provider write-off.
sent to the physician
managing ongoing care
of patient that a fracture
occurred and that the
patient was or should be
tested or treated for
osteoporosis
G8341 Patient not documented N N N/A Regence Not considered a
to have had central Dual- Invalid payable service. Will be
energy X-ray denied provider write-off.
Absorptiometry (DXA)
measurement ordered
or performed or
pharmacologic therapy
for osteoporosis
screening
G8345 Patient not documented N N N/A Regence Not considered a
to have had central Invalid payable service. Will be
DEXA measurement denied provider write-off.
ordered or performed or
pharmacologic therapy
following fracture
G8351 Patient not documented N N N/A Regence Not considered a
to have had ECG Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
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Code
G8354 Patient not documented N N N/A Regence Not considered a
to have received or Invalid payable service. Will be
taken aspirin 24 hours denied provider write-off.
before emergency
department arrival or
during emergency
department stay
G8357 Patient not documented N N N/A Regence Not considered a
to have had ECG Invalid payable service. Will be
denied provider write-off.
G8360 Patient not documented N N N/A Regence Not considered a
to have vital signs Invalid payable service. Will be
recorded and reviewed denied provider write-off.
G8362 Patient not documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
oxygen saturation
assessment
G8365 Patient not documented N N N/A Regence Not considered a
to have mental status Invalid payable service. Will be
assessed denied provider write-off.
G8367 Patient not documented N N N/A Regence Not considered a
to have appropriate Invalid payable service. Will be
empiric antibiotic denied provider write-off.
prescribed
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8370 Asthma patients with N N N/A Regence Not considered a
numeric frequency of Invalid payable service. Will be
symptoms or patient denied provider write-off.
completion of an asthma
assessment
tool/survey/questionnair
e not documented
G8371 Chemotherapy N N N/A Regence Not considered a
documented as not Invalid payable service. Will be
received or prescribed denied provider write-off.
for Stage III colon
cancer patients
G8372 Chemotherapy N N N/A Regence Not considered a
documented as received Invalid payable service. Will be
or prescribed for Stage denied provider write-off.
III colon cancer patients
G8373 Chemotherapy plan N N N/A Regence Not considered a
documented prior to Invalid payable service. Will be
chemotherapy denied provider write-off.
administration
G8374 Chemotherapy plan not N N N/A Regence Not considered a
documented prior to Invalid payable service. Will be
chemotherapy denied provider write-off.
administration
G8375 Chronic lymphocytic N N N/A Regence Not considered a
leukemia (CLL) patient Invalid payable service. Will be
with no documentation denied provider write-off.
of baseline flow
cytometry performed
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8376 Clinician documentation N N N/A Regence Not considered a
that breast cancer Invalid payable service. Will be
patient was not eligible denied provider write-off.
for tamoxifen or
aromatose inhibitor
therapy measure
G8377 Clinician documentation N N N/A Regence Not considered a
that colon cancer patient Invalid payable service. Will be
is not eligible for denied provider write-off.
chemotherapy measure
G8378 Clinician documentation N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
radiation therapy
measure
G8379 Documentation of N N N/A Regence Not considered a
radiation therapy Invalid payable service. Will be
recommended within 12 denied provider write-off.
months of first office
visit
G8380 For patients with ER or N N N/A Regence Not considered a
PR positive, Stage IC-III Invalid payable service. Will be
breast cancer, clinician denied provider write-off.
did not document that
the patient received or
was prescribed
tamoxifen or aromatase
inhibitor
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8381 For patients with ER or N N N/A Regence Not considered a
PR positive, Stage IC-III Invalid payable service. Will be
breast cancer, clinician denied provider write-off.
documented or
prescribed that the
patient is receiving
tamoxifen or aromatase
inhibitor
G8382 Multiple myeloma N N N/A Regence Not considered a
patients with no Invalid payable service. Will be
documentation of denied provider write-off.
prescribed or received
intravenous
biphosphonate therapy
G8383 No documentation of N N N/A Regence Not considered a
radiation therapy Invalid payable service. Will be
recommended within 12 denied provider write-off.
months of first office
visit
G8384 Baseline cytogenetic N N N/A Regence Not considered a
testing not performed in Invalid payable service. Will be
patients with denied provider write-off.
Myelodysplastic
Syndrome (MDS) or
Acute Leukemia
G8385 Diabetic patients with no N N N/A Regence Not considered a
documentation of Invalid payable service. Will be
Hemoglobin A1c level denied provider write-off.
(within the last 12
months)
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8386 Diabetic patients with no N N N/A Regence Not considered a
documentation of low- Invalid payable service. Will be
density lipoprotein denied provider write-off.
(within the last 12
months)
G8387 End-stage renal disease N N N/A Regence Not considered a
patient with a hematocrit Invalid payable service. Will be
or hemoglobin not denied provider write-off.
documented
G8388 End-stage renal disease N N N/A Regence Not considered a
patient with URR or Kt/V Invalid payable service. Will be
value not documented, denied provider write-off.
but otherwise eligible for
measure
G8389 Myelodysplastic N N N/A Regence Not considered a
Syndrome (MDS) Invalid payable service. Will be
patients with no denied provider write-off.
documentation or iron
stores prior to receiving
erythropoietin therapy
G8390 Diabetic patients with no N N N/A Regence Not considered a
documentation of blood Invalid payable service. Will be
pressure measurement denied provider write-off.
(within the last 12
months)
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8391 Patients with persistent N N N/A Regence Not considered a
asthma, no Invalid payable service. Will be
documentation of denied provider write-off.
preferred long term
control medication or
acceptable alternative
treatment prescribed
G8395 Left ventricular ejection N N N/A Regence Not considered a
fraction (LVEF) >= 40% Invalid payable service. Will be
or documentation as denied provider write-off.
normal or mildly
depressed left
ventricular systolic
function
G8396 Left ventricular ejection N N N/A Regence Not considered a
fraction (LVEF) not Invalid payable service. Will be
performed or denied provider write-off.
documented
G8397 Dilated macular or N N N/A Regence Not considered a
fundus exam performed, Invalid payable service. Will be
including documentation denied provider write-off.
of the presence or
absence of macular
edema and level of
severity of retinopathy
G8398 Dilated macular or N N N/A Regence Not considered a
fundus exam not Invalid payable service. Will be
performed denied provider write-off.
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8399 Patient with central dual- N N N/A Regence Not considered a
energy x-ray Invalid payable service. Will be
absorptiometry (DXA) denied provider write-off.
results documented or
ordered or
pharmacologic therapy
(other than
mineral/vitamins) for
osteoporosis prescribed
G8400 Patient with central dual- N N N/A Regence Not considered a
energy x-ray Invalid payable service. Will be
absorptiometry (DXA) denied provider write-off.
results not documented
or not ordered or
pharmacologic therapy
(other than
minerals/vitamins) for
osteoporosis not
prescribed
G8401 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
screening or therapy for
osteoporosis for women
measure
G8402 Tobacco (smoke) use N N N/A Regence Not considered a
cessation intervention, Invalid payable service. Will be
counseling denied provider write-off.
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8403 Tobacco (smoke) use N N N/A Regence Not considered a
cessation intervention, Invalid payable service. Will be
not counseled denied provider write-off.
G8404 Lower extremity N N N/A Regence Not considered a
neurological exam Invalid payable service. Will be
performed and denied provider write-off.
documented
G8405 Lower extremity N N N/A Regence Not considered a
neurological exam not Invalid payable service. Will be
performed denied provider write-off.
G8406 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
lower extremity
neurological exam
measure
G8407 ABI measured and N N N/A Regence Not considered a
documented Invalid payable service. Will be
denied provider write-off.
G8408 ABI measurement was N N N/A Regence Not considered a
not obtained Invalid payable service. Will be
denied provider write-off.
G8409 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
ABI measurement
measure
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8410 Footwear evaluation N N N/A Regence Not considered a
performed and Invalid payable service. Will be
documented denied provider write-off.
G8415 Footwear evaluation N N N/A Regence Not considered a
was not performed Invalid payable service. Will be
denied provider write-off.
G8416 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
footwear evaluation
measure
G8417 BMI >= 30 was N N N/A Regence Not considered a
calculated and a follow- Invalid payable service. Will be
up plan was denied provider write-off.
documented in the
medical record
G8418 BMI <22 was calculated N N N/A Regence Not considered a
and a follow-up plan Invalid payable service. Will be
was documented in the denied provider write-off.
medical record
G8419 BMI >= 30 or < 22 was N N N/A Regence Not considered a
calculated, but no follow- Invalid payable service. Will be
up plan was denied provider write-off.
documented in the
medical record
G8420 BMI <30 and >= 22 was N N N/A Regence Not considered a
calculated and Invalid payable service. Will be
documented denied provider write-off.
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8421 BMI not calculated N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G8422 Patient not eligible for N N N/A Regence Not considered a
BMI calculation Invalid payable service. Will be
denied provider write-off.
G8423 Documented that patient N N N/A Regence Not considered a
was screened and either Invalid payable service. Will be
influenza vaccination denied provider write-off.
status is current or
patient was counseled
G8424 Influenza vaccine status N N N/A Regence Not considered a
was not screened Invalid payable service. Will be
denied provider write-off.
G8425 Influenza vaccine status N N N/A Regence Not considered a
screened, patient not Invalid payable service. Will be
current and counseling denied provider write-off.
was not provided
G8426 Documented that patient N N N/A Regence Not considered a
was not appropriate for Invalid payable service. Will be
screening and/or denied provider write-off.
counseling
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 168 of 908
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CPT Required Y/N Required When?
Code
G8427 Written provider N N N/A Regence Not considered a
documentation was Invalid payable service. Will be
obtained confirming that denied provider write-off.
current medications with
dosages (includes
prescription, over-the-
counter, herbals,
vitamin/mineral/dietary
(nutritional)
supplements) were
verified with the patient
or authorized
representative or patient
assessed and is not
currently on any
medications
G8428 Current medication with N N N/A Regence Not considered a
dosages (includes Invalid payable service. Will be
prescriptionm, over-the- denied provider write-off.
counter, herbals,
vitamin/mineral/dietary
(nutritional)
supplements) were
documented without
documented patient
verification
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 169 of 908
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CPT Required Y/N Required When?
Code
G8429 Incomplete or not N N N/A Regence Not considered a
documentation that Invalid payable service. Will be
patient's current denied provider write-off.
medications with
dosages (includes
prescription, over-the-
counter, herbals,
vitamin/mineral/dietary
(nutritional)
supplements) were
assessed
G8430 Documentation that N N N/A Regence Not considered a
patient was not eligible Invalid payable service. Will be
for medication denied provider write-off.
assessment
G8431 Documentation of N N N/A Regence Not considered a
clinical depression Invalid payable service. Will be
screening using a denied provider write-off.
standardized tool
G8432 No documentation of N N N/A Regence Not considered a
clinical depression Invalid payable service. Will be
screening using a denied provider write-off.
standardized tool
G8433 Patient not eligible/not N N N/A Regence Not considered a
appropriate for clinical Invalid payable service. Will be
depression screening denied provider write-off.
G8434 Documentation of N N N/A Regence Not considered a
cognitive impairment Invalid payable service. Will be
screening using a denied provider write-off.
standardized tool
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 170 of 908
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CPT Required Y/N Required When?
Code
G8435 No documentation of N N N/A Regence Not considered a
cognitive impairment Invalid payable service. Will be
screening using a denied provider write-off.
standardized tool
G8436 Patient not eligible/not N N N/A Regence Not considered a
appropriate for cognitive Invalid payable service. Will be
impairment screening denied provider write-off.
G8437 Documentation of N N N/A Regence Not considered a
clinician and patient Invalid payable service. Will be
involvement with the denied provider write-off.
development of a
treatment plan/plan of
care including signature
by the practitioner and
either co-signature by
the patient or
documented verbal
agreement obtained
from patient or, when
necessary an authorized
representative
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 171 of 908
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CPT Required Y/N Required When?
Code
G8438 No documentation of N N N/A Regence Not considered a
clinician and patient Invalid payable service. Will be
involvement with the denied provider write-off.
development of a
treatment plan/plan of
care including signature
by the practitioner and
either a co-signature by
the patient or
documented verbal
agreement obtained
from patient or, when
necessary, an
authorized
representative.
G8439 Documentation that N N N/A Regence Not considered a
patient is not eligible for Invalid payable service. Will be
co-developing a denied provider write-off.
treatment plan/plan of
care including signature
by the practitioner and
either a co-signature by
the patient or
documented verbal
agreement obtained
from patient or, when
necessary, an
authorized
representative
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8440 Documentation of pain N N N/A Regence Not considered a
assessment (including Invalid payable service. Will be
location, intensity and denied provider write-off.
description) prior to
initiation of treatment or
doucmentation of the
absence of pain as a
result of assessment
G8441 No documentation of N N N/A Regence Not considered a
pain assessment Invalid payable service. Will be
(including location, denied provider write-off.
intensity and
description) prior to
initiation of treatment
G8442 Documentation that N N N/A Regence Not considered a
patient is not eligible for Invalid payable service. Will be
pain assessment denied provider write-off.
G8443 All prescriptions created N N N/A Regence Not considered a
during the encounter Invalid payable service. Will be
generated using a denied provider write-off.
qualified E-prescribing
system
G8445 No prescriptions were N N N/A Regence Not considered a
generated during the Invalid payable service. Will be
encounter, provider denied provider write-off.
does have access to a
qualified E-prescribing
system
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 173 of 908
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CPT Required Y/N Required When?
Code
G8446 Some or all N N N/A Regence Not considered a
prescriptions generated Invalid payable service. Will be
during the encounter denied provider write-off.
were handwritten or
phoned in due to one of
the following: required
by state law, patient
request or qualified E-
prescribing system
being temporarily
inoperable
G8447 Patient encounter was N N N/A Regence Not considered a
documented using a Invalid payable service. Will be
CCHIT certified EMR denied provider write-off.
G8448 Patient encounter was N N N/A Regence Not considered a
documented using a Invalid payable service. Will be
non-CCHIT certfied denied provider write-off.
EMR; to qualify, the
system must be capable
of all of the following:
generating a medication
list, generating a
problem list, entering
laboratory tests as
discrete searchable date
elements
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 174 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8449 Patient encounter was N N N/A Regence Not considered a
not documented using Invalid payable service. Will be
an EMR due to system denied provider write-off.
reasons such as, the
system being inoperabel
at the time of the visit;
use of this code implies
that an EMR is in place
and generally available
G8450 Beta-blocker therapy N N N/A Regence Not considered a
prescribed for patients Invalid payable service. Will be
with left ventricular denied provider write-off.
ejection fraction (LVEF)
<49 % or documentation
is moderately or
severely depressed left
ventricular systolic
function
G8451 Clincian documented N N N/A Regence Not considered a
patient with left Invalid payable service. Will be
ventricular ejection denied provider write-off.
fraction (LVEF) <40% or
documentation as
moderately or severely
depressed left
ventricular systolic
function was not eligible
candidate for beta-
blocker therapy
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 175 of 908
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CPT Required Y/N Required When?
Code
G8452 Beta-blocker therapy not N N N/A Regence Not considered a
prescribed for patients Invalid payable service. Will be
with left ventricular denied provider write-off.
ejection fraction (LVEF)
<40% or documentation
as moderately or
severely depressed left
ventricular systolic
function
G8453 Tobacco use cessation N N N/A Regence Not considered a
intervention, counseling Invalid payable service. Will be
denied provider write-off.
G8454 Tobacco use cessation N N N/A Regence Not considered a
intervention not Invalid payable service. Will be
counseled, reason not denied provider write-off.
specified
G8455 Current tobacco smoker N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G8456 Current smokeless N N N/A Regence Not considered a
tobacco user Invalid payable service. Will be
denied provider write-off.
G8457 Tobacco non-user N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
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CPT Required Y/N Required When?
Code
G8458 Clinician documented N N N/A Regence Not considered a
that patient is not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
genotype testing; patient
not receiving antiviral
treatment for hepatitis C
G8459 Clinician documentat N N N/A Regence Not considered a
that patient is receiving Invalid payable service. Will be
antiviral treatment for denied provider write-off.
Hepatitis C
G8460 Clinician documented N N N/A Regence Not considered a
that patient is not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
quantitative RNA testing
at week 12; patient not
receiving antiviral
treatment for Hepatitis C
G8461 Patient receiving N N N/A Regence Not considered a
antiviral treatment for Invalid payable service. Will be
Hepatitis C denied provider write-off.
G8462 Clinician documented N N N/A Regence Not considered a
that patient is not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
counseling regarding
contraception prior to
antiviral treatment;
patient not receiving
antiviral treatment for
Hepatitis C
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 177 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8463 Patient receiving N N N/A Regence Not considered a
antiviral treatment for Invalid payable service. Will be
Hepatitis C documented denied provider write-off.
G8464 Clinician documented N N N/A Regence Not considered a
that prostate cancer Invalid payable service. Will be
patient is not an eligible denied provider write-off.
candidate for adjuvant
hormonal therapy; low
or intermediate risk of
recurrence or risk of
recurrence not
determined
G8465 High risk of recurrence N N N/A Regence Not considered a
of prostate cancer Invalid payable service. Will be
denied provider write-off.
G8466 Clinician documented N N N/A Regence Not considered a
that patient is not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
suicide risk
G8467 Documentation of new N N N/A Regence Not considered a
diagnosis of initial or Invalid payable service. Will be
recurrent episode of denied provider write-off.
major depressive
disorder
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 178 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8468 Angiotensin converting N N N/A Regence Not considered a
enzyme (ACE) inhibitor Invalid payable service. Will be
or angiotensin receptor denied provider write-off.
blocker (ARB) therapy
prescribed for patients
with a left ventricular
ejection fraction (LVEF)
<40% or documentation
of moderately or
severely depressed left
ventricular systolic
function
G8469 Clinician documented N N N/A Regence Not considered a
that patient with a left Invalid payable service. Will be
ventricular ejection denied provider write-off.
fraction (LVEF) <40% or
documentation of
moderately or severely
depressed left
ventricular systolic
function was not an
eligible candidate for
angiotension converting
enzyme (ACE) inhibitor
or angiotensin receptor
blocker (ARB) therapy
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 179 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8470 Patient with left N N N/A Regence Not considered a
ventricular ejection Invalid payable service. Will be
fraction (LVEF) >40% or denied provider write-off.
documentation as
normal or mildly
depressed left
ventricular systolic
function
G8471 Left ventricular ejection N N N/A Regence Not considered a
fraction (LVEF) was not Invalid payable service. Will be
performed or denied provider write-off.
documented
G8472 Angiotensin converting N N N/A Regence Not considered a
enzyme (ACE) inhibitor Invalid payable service. Will be
or angiotensin receptor denied provider write-off.
blocker (ARB) therapy
not prescribed for
patients with a left
ventricular ejection
fraction (LVEF) <40% or
documentation of
moderately or severely
depressed left
ventricular systolic
function, reason not
specified
G8473 Angiotensin converting N N N/A Regence Not considered a
enzyme (ACE) inhibitor Invalid payable service. Will be
or angiotensin receptor denied provider write-off.
blocker (ARB) therapy
prescribed
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 180 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8474 Angiotensin converting N N N/A Regence Not considered a
enzyme (ACE) inhibitor Invalid payable service. Will be
or angiotensin receptor denied provider write-off.
blocker (ARB) therapy
not prescribed for
reasons documented by
the clinician
G8475 Angiotensin converting N N N/A Regence Not considered a
enzyme (ACE) inhibitor Invalid payable service. Will be
or angiotensin receptor denied provider write-off.
blocker (ARB) therapy
not prescribed, reason
not specified
G8476 Most recent blood N N N/A Regence Not considered a
pressure has a systolic Invalid payable service. Will be
measurement of <130 denied provider write-off.
mm/hg and a diastolic
measurement of <80
mm/hg
G8477 Most recent blood N N N/A Regence Not considered a
pressure has a systolic Invalid payable service. Will be
measurement of >=130 denied provider write-off.
mm/hg and or a diastolic
measurement of >=80
mm/hg
G8478 Blood pressure N N N/A Regence Not considered a
measurement not Invalid payable service. Will be
performed or denied provider write-off.
documented, reason not
specified
Effective Date: 11/1/2008
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8479 Clinician prescribed N N N/A Regence Not considered a
angiotensin converting Invalid payable service. Will be
enzyme (ACE) inhibitor denied provider write-off.
or angiotensin receptor
blocker (ARB) therapy
G8480 Clinician documented N N N/A Regence Not considered a
that patient was not an Invalid payable service. Will be
eligible candidate for denied provider write-off.
angiotensin converting
enzyme (ACE) inhibitor
or angiotensin receptor
blocker (ARB) therapy
G8481 Clinician did not N N N/A Regence Not considered a
prescribe angiotensin Invalid payable service. Will be
converting enzyme denied provider write-off.
(ACE) inhibitor or
angiotensin receptor
blocker (ARB) therapy,
reason not specified
G8482 Influenza immunization N N N/A Regence Not considered a
was ordered or Invalid payable service. Will be
administered denied provider write-off.
G8483 Influenza immunizatioin N N N/A Regence Not considered a
was not ordered or Invalid payable service. Will be
administered for denied provider write-off.
reasons documented by
clinician
Effective Date: 11/1/2008
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G8484 Influenza immunization N N N/A Regence Not considered a
was not ordered or Invalid payable service. Will be
administered, reason denied provider write-off.
not specified
G8485 Clinician intends to N N N/A Regence Not considered a
report the Diabetes Invalid payable service. Will be
measure group denied provider write-off.
G8486 Clinician intends to N N N/A Regence Not considered a
report the Preventive Invalid payable service. Will be
Care measure group denied provider write-off.
G8487 Clinician intends to N N N/A Regence Not considered a
report the Chronic Invalid payable service. Will be
Kidney Disease (CKD) denied provider write-off.
measure group
G8488 Clinician intends to N N N/A Regence Not considered a
report the End Stage Invalid payable service. Will be
Renal Disease (ESRD) denied provider write-off.
measure group
G9001 MCCD, initial rate N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9002 MCCD,maintenance N N N/A Regence Not considered a
rate Invalid payable service. Will be
denied provider write-off.
G9003 MCCD, risk adj hi, initial N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 183 of 908
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CPT Required Y/N Required When?
Code
G9004 MCCD, risk adj lo, initial N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9005 MCCD, risk adj, N N N/A Regence Not considered a
maintenance Invalid payable benefit of any
member policies.
G9006 MCCD, Home N N N/A Regence Not considered a
monitoring Invalid payable benefit of any
member policies.
G9007 MCCD, sch team conf N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9008 Mccd,phys coor-care N N N/A Regence Not considered a
ovrsght Invalid payable service. Will be
denied provider write-off.
G9009 MCCD, risk adj, level 3 N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9010 MCCD, risk adj, level 4 N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9011 MCCD, risk adj, level 5 N N N/A Regence Not considered a
Invalid payable service. Will be
denied provider write-off.
G9012 Other Specified Case N N N/A Regence Not considered a
Management Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 184 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9013 ESRD demo basic N N N/A Regence Not considered a
bundle Level I Invalid payable service. Will be
denied provider write-off.
G9014 ESRD demo expanded N N N/A Regence Not considered a
bundle including venous Invalid payable service. Will be
access and related denied provider write-off.
services
G9016 Demo-smoking N N N/A Regence Not considered a
cessation coun Invalid payable service. Will be
denied provider write-off.
G9017 Amantadine N N N/A Regence Not considered a
hydrochloride, oral, per Invalid payable service. Will be
100 mg (for use as a denied provider write-off.
Medicare-approved
demonstration project)
G9018 Zanamvir, inhalation N N N/A Regence Not considered a
powder administered Invalid payable service. Will be
through inhaler, per 10 denied provider write-off.
mg (for use as a
Medicare-approved
demonstration project)
G9019 Oseltamivir phosphate, N N N/A Regence Not considered a
oral, per 75 mg (for use Invalid payable service. Will be
as a Medicare-approved denied provider write-off.
demonstration project)
G9020 Rimantadine N N N/A Regence Not considered a
hydrochloride, oral, per Invalid payable service. Will be
100 mg (for use as a denied provider write-off.
Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 185 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9033 Amantadine N N N/A Regence Not considered a
hydrochloride, oral, Invalid payable service. Will be
brand, per 100 mg (for denied provider write-off.
use in a Medicare-
approved demonstration
project)
G9034 Zanamivir, inhalation N N N/A Regence Not considered a
powder, administered Invalid payable service. Will be
through inhaler, brand, denied provider write-off.
per 10 mg (for use in a
Medicare-approved
demonstration project)
G9035 Oseltamivir phosphate, N N N/A Regence Not considered a
oral, brand, per 75 mg Invalid payable service. Will be
(for use in a Medicare- denied provider write-off.
approved demonstration
project)
G9036 Rimantadine N N N/A Regence Not considered a
hydrochloride, oral, Invalid payable service. Will be
brand, per 100 mg (for denied provider write-off.
use in a Medicare-
approved demonstration
project)
G9041 Low vision rehabilitation N N N/A Regence Not considered a
services, certified Invalid payable service. Will be
licensed occupational denied provider write-off.
therapist, each 15 min
G9042 Low vision rehabilitation N N N/A Regence Not considered a
services, certified Invalid payable service. Will be
orientation and mobility denied provider write-off.
specialist, each 15
minutes
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 186 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9043 Low vision rehabilitation N N N/A Regence Not considered a
services, certified low Invalid payable service. Will be
vision therapist, each 15 denied provider write-off.
minutes
G9044 Low vision rehabilitation N N N/A Regence Not considered a
services, qualified Invalid payable service. Will be
rehabilitation teacher, denied provider write-off.
each 15 minutes
G9050 Oncology (for use in a N N N/A Regence Not considered a
Mediare approved Invalid payable service. Will be
demonstration project) denied provider write-off.
G9051 Oncology; primary focus N N N/A Regence Not considered a
of visit; treatment Invalid payable service. Will be
decision-making after denied provider write-off.
disease is staged or
restaged, discussion of
treatment options,
supervising/coordinating
active cancer directed
therapy or managing
consequences of cancer
directed therapy (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 187 of 908
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HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9052 Oncology; primary focus N N N/A Regence Not considered a
of visit; surveillance for Invalid payable service. Will be
disease recurrence for denied provider write-off.
patient who has
completed definitive
ancer-directed therapy
and currently lacks
evidence of recurrent
disease; cancer directed
therapy might be
considered in the future
(for use in a Medicare-
approved demonstration
project)
G9053 Oncology; primary focus N N N/A Regence Not considered a
of visit; expectant Invalid payable service. Will be
management of patient denied provider write-off.
with evidence of cancer
for whom no cancer
directed therapy is being
administered or
arranged at present;
cancer directed therapy
might be considered in
the future (for use in a
Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 188 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9054 Oncology; primary focus N N N/A Regence Not considered a
of visit; supervising, Invalid payable service. Will be
coordinating or denied provider write-off.
managing care of
patient with terminal
cancer or for hwom
other medical illness
prevents further cancer
treatment; includes
symptom management,
end-of-life care
planning, management
of palliative therapies
(for use in a Medicare-
approved demonstration
project)
G9055 Oncology; primary focus N N N/A Regence Not considered a
of visit; other, Invalid payable service. Will be
unspecified service not denied provider write-off.
otherwise listed (for use
in a Medicare-approved
demonstration project)
G9056 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
adheres to guidelines denied provider write-off.
(for use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 189 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9057 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
differs from guidelines denied provider write-off.
as a result of patient
enrollment in an
institutional review
board approved clinical
trial (for use in a
Medicare-approved
demonstration project)
G9058 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
differs from guidelines denied provider write-off.
because the treating
physician disagrees with
guideline
recommendations (for
use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 190 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9059 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
differs from guidelines denied provider write-off.
because the patient,
after being offered
treatment consistent
with guidelines has
opted for alternative
treatment or
management, including
no treatment (for use in
a Medicare-approved
demonstration project)
G9060 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
differs from guidelines denied provider write-off.
for reason(s) associated
with patient comorbid
illness or performance
status not factored into
guidelines (for use in a
Medicare-approved
demonstration project)
G9061 Oncology; practice N N N/A Regence Not considered a
guidelines; patient's Invalid payable service. Will be
condition not addressed denied provider write-off.
by available guidelines
(for use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 191 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9062 Oncology; practice N N N/A Regence Not considered a
guidelines; management Invalid payable service. Will be
differs from guidelines denied provider write-off.
for other reason(s) not
listed (for use in a
Medicare-approved
demonstration project)
G9063 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell lung cancer; denied provider write-off.
extent of disease initially
established as stage I
(prior to neoadjuvant
therapy, if any) with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 192 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9064 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell lung cancer; denied provider write-off.
extent of disease initially
established as stage II
(prior to neo-adjuvant
therapy, if any) with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare-approved
demonstration project)
G9065 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell lung cancer; denied provider write-off.
extent of disease initially
established as stage III
A (prior to neo-adjuvant
therapy, if any) with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 193 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9066 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell lung cancer; denied provider write-off.
stage IIIB-IV at
diagnosis, metastatic,
locally recurrent, or
progressive (for use in a
Medicare-approved
demonstration project)
G9067 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell lung cancer; denied provider write-off.
extent of disease
unknown, under
evaluation, not yet
determined, or not listed
(for use in a Medicare-
approved demonstration
project)
G9068 Oncology; disease N N N/A Regence Not considered a
status; limited to non- Invalid payable service. Will be
small cell and combined denied provider write-off.
small cell/non-small cell;
extent of disease initially
established as limited
with no evidence of
disease progression,
recurrence, or
metastses (for use in a
Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 194 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9069 Oncology; disease N N N/A Regence Not considered a
status; small cell lung Invalid payable service. Will be
cancer, limited to small denied provider write-off.
cell and combined small
cell/non-small cell;
extensive stage at
diagnosis, metastatic,
locally recurrent, or
progressive (for use in a
Medicare-approved
demonstration project)
G9070 Oncology; disease N N N/A Regence Not considered a
status; small cell lung Invalid payable service. Will be
cancer, limited to small denied provider write-off.
cell and combined small
cell/non-small; extent of
disease unknown, under
evaluation, pre-surgical,
or not listed (for use in a
Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 195 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9071 Oncology; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
stage I or stage IIA-IIB;
or T3, N1, M0; and
ER/and or PR positive;
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare-approved
demonstration project)
G9072 Oncology; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
stage I, or stage IIA-IIB;
or T3, N1, M0; and ER
and PR negative; with
no evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare-approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 196 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9073 Oncology ; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
stage IIIA-IIIB; and not
T3, N1, M0; and ER
and/or PR positive; with
no evidence of disease
progression, recurrence
or metastases (for use
in a medicare-approved
demonstation project)
G9074 Oncology ; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
stage IIIA-IIIB; and not
T3, N1, M0; and ER and
PR negative; with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 197 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9075 Oncology; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
M1 at diagnosis,
metastatic, locally
recurrent, or progressive
(for use in a Medicare
approved demonstration
project)
G9077 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
T1-T2C and gleason 2-7
and PSA < or equal to
20 at diagnosis with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 198 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9078 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
T2 or gleason 8-10 or
PSA >20 at diagnosis
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9079 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
T3B-T4, any N; any T,
N1 at diagnosis with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 199 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9080 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma; after
initial treatment with
rising PSA or failure of
PSA decline (for use in
a Medicare approved
demonstration project)
G9083 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma; extent
of disease unknown,
under evaluation or not
listed (for use in a
Medicare approved
demonstration project)
G9084 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T1-3, N0,
M0 with no evidence of
disease progression,
recurrence, or
meastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 200 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9085 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T4, N0,
M0 with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9086 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T1-4, N1-
2, M0 with no evidence
of disease progression,
recurrence, or
metastases (for us in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 201 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9087 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type,
M1 at diagnosis,
metastatic, locally
recurrent, or progressive
with current clinical,
radiologic, or
biochemical evidence of
disease (for use in a
Medicare approved
demonstration project)
G9088 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type,
M1 at diagnosis,
metastatic, locally
recurrent, or progressive
without current clinical,
radiologic, or
biochemical evidence of
disease (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 202 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9089 Oncology; disease N N N/A Regence Not considered a
status; colon cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease
unknown, not yet
determined, under
evaluation, pre-surgical,
or not listed (for use in a
Medicare approved
demonstration project)
G9090 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T1-2, N0,
M0 (prior to neo-
adjuvant therapy, if any)
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 203 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9091 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T3, N0,
M0, (prior neo-adjuvant
therapy, if any) with no
evidence of disease
progression, recurrence,
or metastases (for use
in a Medicare approved
demonstration project)
G9092 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T1-3, N1-
2, M0 (prior to neo-
adjuvant therapy, if any)
with no evidence of
disease progression,
recurrence or
metastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 204 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9093 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease initially
established as T4, any
N, M0 (prior to neo-
adjuvant therapy, if any)
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9094 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
M1 at diagnosis;
metastatic, locally
recurrent, or progressive
(for use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 205 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9095 Oncology; disease N N N/A Regence Not considered a
status; rectal cancer, Invalid payable service. Will be
limited to invasive denied provider write-off.
cancer,
adenocarcinoma as
predominant cell type;
extent of disease
unknown, not yet
determined, under
evaluation, pre-surgical,
or not listed (for use in a
Medicare approved
demonstration project)
G9096 Oncology; disease N N N/A Regence Not considered a
status; esophageal Invalid payable service. Will be
cancer , limited to denied provider write-off.
adenocarcinoma or
squamous cell
carcinoma as
predominant cell type;
extent of disease initially
established as T1-3, N0-
N1 or NX (prior to neo-
adjuvant therapy, if any)
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 206 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9097 Oncology; disease N N N/A Regence Not considered a
status; esophageal Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma or
squamous cell
carcinoma as
predominant cell type;
extent of disease initially
established as T4, any
N, M0 (prior to neo-
adjuvant therapy, if any)
with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9098 Oncology; disease N N N/A Regence Not considered a
status; esophageal Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma or
squamous cell
carcinoma as
predominant cell type;
M1 at diagnosis,
metastatic, locally
recurrent, or progressive
(for use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 207 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9099 Oncology; disease N N N/A Regence Not considered a
status; esophageal Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma or
squamous cell
carcinoma as
predominant cell type;
extent of disease
unknown, not yet
determined, under
evaluation, pre-surgical,
or not listed (for use in a
Medicare approved
demonstration project)
G9100 Oncology; disease N N N/A Regence Not considered a
status; gastric cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
post R0 resection (with
or without neoadjuvant
therapy) with no
evidence of disease
recurrence, progression,
or metastases (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 208 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9101 Oncology; disease N N N/A Regence Not considered a
status; gastric cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
post R1 or R2 resection
(with or without
neoadjuvant therapy)
with no evidence of
disease progression, or
metastases (for use in a
Medicare approved
demonstration project)
G9102 Oncology; disease N N N/A Regence Not considered a
status; gastric cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
clinical or pathologic M0,
unresectable with no
evidence of disease
progression, or
metastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 209 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9103 Oncology; disease N N N/A Regence Not considered a
status; gastric cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
clinical or pathologic M1
at diagnosis, metastatic,
locally recurrent, or
progressive (for use in a
Medicare approved
demonstration project)
G9104 Oncology; disease N N N/A Regence Not considered a
status; gastric cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
extent of disease
unknown, under
evaluation not yet
determined, pre-
surgical, or not listed
(for use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 210 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9105 Oncology; disease N N N/A Regence Not considered a
status; pancreatic Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma as
predominant cell type;
post R0 resection
without evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstation project)
G9106 Oncology; disease N N N/A Regence Not considered a
status; pancreatic Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma; post
R1 or R2 resection with
no evidence of disease
progression, or
metastases (for use in a
Medicare approved
demonstration project)
G9107 Oncology; disease N N N/A Regence Not considered a
status; pancreatic Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma;
unresectabe at
diagnosis, M1 at
diagnosis, metastatic,
locally recurrent, or
progressive (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 211 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9108 Oncology; disease N N N/A Regence Not considered a
status; panceatic Invalid payable service. Will be
cancer, limited to denied provider write-off.
adenocarcinoma; extent
of disease unknown,
under evaluation, not yet
determined, pre-
surgical, or not listed
(for use in a Medicare
approved demonstration
project)
G9109 Oncology; disease N N N/A Regence Not considered a
status; head and neck Invalid payable service. Will be
cancer, limited to denied provider write-off.
cancers of oral cavity,
pharynx, larynx with
squamous cell as
predominant cell type;
extent of disease initially
established as T1-T2
and N0, M0 (prior to neo-
adjuvant therapy, if any)
with no evidence of
disese progession,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 212 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9110 Oncology; disease N N N/A Regence Not considered a
status; head and neck Invalid payable service. Will be
cancer, limited to denied provider write-off.
cancers of oral cavity,
pharynx, larynx with
squamous cell as
predominant cell type;
extent of disease initially
established as T3-4
and/or N1-3, M0 (prior to
neo adjuvant therapy, if
any) with no evidence of
disease progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9111 Oncology; disease N N N/A Regence Not considered a
status; head and neck Invalid payable service. Will be
cancer, limited to denied provider write-off.
cancers of oral cavity,
pharynx and larynx with
squamous cell as
predominant cell type;
M1 at diagnosis,
metastatic locally
recurrent, or progressive
(for use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 213 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9112 Oncology; disease N N N/A Regence Not considered a
status; head and neck Invalid payable service. Will be
cancer, limited to denied provider write-off.
cancers of oral cavity,
pharynx and larynx with
squamous cell as
predominant cell type;
extent of disease
unknown, not yet
determined, pre-
surgical, or not listed
(for use in a Medicare
approved demonstration
project)
G9113 Oncology; disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to epithelial denied provider write-off.
cancer; pathologic stage
IA-B (grade I) without
evidence of disese
progression, recurrence,
or metastases (for use
in a Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 214 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9114 Oncology; disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to epithelial denied provider write-off.
cancer; pathologic stage
IA-B (grade 2-3); or
stage IC (all gades); or
stage II; without
evidence of disease
progression, recurrence,
o metastases (for use in
a Medicare approved
demonstration project)
G9115 Oncology; disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to epithelial denied provider write-off.
cancer; pathologic stage
III-IV; without evidence
of progression,
recurrence, or
metastases (for use in a
Medicare approved
demonstration project)
G9116 Oncology; disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to epithelial denied provider write-off.
cancer; evidence of
disease pogession or
recurrence, and/or
platinum resistance (for
use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 215 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9117 Oncology; disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to epihelial denied provider write-off.
cancer; extent of
disease unknown, under
evaluation, incomplete
surgical stagng, pre-
surgical staging, or not
listed (for use in a
Medicare approved
demonstation project)
G9123 Oncology; disease N N N/A Regence Not considered a
status; non-hodgkin's Invalid payable service. Will be
lymphoma, limited to denied provider write-off.
follicular lymphoma,
mantle cell lymphoma,
diffuse large B-cell
lymphoma, or
histologically
transformed from
follicular lymphoma to
diffuse large B-cell
lymphoma; relapsed or
refractory (for use in a
Medicare approved
demonstration project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 216 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9124 Oncology; disease N N N/A Regence Not considered a
status; non-hodgkin's Invalid payable service. Will be
lymphoma, limited to denied provider write-off.
follicular lymphoma,
mantle cell lymphoma,
diffuse large B-cell
lymphoma, peripheral T
cell lymphoma or small
lymphocytic lymphoma;
relapsed and refractory
(for use in a Medicare
approved demonstration
project)
G9125 Oncology; disease N N N/A Regence Not considered a
status; non-hodgkin's Invalid payable service. Will be
lymphoma, limited to denied provider write-off.
follicular lympoma,
mantle cell lymphoma,
diffuse large B-cell
lymphoma, peripheral T
cell lymphoma or small
lymphocytic lymphoma,
diagnostic evaluation,
stage not determined,
evaluation of possible
relapse or non-response
to therapy, or not listed
(for use in a Medicare
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 217 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9126 Oncology, disease N N N/A Regence Not considered a
status; ovarian cancer, Invalid payable service. Will be
limited to athologically denied provider write-off.
stage patients with
epithelial cancer; stage
IA/IB (for use in a
Medicare approved
demonstration project)
G9128 Oncology; disease N N N/A Regence Not considered a
status; limited to Invalid payable service. Will be
multiple myeloma, denied provider write-off.
systemic disease; stage
II or higher (for use in a
Medicare approved
demonstration project)
G9129 Oncology; disease N N N/A Regence Not considered a
status; chronic Invalid payable service. Will be
myelogenous leukemia, denied provider write-off.
limited to philadelphia
chromosome positive
and/or BCR-ABL
positive; extent of
disease unknown, under
evaluation, not listed, or
treatment options being
considered (for use in a
Medicare approved
demonstration project
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 218 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9130 Oncology; disease N N N/A Regence Not considered a
status; limited to Invalid payable service. Will be
multiple myeloma, denied provider write-off.
systemic disease; extent
of disease unknown,
under evaluation, or not
listed (for use in a
Medicare approved
demonstration project)
G9131 Oncology; disease N N N/A Regence Not considered a
status; invasive female Invalid payable service. Will be
breast cancer (does not denied provider write-off.
include ductal
carcinoma in situ);
adenocarcinoma as
predominant cell type;
extent of disease
unknown, staging in
progress, or not listed
(for use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 219 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9132 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma;
hormone-
refractory/androgen-
independent (e.g., rising
PSA on anti-androgen
therapy or post-
orchiectomy); clinical
metastases (for use in a
Medicare-approved
demonstration project)
G9133 Oncology; disease N N N/A Regence Not considered a
status; prostate cancer, Invalid payable service. Will be
limited to denied provider write-off.
adenocarcinoma;
hormone-response;
clinical metastases or
M1 at diagnosis (for use
in a Medicare-approved
demonstration project)
G9134 Oncology; disease N N N/A Regence Not considered a
status; non-Hodgkin's Invalid payable service. Will be
lymphoma, any cellular denied provider write-off.
classification; stage I, II
at diagnosis, not
relapsed, not refractory
(for use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 220 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9135 Oncology; disease N N N/A Regence Not considered a
status; non-Hodgkin's Invalid payable service. Will be
lymphoma, any cellular denied provider write-off.
classification; stage III,
IV, not relapsed, not
refractory (for use in a
Medicare-approved
demonstration project)
G9136 Oncology; disease N N N/A Regence Not considered a
status; non-Hodgkin's Invalid payable service. Will be
lymphoma, transformed denied provider write-off.
from original cellular
diagnosis to a second
cellular classification (for
use in a Medicare-
approved demonstration
project)
G9137 Oncology; disease N N N/A Regence Not considered a
status; non-Hodgkin's Invalid payable service. Will be
lymphoma, any cellular denied provider write-off.
classification;
relapsed/refractory (for
use in a Medicare-
approved demonstration
project)
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 221 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
G9138 Oncology; disease N N N/A Regence Not considered a
status; non-Hodgkin's Invalid payable service. Will be
lymphoma, any cellular denied provider write-off.
classification; diagnostic
evaluation, stage not
determined, evaluation
of possible relapse or no-
response to therapy, or
not listed (for use in a
Medicare-approved
demonstration project)
G9139 Oncology; disease N N N/A Regence Not considered a
status; chronic Invalid payable service. Will be
myelogenous leukemia, denied provider write-off.
limited to Philadelphia
chromosome positive
and/or BCR-ABL
positive; extent of
disease unknown,
staging in progress, not
listed (for use in a a
Medicare-approved
demonstration project)
G9140 Frontier extended stay N N N/A Regence Not considered a
clinic demonstration; for Invalid payable service. Will be
a patient stay in a clinic denied provider write-off.
approved for the CMS
demonstration project;
the following measures
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 222 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H0001 Alcohol and / or drug N N N/A Regence Not considered a
assess Invalid payable service. Will be
denied provider write-off.
H0003 Alcohol and / or drug N N N/A Regence Not considered a
screening Invalid payable service. Will be
denied provider write-off.
H0004 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0005 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0008 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0009 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0010 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0011 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 223 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H0012 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0013 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0014 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0016 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0017 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0018 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0019 Alcohol and / or drug N N N/A Regence Not considered a
services Invalid payable service. Will be
denied provider write-off.
H0030 Alcohol and/or drug N N N/A Edit Removed Not considered a
hotline 01-2005 payable benefit of any
member policies.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 224 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H0031 Mental health assement, N N N/A Regence Not considered a
non-physician Invalid payable service. Will be
denied provider write-off.
H0035 Mental health partial N N N/A Regence Not considered a
admission; less than 24 Invalid payable service. Will be
hours denied provider write-off.
H0038 Self-help/peer svc per N N N/A N/A N/A
15min
H0039 Asser com tx face- N N N/A N/A N/A
face/15min
H0040 Assert comm tx pgm per N N N/A N/A N/A
diem
H0041 Fos c chld non-ther per N N N/A N/A N/A
diem
H0042 Fos c chld non-ther per N N N/A N/A N/A
mon
H0043 Supported housing, per N N N/A N/A N/A
diem
H0044 Supported housing, per N N N/A N/A N/A
month
H0045 Respite care services, N N N/A Edit Removed Documentation
not in the home 01-2005 requested as indicated
by Medical Services.
H0046 Mental health services, N N N/A N/A Not considered a
NOC payable benefit of any
member policies.
H0049 Alcohol and/or drug N N N/A Regence Not considered a
screening Invalid payable service. Will be
denied provider write-off.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 225 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H0050 Alcohol and/or drug N N N/A Regence Not considered a
services, brief Invalid payable service. Will be
intervention, per 15 denied provider write-off.
minutes
H1000 Prenatal care, at-risk N Review Member Services N/A N/A
assessment Required Fax 1-888-606-6658
H1001 Prenatal care, at-risk N Review Member Services N/A N/A
enhanced service; Required Fax 1-888-606-6658
antepartum
management
H1002 Prenatal care, at-risk N Review Member Services N/A N/A
enhanced service; care Required Fax 1-888-606-6658
coordination
H1003 Prenatal care, at-risk N Review Member Services N/A N/A
enhanced service; Required Fax 1-888-606-6658
education
H1004 Prenatal care, at-risk N Review Member Services N/A N/A
enhanced service; follow- Required Fax 1-888-606-6658
up home visit
H1005 Prenatal care, at-risk N Review Member Services N/A N/A
enhanced service Required Fax 1-888-606-6658
pakage (includes H1001
- H1004)
H1010 Nonmed family planning N N N/A N/A N/A
ed
H1011 Family assessment N N N/A N/A N/A
H2001 Rehabilitation program, N Review Member Services Benefit May not be a covered
per 1/2 day Required Fax 1-888-606-6658 benefit.
H2010 Comprehensive N N N/A Edit Removed Call Customer Service
Medication Services, per 01-2005 to verify benefit
15 minutes information at 1-866-699-
8170
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 226 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H2011 Crisis Intervention N N N/A Edit Removed Call Customer Service
Service, per 15 minutes 01-2005 to verify benefit
information at 1-866-699-
8170
H2012 Behavioral Health Day N N N/A Edit Removed Call Customer Service
Treatment, per hour 01-2005 to verify benefit
information at 1-866-699-
8170
H2013 Psychiatric health facilty N N N/A Regence Not considered a
service; per diem Invalid payable service. Will be
denied provider write-off.
H2014 Skills Training and N N N/A Edit Removed Not considered a
Development, per 15 01-2005 payable benefit of any
minutes member policies.
H2015 Comprehensive N N N/A Edit Removed Not considered a
Community Support 01-2005 payable benefit of any
Services, per 15 member policies.
minutes
H2016 Comprehensive N N N/A Edit Removed Not considered a
Community Support 01-2005 payable benefit of any
Services, per diem member policies.
H2017 Psychosocial N N N/A Edit Removed Call Customer Service
Rehabilitation Services, 01-2005 to verify benefit
per 15 minutes information at 1-866-699-
8170
H2018 Psychosocial N N N/A Edit Removed Call Customer Service
Rehabilitation Services, 01-2005 to verify benefit
per diem information at 1-866-699-
8170
H2019 Therapeutic Behavioral N N N/A Edit Removed Call Customer Service
Services, per 15 01-2005 to verify benefit
minutes information at 1-866-699-
8170
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 227 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H2020 Therapeutic Behavioral N N N/A Edit Removed Call Customer Service
Services, per diem 01-2005 to verify benefit
information at 1-866-699-
8170
H2021 Community-Based N N N/A N/A N/A
Wrap-Around Services,
per 15 minutes
H2022 Community-Based N N N/A N/A N/A
Wrap-Around Services,
per diem
H2023 Supported Employment, N N N/A N/A N/A
per 15 minutes
H2024 Supported Employment, N N N/A N/A N/A
per diem
H2025 Ongoing Support to N N N/A N/A N/A
Maintain Employment,
per 15 minutes
H2026 Ongoing Support to N N N/A N/A N/A
Maintain Employment,
per diem
H2027 Psychoeducational N N N/A Edit Removed Call Customer Service
Service, per 15 minutes 01-2005 to verify benefit
information at 1-866-699-
8170
H2028 Sexual Offender N N N/A N/A N/A
Treatment Service, per
15 minutes
H2029 Sexual Offender N N N/A N/A N/A
Treatment Service, per
diem
H2030 Mental Health N N N/A N/A N/A
Clubhouse Services, per
15 minutes
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 228 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
H2031 Mental Health N N N/A N/A N/A
Clubhouse Services, per
diem
H2032 Activity Therapy, per 15 N N N/A Edit Removed Call Customer Service
minutes 01-2005 to verify benefit
information at 1-866-699-
8170
H2033 Multisystemic Therapy N N N/A Edit Removed Call Customer Service
for Juveniles, per 15 01-2005 to verify benefit
minutes information at 1-866-699-
8170
H2034 Alcohol and/or Drug N N N/A N/A N/A
Abuse Halfway House
Services, per diem
H2035 Alcohol and / or drug N N N/A Regence Not considered a
treatment program, per Invalid payable service. Will be
hour denied provider write-off.
H2036 Alcohol and / or drug N N N/A Regence Not considered a
treatment program, per Invalid payable service. Will be
diem denied provider write-off.
H2037 Developmental Delay N N N/A Edit Removed Call Customer Service
Prevention Activities, 01-2005 to verify benefit
Dependent Child of information at 1-866-699-
Client, per 15 minutes 8170
J0129 Injection, Abatacept, 10 Preauth N Pharmacy N/A Documentation
mg Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J0135 Adalimumab injection Preauth N Pharmacy N/A Documentation
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 229 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J0205 Injection, alglucerase N N N/A N/A N/A
J0215 Injection, alefacept Preauth N Pharmacy N/A Documentation DRU088
(Amevive) Required Fax 1-800-884-4282 requested: Send letter of
medical necessity and
six months of chart
notes for review.
J0256 Injection, alpha 1 - N N N/A N/A N/A DRU3
proteinase inhibitor (03-3003)
J0470 Injection, dimercaprol N N N/A Edit Removed Documentation DRU089 MED6
04-2007 requested: Medical (07-2003)
records pertinent to the
diagnosis.
J0585 Botulinum toxin type A Preauth N Pharmacy N/A Documentation DRU006
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J0587 Botulinum toxin type B Preauth N Pharmacy N/A May be considered DRU048
Required Fax 1-800-884-4282 investigational.
Documentation
requested: Medical
records pertinent to the
diagnosis.
J0600 Injection, edetate N N N/A Edit Removed Documentation DRU089 MED6
calcium disodium 04-2007 requested: Medical (07-2003)
records pertinent to the
diagnosis.
J0630 Injection, calcitonin- N N N/A N/A N/A SUR110
salmon up to 400 units
J0725 Injection, chorionic N Review Member Services Benefit May not be a covered
gondadotropin Required Fax 1-888-606-6658 benefit. Need clinical
records pertinent to
diagnosis, treatment
plan and planned
duration of use.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 230 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J0881 Darbepoetin alfa, non- Preauth N Pharmacy N/A Refer to the specific DRU076
ESRD (Aranesp) Required Fax 1-800-884-4282 medication policy to
determine medical
necessity for coverage
J0882 Injection, darbepoetin, Preauth N Pharmacy N/A Refer to the specific DRU076
(for ESRD use), per 1 Required Fax 1-800-884-4282 medication policy to
mcg determine medical
necessity for coverage
J0885 Injection, epoetin alpha Preauth N Pharmacy N/A Refer to the specific DRU012
(for non-ESRD use), per Required Fax 1-800-884-4282 medication policy to
1,000 units determine medical
necessity for coverage
J0886 Injection, epoetin alpha Preauth N Pharmacy N/A Refer to the specific DRU012
(for ESRD use), per Required Fax 1-800-884-4282 medication policy to
1,000 units determine medical
necessity for coverage
J0895 Injection, deferoxamine N N N/A Edit Removed Documentation DRU089 MED6
mesylate 04-2007 requested: Medical (07-2003)
records pertinent to the
diagnosis.
J0970 Estradiol valerate N N N/A N/A N/A
injection
J1000 Depo-estradiol N N N/A N/A N/A
cypionate injection
J1055 Injection, N N N/A Edit Removed May not be a covered
medroxprogesterone 01-2005 benefit. Need clinical
acetate for contraeptive records pertinent to
use diagnosis, treatment
plan and planned
duration of use.
J1060 Testoterone cypionate 1 N N N/A N/A N/A
ml
J1325 Injection, epoprostenol N N N/A N/A N/A DRU011
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 231 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J1380 Estradiol valerate 10 mg N N N/A N/A N/A
injection
J1390 Estradiol valerate 20 mg N N N/A N/A N/A
injection
J1438 Etanercept injection Preauth N Pharmacy N/A Documentation DRU035,
Required Fax 1-800-884-4282 requested: Obtain DRU110
clinical records pertinent
to diagnosis, treatment
plan and Modified Health
Assessment
Questionaire (MHAQ)
score.
J1440 Injection, filgrastim (G- N N N/A N/A N/A DRU110 DRU009
CSF), 300 mcg
J1441 Injection, filgrastim (G- N N N/A N/A N/A DRU009
CSF), 480 mcg
J1460 Gamma globulin 1 CC N N N/A N/A N/A
injection
J1470 Gamma globulin 2 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1480 Gamma globulin 3 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1490 Gamma globulin 4 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1500 Gamma globulin 5 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1510 Gamma globulin 6 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1520 Gamma globulin 7 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1530 Gamma globulin 8 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 232 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J1540 Gamma globulin 9 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1550 Gamma globulin 10 CC N Review Member Services N/A N/A
injection Required Fax 1-888-606-6658
J1560 Gamma globulin > 10 N Review Member Services N/A N/A
CC injection Required Fax 1-888-606-6658
J1561 Gamunex injection Preauth N Pharmacy N/A Documentation DRU020
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J1562 Injection, immune Preauth N Pharmacy N/A Documentation DRU020
globulin, subcutaneous, Required Fax 1-800-884-4282 requested: Medical
100 mg records pertinent to the
diagnosis.
J1565 RSV-IVIG, Synagis, N N N/A N/A N/A DRU020
Respigam
J1566 Immune globulin, Preauth N Pharmacy N/A Documentation DRU020
powder Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J1567 Immune globulin, liquid N N N/A N/A N/A DRU020
Code
deleted
12/31/20
07
J1568 Octagam injection Preauth N Pharmacy N/A Documentation DRU020
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J1569 Gammagard liquid Preauth N Pharmacy N/A Documentation DRU020
injection Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 233 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J1572 Flebogamma injection Preauth N Pharmacy N/A Documentation DRU020
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J1610 Injection, glucagon HCl, N N N/A N/A N/A DRU110
per 1 mg
J1645 Injection, dalteparin N N N/A N/A N/A DRU110
sodium, per 1,000 units
J1655 Injection, tinzaparin N N N/A N/A N/A DRU110
sodium, 1000 IU
J1670 Tetanus immune N Review Member Services N/A N/A
globulin injection Required Fax 1-888-606-6658
J1745 Injection, infliximab, 10 Preauth N Pharmacy N/A Documentation DRU036
mg Required Fax 1-800-884-4282 requested: Obtain
clinical records pertinent
to diagnosis, treatment
plan and Modified Health
Assessment
Questionaire (MHAQ)
score.
J1785 Injection, imiglucerase, Preauth N Pharmacy N/A Documentation DRU002
per unit Required Fax 1-800-884-4282 requested: Clinical
records pertinent to
diagnosis and treatment
plan.
J1825 Injection, interferon beta- N N N/A N/A N/A DRU110
1a, 33 mcg
J1830 Injection, interferon beta- N N N/A N/A N/A DRU108,
1b (Betaseron) DRU110
Effective Date: 11/1/2008
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J2170 Injection, Mecasermin, 1 Preauth N Pharmacy N/A Documentation
mg Required Fax 1-800-884-4282 requested: Clinical
records pertinent to
diagnosis and treatment
plan.
J2310 Injection, naloxone HC1 N N N/A Edit Removed May be considered MH14
10-2003 investigational; Need
clinical records pertinent
to diagnosis and
treatment plan.
J2323 Natalizuamb injection Preauth N Pharmacy N/A Documentation DRU111
Required Fax 1-800-884-4282 requested: Medical
records pertinent to the
diagnosis.
J2355 Injection, oprelvekin, 5 N N N/A N/A N/A SUR110
mg
J2357 Omalizumab injection Preauth N Pharmacy N/A Physician should enroll DRU087
(Xolair) Required Fax 1-800-884-4282 patient with Curascript
pharmacy and send
medical records with lab
results
J2505 Injection, pegfilgrastim, N N N/A N/A N/A SUR110
6 mg
J2792 Injection, Rho D N N N/A N/A N/A DRU020
immune globulin,
intravenous
J2820 Injection, sargramostim N N N/A N/A N/A DRU110 DRU009
J2940 Injection, somatrem, 1 N Review Pharmacy Benefit Call Customer Service DRU015,
mg Required Fax 1-800-884-4282 to verify benefit DRU110
information at 1-866-699-
8170
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 235 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J2941 Injection, somatropin, 1 Preauth N Pharmacy Benefit Documentation DRU015,
mg Required Fax 1-800-884-4282 requested: Clinical DRU110
records pertinent to
diagnosis and treatment
plan.
J3010 Fentanyl citrate injection N N N/A N/A N/A
J3030 Injection, sumatriptan N N N/A N/A N/A DRU055,
succinate DRU110
J3110 Terparatide injection N N N/A N/A N/A
J3396 Injection, verteporfin 0.1 N N N/A N/A N/A MED87
mg
J3465 Injection, vorconazole N N N/A N/A N/A DRU097
J3490 Unclassified drugs N N N/A N/A N/A DRU001,
DRU029,
DRU036,
DRU049,
DRU081,
DRU097,
DRU120,
DRU121
J3520 Edetate disodium N N N/A Edit Removed Documentation DRU089
05-2007 requested: Medical
records pertinent to the
diagnosis.
J3535 Metered dose inhaler N N N/A Regence Not considered a
drug Invalid payable service. Will be
denied provider write-off.
J3570 Laetrile, amydalin, N N N/A Investigational Considered
vitamin B-17 Denial investigational;
investigational services
are not covered.
J3590 Unclassified biologics N N N/A N/A N/A DRU087
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 236 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J7130 Hypertonic saline N N N/A Edit Removed May be investigational; SUR94
solution 03-2003 need clinical records
pertinent to the
diagnosis and treatment
plan.
J7300 Intrauterine copper N N N/A Edit Removed May not be a covered
contraceptive 01-2005 benefit. Need clinical
records pertinent to
diagnosis, treatment
plan and planned
duration of use.
J7302 Levonorgestrel IU N N N/A Edit Removed Call Customer Service DRU079
contraceptive system 01-2005 to verify benefit
information at 1-866-699-
8170
J7303 Contraceptive supply, N N N/A Benefit Call Customer Service
hormone containing to verify benefit
vaginal ring, each information at 1-866-699-
8170
J7308 Aminolevulinic acid HC1 N N N/A Edit Removed May be investigational; MED99
for topical admin 07-2008 need clinical records
pertinent to the
diagnosis and treatment
plan.
J7321 Hyaluronan or N N N/A N/A N/A
derivative, Hyalgan or
Supartz, for intra-
articular injection, per
dose
J7330 Autologous cultured N N N/A Investigational Considered SUR87
chondrocytes, implant Denial investigational;
investigational services
are not covered.
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 237 of 908
Regence Clinical Edits by Code List
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J7341 Dermal (substitute) N Review Medical Services Medical Documentation
tissue of non-human Required Fax 1-800-453-4341 Necessity requested: Need letter of
origin, with or without medical necessity along
other bioengineered or with 6-12 months clinical
processed elements, records pertinent to
with metabolically active diagnosis and treatment
elements, per square plan.
centimeter
J7342 Metabolically active Preauth Review Medical Services Potential Documentation
tissue Required Required Fax 1-800-453-4341 Investigational requested: Medical
records pertinent to the
diagnosis and treatment
plan.
J7599 Immunosuppressive N N N/A N/A N/A DRU020
drug, NOC
J7699 Inhalation solution for N N N/A N/A NDC is required.
DME
J7799 Non-inhalation drug for N N N/A N/A N/A
DME
J8498 Antiemetic rectal / supp N N N/A N/A NDC is required.
NOS
J8499 Prescription drug, oral, N N N/A N/A N/A
non-chemotherapeutic,
NOS
J8565 Gefinib oral N N N/A N/A N/A
J8597 Antiemetic drug oral N N N/A N/A N/A
NOS
J8999 Prescription drug, oral, N N N/A N/A N/A
chemotherapeutic, NOS
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 238 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9000 Doxorubicin HC1 N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 239 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9001 Doxorubicin HC1, all N N N/A N/A N/A TRA22,
lipid formulations TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 240 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9010 Alemtuzum N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 241 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9015 Aldesleukin N N N/A Edit Removed Documentation TRA22,
06-2008 requested: Medical TRA23,
records pertinent to the TRA24,
diagnosis. TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 242 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9017 Arsenic trioxide N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 243 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9020 Asparaginase N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 244 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9031 BCG live (intravesical) N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 245 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9040 Bleomycin sulfate N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 246 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9045 Carboplatin N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 247 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9050 Carmustine N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 248 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9060 Cisplatin, powder or N N N/A N/A N/A TRA22,
solution TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 249 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9062 Cisplatin, 50 mg N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 250 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9065 Injection, cladrbine N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 251 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9070 Cyclophosphamide, 100 N N N/A N/A N/A TRA22,
mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 252 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9080 Cyclophosphamide, 200 N N N/A N/A N/A TRA22,
mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 253 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9090 Cyclophosphamide, 500 N N N/A N/A N/A TRA22,
mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 254 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9091 Cyclophosphamide, 1 N N N/A N/A N/A TRA22,
mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 255 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9092 Cyclophosphamide, 2 N N N/A N/A N/A TRA22,
mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 256 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9093 Cyclophosphamide, N N N/A N/A N/A TRA22,
lyophilized, 100 mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 257 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9094 Cyclophosphamide, N N N/A N/A N/A TRA22,
lyophilized, 200 mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 258 of 908
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Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9095 Cyclophosphamide, N N N/A N/A N/A TRA22,
lyophilized, 500 mg TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 259 of 908
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Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9096 Cyclophosphamide, N N N/A N/A N/A TRA22,
lyophilized 1 g TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 260 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9097 Cyclophosphamide, N N N/A N/A N/A TRA22,
lyophilized 2 g TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 261 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9100 Cytarabine, 100 mg N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 262 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9110 Cytarabine, 500 mg N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 263 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9120 Dactinomycin, 0.5 mg N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33,
TRA34,
TRA35,
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 264 of 908
Regence Clinical Edits by Code List
Complete List
Applies to All Commercial Products (excl. Medicare)
HCPCS/ Description Preauth Review Who Reviews? Edit Type Additional Information Med Pol# Archv'd
CPT Required Y/N Required When?
Code
J9130 Dacarbazine, 100 mg N N N/A N/A N/A TRA22,
TRA23,
TRA24,
TRA25,
TRA26,
TRA27,
TRA28,
TRA29,
TRA30,
TRA31,
TRA32,
TRA33.
TRA34,
TRA35.
TRA36,
TRA37,
TRA38,
TRA39,
TRA40
Effective Date: 11/1/2008
Date Generated: 11/3/2008 The presence of codes on this list does not necessarily indicate coverage under the member's benefit contract. Page 265 of 908
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