U400 Med Tech Database1

User Manual: U400

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Note regarding Federal members
The Federal Employee Health Benefit Program (FEHBP/FEP) requires that procedures, devices or laboratory tests approved by the U.S. Food and Drug Administration
(FDA) may not be considered investigational for the purposes approved and thus these procedures, devices or laboratory tests may be assessed only on the basis of
their medical necessity.

Note regarding Humanitarian Device Exemption (HDE)


Humanitarian Use Device (HUD) — a medical device intended to benefit patients in the treatment or diagnosis of a disease or condition that affects or is
manifested in not more than 8,000 individuals in the United States per year. (Previously 4000 individuals; increased to 8000 on June 7, 2017)



Humanitarian Device Exemption (HDE) — a marketing application for an HUD. An HDE is exempt from the effectiveness requirements of Sections 514 and
515 of the FD&C Act and is subject to certain profit and use restrictions.

Note regarding Transplant Program Case Management
EmblemHealth's transplant program manages members with health care needs associated with having or preparing for a solid organ or bone marrow transplant. All
transplant services are reviewed with the medical director assigned to support the transplant case management program. All requested transplant services are
reviewed for medical necessity and evidence-based criteria are utilized to support the best care coordination and outcomes for EmblemHealth transplant members. To
request transplant case management services for the EmblemHealth transplant program, members and providers may call 1-800-447-0768.

For additional information pertaining to experimental drugs, new drugs or medical technologies please click here
EmblemHealth’s Medical Guidelines are accessible through hyperlinks within the database or by clicking here

Key

N = No

Y = Yes

FFS = fee for service

HDE = humanitarian device exemption

TECHNOLOGY

COMMERCIAL

MEDICARE

MEDICAID

LAST REVIEW

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

2/9/2018

N

N

N

12/9/2016

AbioCor® Implantable Replacement Heart
NOTE: This investigational device is FDA-approved as a Humanitarian Device Exemption
(HDE) for the treatment of severe biventricular end stage heart disease patients who are
not cardiac transplant candidates and who Are < 75 years old, require multiple inotropic
support, are not treatable by LVAD destination therapy, and are not weanable from
biventricular support if on such support. Pre certification requests when presented as such
will be case by case reviewed for all LOBs EXCEPT for Medicare members, whose costs
relating directly to the provision of services related to the National Coverage Determination
(NCD) (that were non-covered services prior to the issuance of the NCD) will be paid by CMS
intermediaries and carriers when beneficiaries are enrolled in a clinical study that meets the
criteria put forth within the NCD.

CPT ([33927, 33928, 33929 eff. 01/01/2018], [(0051T, 0052T, 0053T del.
01/01/2018])
Acticon™ Neosphincter artificial bowel sphincter
(See also Fecal Incontinence Treatment)
CPT (No specific code)
Actigraphy as a stand-alone measurement parameter for the diagnosis of
obstructive sleep apnea
(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (95803)
Agilium Freestep for unicompartmental osteoarthritis

HCPCS (A9285)
Alcohol septal ablation for hypertrophic cardiomyopathy

Y

CPT (93583, 93799)

Y

Y

4/21/2017

SEE
CMS
NOTE

SEE
Transplant
Program Case
Management

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

4/21/2017

N

N

N

7/14/2017

Y

Y

Y

1/19/2017

N

N

N

7/14/2017

Y

Y

Y

5/12/2017

N

N

N

5/12/2017

Allogeneic hematopoietic stem cell transplantation (HSCT) for multiple
myeloma, myelofibrosis and sickle cell disease
Note: Medicare members, whose costs relating directly to the provision of services related
to the CMS Decision Memo for Stem Cell Transplantation (that were non-covered services
prior to the issuance of the Memo) will be paid by CMS intermediaries and carriers, as part
of the Coverage with Evidence Development (CED) program, when beneficiaries are
enrolled in a clinical study that meets the criteria put forth within the Memo.

SEE
Transplant
Program Case
Management

(See also National Coverage Determinations Manual for complete Medicare coverage
information regarding medically necessary clinical conditions for stem cell transplantation)

CPT (38205, 38240, 38242, 38243, S2142, S2150)
AlloSure® Donor-Derived Cell-Free DNA Test to assess probability of
allograft rejection in kidney transplant recipients
CPT (81479)
Altered auditory feedback devices
(E.g., SpeechEasy®/FluencyMaster)

CPT (No specific code)
HCPCS (E1399)
Amniotic membrane transplantation for ocular reconstruction
CPT (65778, 65779, 65780, 65781, 65782, V2790)
Apheresis therapy with selective high density lipoprotein (HDL)
delipidation and plasma reinfusion
CPT (0342T)
Atherectomy — peripheral, open or percutaneous, infrainguinal
atherosclerotic arterial occlusive disease
CPT (37225, 37227, 37229, 37231)
Atherectomy — peripheral, open or percutaneous, of arterial vasculature
(E.g., abdominal aorta, brachiocephalic, iliac, renal, etc.)

CPT (0234T, 0235T, 0236T, 0237T, 0238T)
Aqueous Shunts/implants for primary open angle glaucoma (FDAapproved external approach insertion)
(E.g., Ahmed glaucoma implant, Baerveldt seton, Ex-PRESS mini glaucoma shunt, Glaucoma
pressure regulator Krupin-Denver valve implant, Molteno implant, Schocket shunt; e.g.,
ExPRESS® Ophthalmic Glaucoma Device)

(See also Glaucoma Surgery)
CPT (66179, 66180, 66183, 66184,66185, 67255)
Aqueous shunts/implants for primary open angle glaucoma (without
FDA approval and/or internal approach insertion)
(E.g., CyPass® iStent®, iStent Supra, Eyepass, or DeepLight SOLX® Gold Shunt, AqueSys XEN
Gel Stent)

(See also Glaucoma Surgery)
Note: Noncoverage exception — the iStent, an internal-approach device, is considered
medically necessary for members with mild to moderate glaucoma who are on medication

and when performed with cataract surgery

CPT (0191T, 0253T, 0376T, 0449T, 0450T, [0474T eff. 07/01/2017])
Argus II Retinal Prosthesis System for advanced retinitis pigmentosa
Note: The Argus II is an investigational device that is FDA-approved as a Humanitarian
Device Exemption (HDE) for use in adults, age 25 years or older, with severe to profound RP
who have bare light perception (can perceive light, but not the direction from which it is
coming) or no light perception in both eyes, evidence of intact inner layer retina function,
and a previous history of the ability to see forms. Patients must also be willing and able to
receive the recommended post-implant clinical follow-up, device fitting, and visual
rehabilitation. Therefore, pre certification requests when presented as such will be
reviewed on a case-by-case basis.

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

N

N

N

4/21/2017

N

N

N

2/9/2018

N

N

N

2/10/2017

N

N

N

7/14/2017

N

N

N

12/12/2017

N

SEE NOTE

N

7/14/2017

N

N

N

7/8/2017

CPT (0100T, [0472T, 0473T new eff. 07/01/17])
Arthroscopic knee surgery with primary diagnosis of osteoarthritis




Arthroscopic lavage used alone for the osteoarthritic knee
Arthroscopic debridement for osteoarthritic patients presenting with knee pain
only
Arthroscopic debridement and lavage with or without debridement for patients
presenting with severe osteoarthritis as defined in the Outerbridge classification
scale, grades III and IV.

(See also Arthroscopy for the Osteoarthritic Knee for covered indications)
CPT (29870, 29871, 29877)
HCPCS (G0289)
Antibody assay testing for detecting neutralizing antibodies against
interferon beta (Betaseron) for multiple sclerosis patients
(E.g., Bab Sreen, NabFeron®)
CPT (86382)
Assisted Embryo Hatching
(See also Assisted Reproductive Technologies for case-by-case
consideration)
CPT (89253)
Audiometry — pure tone/speech (threshold), automated
CPT (0208T, 0209T, 0210T, 0211T, 0212T)
Autologous adipose-derived regenerative cell therapy for scleroderma in
the hands
CPT (0489T, 0490T eff. 01/01/2018)
Autologous blood-derived products/platelet growth factors/platelet rich
plasma for bone/tissue injury (including surgically created wounds and
non-unions; muscle, tendon and ligament injuries
(E.g., Achilles tendinopathy or rupture, anterior cruciate ligament, epicondylitis or type II
shoulder impingement, plantar fasciitis, rotator cuff, etc.)
For Medicare members see Coverage with Evidence Development Autologous Platelet-Rich
Plasma

CPT (0232T)
HCPCS (S9055, G0460)
Autologous bone marrow cell therapy, intramuscular, with preparation of
harvested cells, multiple injections, one, leg, including ultrasound
guidance (if performed)

CPT (0263T, 0264T, 0265T)
Autologous chondrocyte implantation (aka transplantation)
CPT (27412)

Y

Y

Y

10/13/2017

N

N

N

7/14/2017

HCPCS (J7330, S2112)
Automated evacuation of meibomian glands — heat and intermittent
pressure
(E.g., LipiFlow [TearScience®])

CPT (0207T)
Avise MCV™ for the diagnosis and prognosis of rheumatoid arthritis
(See also Gene Expression Profiling)
CPT (83520)

2/9/2018
N

N

N

MCV+

2/9/2018

CPT (83520, 86200)
Avise® MTX (aka Avise PG) for measuring methotrexate polyglutamates
for rheumatoid arthritis (metabolite marker testing)
(See also Gene Expression Profiling)

N

Y

N

2/9/2018

CPT (81479)
Avise® Lupus (aka Avise SLE) diagnostic biomarker panel for diagnosis of
systemic lupus erythematosus (SLE)
2/9/2018

(See also Gene Expression Profiling)
CPT (83520, 86039, 86225, 88184, 88185, 88187)

N

N

N

Avise® CTD (aka Avise SLE+)
(See also Gene Expression Profiling)

2/9/2018

CPT (83520, 86039, 86225, 88184, 88185, 88187, 86235, 86200)
Balloon sinuplasty
(E.g., Balloon Sinuplasty System™ Functional Infundibular Endoscopic Sinus System [FinESS],
Relieva Seeker Balloon Sinuplasty System)
Note: When performed with functional endoscopic sinus surgery (FESS), it is considered
integral to FESS and not separately reimbursable

Y

Y

Y

10/13/2017

N

N

N

12/12/2017

N

N

N

3/10/2017

Y

Y

Y

3/10/2017

CPT (31295, 31296, 31297, [31298 eff. 01/01/2018])
Behavioral prevention program for diabetes — online/electronic
(See also Nutritional Counseling Services)
CPT (0488T eff. 01/01/2018)
Biliopancreatic diversion (BPD) (Scopinaro procedure) for clinically severe
obesity
(See also Bariatric Surgery)
CPT (43847)
Biliopancreatic diversion (BPD) with duodenal switch (DS) for clinically
severe obesity
(See also Bariatric Surgery)
CPT (43845)

Bioelectrical impedance (whole body)
CPT (0358T)

N

N

N

7/8/2017

N

N

N

7/8/2017

Y

Y

Y

7/14/2017

N

N

N

1/12/2018

Y

Y

Y

10/13/2017

Bioimpedance (a form of plethysmography) for the assessment of
lymphedema
(E.g. L-Dex U400)
CPT (93702 )
Note: When plethysmography is reported in conjunction with 93970 or 93971 (as an adjunct
to standard diagnosis) it is also not covered

Bioengineered skin/tissue products for reconstruction
(E.g., abdominal, breast)
AlloDerm®

Q4116

Cortiva™ ™ (prev. AlloMax, NeoForm™),

Q4100- Breast & Misc.
C1781 - Hernia

Cymetra® Micronized AlloDerm® injectable for vocal
cord paralysis

Q4112

Note: Not considered medically necessary for any
other condition
DermaMatrix (discontinued 6/2014)

N/A

FlexHD

Q4128

Bioengineered skin/tissue products for reconstruction
(E.g., abdominal, breast)
DermACELL®

Q4122

AlloPatch HD, Matrix HD

Q4128

Interfyl™ Human Connective Tissue Matrix

Q4171

Marigen

Q4158

NeoxFlo® or ClarixFlo™

Q4155

Neox® Wound Matrix

Q4148, Q4156

Repriza

Q4143

Strattice™ Reconstructive

Q4130

SurgiMend®

(No specific code)

XCM BIOLOGIC® Tissue Matrix

Q4142

XenMatrix™

No specific code

Bioengineered skin/tissue products for wounds/surgical applications
(E.g., diabetic foot ulcers [DFUs], venous stasis ulcers [VSUs], burns)

(See also Application of Bioengineered Skin Substitutes to Lower
Extremity Chronic Non-Healing Wounds)
Affinity

Q4159

AlloSkin™, AlloSkin RT, AlloSkin AC

Q4115, Q4123, Q4141

AlloPatch HD, FlexHD or Matrix HD

Q4128

Amnioband or Guardian per square cm

Q4151 (AmnioBand Viable and
AmnioBand SL)

AmnioBand 1mg

Q4168 (AmnioBand
Particulate)

AmnioExcel or BioDExCel

Q4137

Amniopro, Bioskin, Biorenew, Woundex, Amniogen45, Amniogen-200, per square centimeter

Q4163

Apligraf®

Q4101

Architect, Architect PX or Architect FX

Q4147

Artacent™

Q4169

Biodfence and Biodfence dryflex

Q4140, Q4138

bio-ConneKt® Wound Matrix

Q4161

Biovance

Q4154

CYGNUS

Q4170

Cytal™

Q4166

DermACELL®

Q4122

Dermagraft®

Q4106

DermaPure

Q4152

Dermavest

Q4153

EpiFix®

Q4131

EZ-DERM™

Q4136

FortaDerm™ (New name PuraPly™ eff. 7/1/2015)

Q4172

PuraPly™ Antimicrobial Wound Matrix (PuraPly AM)
PuraPly™ Wound Matrix (PuraPly)
GammaGraft

Q4111

Grafix® core, Grafix® prime

Q4132, Q4133

Helicoll™

Q4164

hMatrix®

Q4134

Hyalomatrix®

Q4117

Integra® Bilayer Matrix, Integra, Integra Matrix

Q4104, Q4108

Integra Dermal Regeneration Template

Q4105

keramatrix®

Q4165

Marigen

Q4158

MatriStem® MicroMatrix, MariStem wound Matrix,
MicroStem Burn Matrix

Q4118, Q4166 for Cytal

(New commercial name for MariStem is Cytal)
Mediskin

Q4135

MemoDerm™, DermaSpan, TranZgraft or InteguPly

Q4126

MIRODERM™

Q4175

Nushield

Q4160

OASIS® Wound Matrix, Oasis Burn Matrix,Ultra Trilayer Matrix

Q4102, Q4103, Q4124

PalinGen or PalinGen XPlus, per square centimeter (to
identify PalinGen®) Membrane and PalinGen®
Hydromembrane

Q4173

PalinGen or ProMatrX (to identify ProMatrX, PalinGen

Q4174

Flow and PalinGen SportFlow
PriMatrix™

Q4110

Revitalon

Q4157

Talymed™

Q4127

Tensix

Q4146

Theraskin®

Q4121

TransCyte

Q4100, Q4182 (eff.
01/01/2018)

Bioengineered skin/tissue products for wounds/surgical applications (E.g.,
diabetic foot ulcers [DFUs], venous stasis ulcers [VSUs], burns)
GRAFTJACKET®

N

Y

N

10/13/2017

N

N

N

10/13/2017

N

N

N

6/9/2017

N

N

N

1/19/2017

N

N

N

1/19/2017

Q4107

Bioengineered skin/tissue products for wounds/surgical applications
(E.g., diabetic foot ulcers [DFUs], venous stasis ulcers [VSUs], burns)

(See also Application of Bioengineered Skin Substitutes to Lower
Extremity Chronic Non-Healing Wounds)
Allowrap

Q4150

AmnioFix®

J3590

Amniopro Flow, Bioskin Flow, Biorenew Flow,
Woundex Flow, Amniogen-A, Amniogen-C, 0.5 cc

Q4162

Amniomatrix® or biodmatrix, injectable

Q4139

Arthroflex®

Q4125

Epifix injectable

Q4145

Excellagen

Q4149

GRAFTJACKET® XPRESS

Q4113

Integra Flowable Wound Injectable

Q4114

Repriza

Q4143

TruSkin™

Q4167

Unite®

No Specific Code

Neopatch, per square centimeter

Q4176 (eff. 01/01/2018)

Floweramnioflo, 0.1 cc

Q4177 (eff. 01/01/2018)

Floweramniopatch, per square centimeter

Q4178 (eff. 01/01/2018)

Flowerderm, per square centimeter

Q4179 (eff. 01/01/2018)

Revita, per square centimeter

Q4180 (eff. 01/01/2018)

Amnio wound, per square centimeter

Q4181 (eff. 01/01/2018)

Biomagnetic Therapy
CPT (97799)
Biomarker testing — growth stimulation expressed gene 2 (ST2,
Interleukin 1 receptor like-1) for assessing multiple medical conditions
including cardiovascular diseases
(See also Gene Expression Profiling)
CPT (83006)
Biomarker testing — Des-gamma-carboxy prothrombin (DCP) for

diagnosing and monitoring hepatocellular carcinoma (HCC) and
other indications

(aka prothrombin produced by vitamin K absence or antagonism II
[PIVKA II])
CPT (83951)
Biomarker testing for assessing and managing iron deficiency anemia in
late-stage chronic kidney disease

N

N

N

7/14/2017

N

N

N

7/14/2017

N

Y

N

2/10/2017

N

N

N

7/8/2017

Y

Y

Y

2/10/2017

N

N

N

12/12/2017

N

N

N

7/14/2017

N

N

N

1/19/2017

N

N

N

1/19/2017

Y

Y

Y

8/11/2017

N

N

N

7/14/2017

CPT (No specific code)
Biomarker testing for assessing cardiac disease risk — secretory type II
phospholipase A2 (sPLA2-IIA)
(E.g., AccuCardia [Zeus Scientific])

CPT (0423T )
Biomarker testing for diagnosis/management of rheumatoid arthritis
(E.g., IdentRA® Panel 2 [Quest Diagnostics, preferred lab; panel includes Rheumatoid
Factor, Cyclic Citrullinated Peptide [CCP] Antibody (IgG) and 14.3.3 eta Protein], Vectra® DA
[Crescendo Bioscience])

(See also Gene Expression Profiling and Vectra DA Coding and Billing
Guidelines for Medicare)
CPT (81490, 83520 86140, 86200, 86431)
Biomarker testing for Alzheimer’s disease (cerebrospinal fluid or urinebased)
(E.g., ADmark® Alzheimer’s Evaluation [Athena])

CPT (83520 )
Biomarker testing for breast cancer — urokinase plasminogen activator
(uPA) and its plasminogen activator inhibitor type 1 (PAI-1)
(See also Gene Expression Profiling and Biomarker Testing for Breast
Cancer)
CPT (85415)
Biomechanical mapping, transvaginal, with report
CPT (0487T eff. 01/01/2018)
Bioness L300 Foot Drop System for traumatic brain Injury (TBI) (aka
functional electrical stimulation)
HCPCS (E0770)
Biosynthetic fistula plugs for enteric/anorectal fistula repair
(E.g., Biodesign Enterocutaneous Fistula Plug, SIS Fistula Plug, Surgisis RVP Recto-Vaginal
Fistula Plug, GORE® BIO -A® Fistula Plug)

CPT (46707)
Biosynthetic Implant for ventral hernia repair/abdominal wall fascial
defect
CPT (0437T)
Blood coagulation home testing devices
HCPCS (E1399, G0248, G0249, G0250)
Body photography — “total” body or “whole” body/computer-based
optical diagnostic devices/imaging techniques for evaluating pigmented

skin lesions suspected of malignancy
(I.e., multispectral digital skin lesion analysis [MSDSLA], Optical coherence tomography,
reflectance confocal microscopy [RCM]; including, but not limited to dermatoscopic
devices/total body systems MoleSafe, such as Episcope™, Nevoscope™, Dermascope™,
MoleMax™, VivaScope®, MelaFind®, MoleMapCD, etc.)

CPT (96904, 96931, 96932, 96933, 96934, 96935, 96936, 0400T, 0401T,
0470T, 0471T [eff. 07/01/2017])
Bone anchored hearing aids
(Access coding and clinical criteria by clicking on link)

Y

Y

Y

3/10/2017

SEE NOTE

SEE NOTE

SEE NOTE

5/12/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

Y

N

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

3/10/17

Bone growth stimulators
(See Osteogenesis Stimulators for covered/noncovered indications)
CPT (20974, 20975, 20979)
HCPCS (E0747, E0748, E0749, E0760, A4559)
Brachytherapy — breast cancer
CPT (19296, 19297, 19298, 76965, 77261, 77262, 77263,77280, 77285,
77290, 77295, 77300, 77316, 77317, 77318, 77750, 77761, 77762, 77763,
77778, 77789, 77790, 77799, 77770, 77771, 77772)
HCPCS (Q3001, 0395T)
Brachytherapy — electronic, skin surface application
CPT (0394T, 0395T)
Note: 0395T (electronic brachytherapy, interstitial or intracavitary) is considered
investigational for interstitial indications. When billed for breast cancer, 0395T is
reimbursable (see row above)

Brachytherapy — endometrial/cervical cancer
CPT (58346, 57155, 57156, 76965, 77261, 77262, 77263, 77280, 77285,
77290, 77295, 77316, 77317, 77318 77750, 77761,77762,77763, 77770,
77771, 77772, 77778, 77789, 77790, 77799)
HCPCS (Q3001)
Brachytherapy — epithelial ovarian cancer
CPT (55920, 76965, 77261, 77262, 77263, 77280, 77285, 77290,77295,
77316, 77317,77318 , 77761, 77762,77763, 77770, 77771, 77772, 77778,
77789, 77790, 77799 )
HCPCS (Q3001)
Brachytherapy — intracoronary for stent restenosis
CPT (77770, 77771, 77772, 92974)
HCPCS (Q3001)
Brachytherapy — prostate, temporary high dose
CPT (55860, 55862,55865, 55875, 55876, 76873, 76965, 77261, 77262,
77263, 77280, 77285, 77290,77295, 77300, 77316, 77317,77318, 77770,
77771, 77772, 77778, 77790, 77799)
HCPCS (Q3001)
Breast ductal endoscopy (aka fiberoptic ductoscopy or mammary
ductoscopy) for breast cancer screening

CPT (No specific code)
Breast ductal lavage for breast cancer screening
(E.g., ForeCYTE Breast Health Test, Halo breast PAP Test System, Mammary Aspirate
Specimen Cytology Test, Pro-Duct Catheter, etc.)

N

N

N

3/10/17

N

N

N

7/14/2017

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

N

N

N

12/12/2017

Y

Y

Y

5/12/2017

N

N

N

5/12/2017

N

N

N

5/12/2017

CPT (19499)
Bronchial thermoplasty for severe asthma
CPT (31660, 31661, 31899)
Bronchoscopy — rigid or flexible, including fluoroscopic guidance; not
considered medically necessary when performed per the CPT code
descriptives below.
Note: The IBV® Valve System is an investigational device that is FDA-approved as a
Humanitarian Device Exemption (HDE) for use to control prolonged air leaks of the lung, or
significant air leaks that are likely to become prolonged air leaks following lobectomy,
segmentectomy, or lung volume reduction surgery (LVRS). An air leak present on postoperative day 7 is considered prolonged unless present only during forced exhalation or
cough. An air leak present on day S should be considered for treatment if it is: 1)
continuous, 2) present during normal inhalation phase of inspiration, or 3) present upon
normal expiration and accompanied by subcutaneous emphysema or respiratory
compromise. IBV Valve System use is limited to 6 weeks per prolonged air leak. The use of
the device is limited to patients who have had endomyocardial biopsy within the previous
month. Therefore, pre certification requests when presented as such will be reviewed on a
case-by-case basis.

CPT
31647 — with balloon occlusion, when performed, assessment of air leak, airway sizing,
and insertion of bronchial valve(s), initial lobe
31648 — with removal of bronchial valve(s), initial lobe
31649 — with removal of bronchial valve(s), each additional lobe (List separately in addition
to code for primary procedure)
31651 — with balloon occlusion, when performed, assessment of air leak, airway sizing, and
insertion of bronchial valve(s), each additional lobe (List separately in addition to code for
primary procedure[s])
31626 – with placement of fiducial markers, single or multiple
31627 – with computer-assisted, image-guided navigation (list separately in addition to
code for primary procedure[s])
31634 - with balloon occlusion, with assessment of air leak, with administration of occlusive
substance (eg, fibrin glue), if performed

Cadaver lung organ perfusion system — initiation, monitoring, surgical
preparation
CPT (0494T, 0495T, 0496T eff. 01/01/2018)
Camera pill — esophageal and small bowel indications
(E.g., PillCam ESO, PillCam SB, Olympus Capsule Endoscope System)

(See also Capsule Endoscopy)
CPT (91110, 91111)
Camera pill — colon (PillCam® Colon)
(See also Capsule Endoscopy)
CPT (0355T)
Camera pill accessory systems to determine gastrointestinal patency
(E.g., Given® AGILE Patency System for Given® PillCam™)

(See also Capsule Endoscopy)
CPT (91299)
Canaloplasty
(See also Canaloplasty and Viscocanalostomy)

Y

Y

Y

4/21/2017

N

N

N

7/14/2017

N

N

N

1/12/2018

N

N

N

7/14/2017

N

N

N

1/12/2018

Y

Y

Y

8/11/2017

N

N

N

1/12/2018

N

N

N

3/10/2017

N

N

N

7/14/2017

CPT (66174, 66175)
Car seat/bed testing for airway integrity, neonate, with continual nursing
observation and continuous recording of pulse oximetry, heart rate and
respiratory rate, with interpretation and report
CPT (94780, 94781)
Cardiac — catheterization (right-heart) with implantation of wireless
pressure sensor in the pulmonary artery, including any type of
measurement, angiography, imaging supervision, interpretation, and
report, includes provision of patient home electronics unit
(See also NGS LCD Cardiac Catheterization and Coronary Angiography)
CPT (93799)
Cardiac — central arterial pressure waveforms analysis
(E.g., SphygmoCor® System)

CPT (93050 )
Cardiac — contractility modulation using an implantable device
(E.g., Cardiac Contractility Modulation [CCM] System Optimizer)

(CPT 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T,
0417T, 0418T)
Cardiac — counterpulsation (external)

(See also Enhanced External Counterpulsation for Chronic Stable Angina)
CPT (92971)
HCPCS (G0166)
Cardiac — counterpulsation (implanted extra-aortic counterpulsation
device [EACD])
CPT (0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T,
0460T, 0461T, 0462T, 0463T)
Cardiac — HeartFlow® digital 3D modeling
CPT ([0501T, 0502T, 0503T, 0504T eff. 01/01/2018], 93799)
Cardiac — hemodynamic monitors, implantable left atrial
(E.g., HeartPOD System, Promote LAP System)

CPT (0293T, 0294T [del. 01/01/2018] No specific code)

Cardiac — leadless pacemaker
(E.g., Micra Transcatheter Pacing System, Nanostim™ Leadless Pacemaker)
Note: Medicare members, whose costs relating directly to the provision of services related
to the NCD for Leadless Pacemakers (that were non-covered services prior to the issuance
of the NCD) will be paid by CMS intermediaries and carriers, as part of the Coverage with
Evidence Development (CED) program, when beneficiaries are enrolled in a clinical study
that meets the criteria put forth within the NCD for the treatment of significant
symptomatic degenerative mitral regurgitation when furnished according to an FDA

N

SEE NOTE

N

1/12/2018

N

SEE NOTE

N

1/12/2018

N

N

N

1/12/2018

N

N

N

6/9/2017

N

N

N

1/12/2018

Y

Y

Y

3/10/2017

Y

Y

Y

7/14/2017

approved indication and when the conditions put forth within the NCD are met. CPT

(0387T, 0388T, 0389T, 0390T, 0391T)
Cardiac — left atrial appendage (LAA) closure devices
(E.g., Amplatzer Amulet/Cardiac Plug devices, AtriClip®, LARIAT Procedure, PLAATO System,
Watchman or any other equivalent device)

(CMS Decision Memo for Percutaneous Left Atrial Appendage (LAA)
Closure Therapy)
Note: Case-by-case consideration will be given (only for FDA-approved devices) to members
with non-valvular atrial fibrillation who:




Are at increased risk for stroke and systemic embolism and are recommended for
anticoagulation therapy
Are deemed by their physicians to be suitable for warfarin
Have an appropriate rationale to seek a nonpharmacologic alternative to
warfarin, taking into account the safety and effectiveness of the device
compared to warfarin

CPT (33340)
Cardiac — left partial ventriculectomy (Batista procedure/ventricular
reduction surgery)
CPT (33542, 33548, 33999)
Cardiac — lipoprotein subclassification testing (aka advanced lipoprotein
testing)
(E.g., VAP Cholesterol Panel [Atherotech®; closed permanently 2/28/2016], FHNEXT
[Ambry])

(See also Lipoprotein Subclassification Testing for Screening, Evaluation
and Monitoring of Cardiovascular Disease)
CPT (No specific code)
Cardiac — myocardial strain imaging (quantitative assessment of
myocardial mechanics using image-based analysis of local myocardial
dynamics)
CPT (0399T)
Note: List separately in addition to code for primary procedure; use in conjunction with
93303, 93304, 93306, 93307, 93308, 93312, 93314, 93315, 93317, 93350, 93351, 93355

Cardiac — resynchronization therapy/biventricular pacing for congestive
heart failure
(E.g., InSync®, St. Jude Frontier™ Biventricular Cardiac Pacing System or any other FDAapproved device)

(See also Cardiac Resynchronization Therapy [Biventricular Pacing])
CPT (33206, 33207,33208, 33211, 33213, 33221, 33214, 33217, 33220,
33224, 33225,33226, 33240, 33241, 33243, 33244, 33249)
Cardiac — septal closure devices

(E.g., Amplatzer®, CardioSEAL®)

CPT (93580, 93581, 33999 )
Cardiac — transcatheter aortic valve replacement or implantation
(TAVR/TAVI) for severe aortic valve stenosis
(E.g., CoreValve [Medtronic, SAPIEN [Edwards])

CPT (33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369)

Y

Y

Y

11/10/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

Y

Y

Y

4/21/2017

Y

Y

Y

5/12/2017

Y

Y

Y

5/12/2017

N

N

N

1/12/2018

Note: Percutaneous closure of paravalvular leakage (CPT 93591, 93592) is considered
investigational. Requests for this service will receive case-by-case review.

Cardiac — transcatheter pulmonary valve implantation (TPVI)
(E.g., Melody® Transcatheter Pulmonary Valve [Medtronic])

CPT (33477)
Stent Placement: In terms of physician work, placing a Melody valve is similar to placing a
stent; however, this does not clearly capture placement of a new valve.
Angioplasty: Melody placement involves predilation of the conduit; however, ballooning is
usually not coded separately when performed as a means of stent deployment.

Cardiac —transcatheter heart valve implantation within an existing
bioprosthetic valve
CPT (No specific code)
Cardiac — ventricular assist devices (VADs) — adult (e.g., Thoratec®,
HeartMate II®)
CPT (33975–33983, 33990, 33991, 33992,33993 )
HCPCS (Q0478–Q0508)
Cardiac — VADs pediatric (Berlin Heart EXCOR® Pediatric Ventricular
Assist Device)
NOTE: The EXCOR is an investigational device that is FDA-approved as a humanitarian
device exemption (HDE), as a bridge to transplant, for severe isolated left ventricular or
biventricular dysfunction; therefore, pre certification requests when presented as such will
receive case-by-case review for all LOBs.

CPT (33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982,33983,
33990, 33991, 33992,33993)
HCPCS (Q0478–Q0506)
Cardiac defibrillators — automatic external (home use, wearable)
(See also Automatic External Defibrillators)
CPT (93292, 93745)
HCPCS (K0606, K0607, K0608, K0609)
Cardiac defibrillators — implantable cardioverter (ICD)
(See also Implantable Cardioverter Defibrillators)
CPT (33215, 33220, 33223, 33226, 33230, 33231, 33240, 33241, 33243,
33244, 33249, 33262, 33263, 33264)
Cardiac defibrillators — subcutaneous implantable (S-ICD)
(E.g. S-ICD™ System)

(See also Implantable Cardioverter Defibrillators)
CPT (33270, 33271, 33272, 33273, 93260, 93261, 93644)
Cardiac monitoring — ECG remote algorithm analysis, computerized

database analysis of multiple cycles of digitized cardiac electrical data (≥
2 leads)
(See also Cardiac Event Monitors)
CPT (0206T)
Cardiac monitoring — external electrocardiographic recording up to 30
days; 24 hour monitoring
(See also Cardiac Event Monitors)

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

12/12/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

12/21/2016

Y

Y

Y

7/14/2017

N

N

N

12/21/2016

CPT (93268, 93270, 93271, 93272)
Cardiac monitoring — external electrocardiographic recording up to 48
hours
(See also Cardiac Event Monitors)
CPT (93224, 93225, 93226, 93227)
Cardiac monitoring — external electrocardiographic recording > 48 hours
up to 21 days
(E.g., Zio Patch)

(See also Cardiac Event Monitors)
CPT (0295T, 0296T, 0297T, 0298T)
Cardiac monitoring — external patient-activated, physician- or other
qualified health care professional-prescribed, electrocardiographic
rhythm derived event recorder without 24 hour attended monitoring; inoffice connection/review and interpretation by a physician or other
qualified health care professional per 30 days with at least one patientgenerated triggered event
(See also Cardiac Event Monitors)
CPT (0497T, 0498T eff. 01/01/2018)
Cardiac monitoring — external heart rate and 3-axis accelerometer data
(up to 14 days) for diagnosing nocturnal epileptic seizures
(accelerometry)
(E.g., ProGuardianREST)

CPT (0381T, 0382T, 0383T, 0384T, 0385T, 0386T)
Cardiac monitoring — fetal magnetic cardiac, at least 3 channels
CPT (0475T, 0476T, 0477T, 0478T eff. 07/01/2017)
Cardiac monitoring — hemodynamic, left atrial
(E.g., HeartPOD System, Promote LAP System)

CPT (No specific code [0293T, 0294T del. 01/01/2018])
Cardiac monitoring — implantable loop recorders for recurrent
infrequent syncopal episodes
(E.g., Reveal Insertable Loop Recorder [Medtronic])

(See also Cardiac Event Monitors)
CPT (33282, 33284, 93285, 93291, 93298, 93299)
Cardiac monitoring — intracardiac ischemic to detect potential heart
attack
(E.g., AngelMed Guardian System)

CPT (0302T, 0303T, 0304T, 0305T, 0306T, 0307T [del. 01/01/2018]) (No
specific code)
Cardiac monitoring — real-time/mobile outpatient cardiac telemetry
Current EmblemHealth contracts:
Alere Home Monitoring
CardioLink
CardioNet
Medtronic Monitoring
Life Watch Service
Raytel Cardiac Services

Y

Y

Y

7/14/2017

N

N

N

1/12/2018

N

N

N

1/12/2018

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

2/10/2017

(See also Cardiac Event Monitors)
CPT (93228, 93229)
Cardiography — combined acoustic and electrical
(Aka, acoustic heart sound recording, computer analysis and interpretation; e.g., Zargis
Acoustic Cardioscan)

CPT (93799)
Cardiophysiologic mapping/multichannel electrocardiography (≤ 64leads)
(E.g. EnSite Velocity, Rhythmia Mapping System, CARTO 3, Polar Constellation Advanced
Mapping System, PRIME ECG System, Visual ECG; list not meant to be all-inclusive)

CPT (0178T, 0179T, 0180T [del. 01/01/2018] No specific code)
Carotid artery stenting
(E.g., Enroute Transcarotid Neuroprotection System)

CPT (37215, 37216, 37217, 37218)
Note: CPT codes 0075T and 0076T are not reimbursable
Carotid sinus baroreflex activation device — all aspects
(E.g., Barostim™ neo™ Legacy System ([CVRx Inc.])
Note: The Barostim is an investigational device that is FDA-approved as a Humanitarian
Device Exemption (HDE) for use in patients with resistant hypertension who have had
bilateral implantation of the Rheos Carotid Sinus Leads (Models 1010R, 1010L, 1014L and
1014R) which have been discontinued and are obsolete and were determined to be
responders in the Rheos pivotal clinical study. The approved implantable pulse generator
(IPG) will replace an existing IPG in a patient whose battery is depleted and needs to be
replaced and/or electrode lead repair procedures are necessary. Therefore, pre certification
requests when presented as such will be reviewed on a case-by-case basis.

CPT (0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T)
Ceramic-on-ceramic hip replacements
(E.g., Ceramic TRANSCEND® Hip Articulation System, Duraloc® Option Ceramic Hip System,
Keramos™ Ceramic/Ceramic Total Hip System, Novation™ Ceramic Articulation Hip System,
Reflection® Ceramic Acetabular System or any other FDA-approved device)

CPT (27130, 27132, 27134, 27137, 27138)
Cerebral perfusion analysis using computed tomography with contrast
administration, including post-processing of parametric maps with
determination of cerebral blood flow, cerebral blood volume, and mean
transit time
CPT (0042T)
Chelation therapy for heavy metal toxicity and overload conditions
HCPCS (J0470, J0600, J0895, J3520)

Chemical peels for actinic keratoses (AKs)/premalignant skin lesions
Note: Click on Medical Guideline link for clinical criteria and coverage
specifics

Y

Y

Y

8/11/2017

Y

Y

Y

7/14/2017

N

N

N

4/21/2017

N

N

N

3/10/2017

Y

Y

Y

7/14/2017

Y

Y

Y

6/9/2017

Y

Y

Y

3/10/2017

N

N

N

7/14/2017

Y

Y

Y

10/13/2017

CPT (15788, 15789, 15792, 15793)
Chemoembolization for hepatic cancer
CPT (37243, 75894)
Chemosensitivity and chemoresistance assays for cancer (i.e., laboratory
tests used to identify chemotherapeutic agents that may be ineffective
against tumor growth)
(E.g., chemoresistance assays; including but not limited to the Oncotech Extreme Drug
Resistance, EDR® Assay or the Drug Resistances Assay [DRATM], and chemosensitivity
assays [including but not limited to ChemoFX® assay])

(See also Genetic Counseling and Testing)
CPT (89240, 81535, 81536)
Circulating tumor cell (CTC) assay (aka immunological detection
techniques for quantify circulating tumor cells in the blood)
(E.g. CellSearch System®, Oncotype SEQ™, Foundation ACT, OnoCEE, Cancer Intercept,
GeneStrat®, PCR [RTPCR], etc.)

(See also Genetic Counseling and Testing and Medicare LCD: Circulating
Tumor Cell Testing)
CPT (86152, 86153, 81445 [GeneStrat])
Cochlear implants (single and multichannel)
Note: Links to approved indications (list may not be all-inclusive):
Advanced Bionics HiResolution® Bionic Ear System
Advanced Bionics Clarion Multi-Strategy
Advanced Bionics Clarion HiFocus
Cochlear Limited ® Cochlear ™ Nucleus® cochlear implants
MED-ELMaestro® (Sonata, or Pulsar) -Predecessor CI: Combi 40+
CPT (69930, 92601, 92602, 92603, 92604, V5273)
HCPCS (L8614–L8629)
Cochlear implants (hybrid)
(E.g., Nucleus® Hybrid™ L24 Cochlear Implant System)

CPT (69930, 92601, 92602, 92603, 92604)
HCPCS (L8614, L8615, L8616, L8617, L8618, L8619, V5273)
Cognitive rehabilitation
CPT (97532)
Coenzyme Q10 (CoQ10 or Q10) serum/body fluid testing of Q10 levels for
supplementation of any disease
(Aka ubiquinone, ubidecarenone, coenzyme Q)

(See also Medicare Local Coverage Determination [LCD]: Coenzyme Q10)
CPT (No specific code)
Coil embolization for arterio-venous malformations (AVMs)/aneurysm

and splenic artery aneurysm
CPT (37241, 37242, 37243, 37244, 61624, 61635, 75894)
Collagen meniscus implant
(E.g., Menaflex™)

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

10/13/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

HCPCS (G0428)
Common carotid intima-media thickness (IMT) study for evaluation of
atherosclerotic burden or coronary heart disease risk factor assessment
CPT (93895, 0126T)
Complex decongestion physiotherapy for lymphedema
(See also Lymphedema Treatment)
CPT (97140, 97016)
HCPCS (S8950, E0650, E0651, E0652, E0655, E0660, E0665–E0673, E0676)
Note: HCPCS code E0676 is not covered for DVT Prophylaxis

Computed tomography (CT) — low dose for lung cancer detection
CPT (No specific code)
HCPCS (G0296, G0297)
Computed tomography (CT) screening for coronary artery disease
(E.g., calcium scoring using electron beam computed tomography [EBCT], ultrafast CT, etc.)

CPT (75571)
HCPCS (S8092)
Computed tomographic angiography (CTA) for coronary diagnostics via
multislice or multidetector CT modalities
CPT (75574)
Computer-aided animation and analysis of time series retinal images for
disease-progression monitoring
CPT (0380T)
Computer-assisted detection (computer algorithm analysis of digital
image data for lesion detection) with further physician review for
interpretation and report, with or without digitization of film
radiographic images, chest radiograph(s), performed concurrent with
primary interpretation or remotely
CPT (0174T, 0175T)
Computer-assisted detection breast MRI
CPT (0159T)
Computer-assisted detection breast ultrasound
CPT (76999)
Computer-assisted brush biopsy, with or without melanoma-associated
antigens A (MAGE-A) staining, for detecting cancers of the esophagus,
oral cavity, pharynx and larynx
(E.g., OralCDx® BrushTest®, WATS3D [formerly known as EndoCDx])

CPT (No specific code)

Computer-assisted detection mammography (e.g., MammoReader or any
other FDA-approved device)
CPT (No specific code)

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

5/12/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

6/9/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Note: New 2017 mammography codes now include computer-assisted detection
mammography

Computer-assisted orthopedic surgery
CPT (20985, 0054T, 0055T, 0396T)
Confocal laser endomicroscopy (CLE) (aka confocal fluorescent
endomicroscopy and optical endomicroscopy)
CPT (43206, 43252, 88375, 0397T)
Continuous or intermittent measurement, computerized or electronic,
wheeze rate detectors during treatment assessment or during sleep for
documentation of nocturnal wheeze and cough for diagnostic evaluation,
3–24 hours
(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (94799)
Continuous passive motion devices
HCPCS (E0935)
Cooling devices in the home setting for neuro/musculoskeletal
conditions, pain conditions, post-surgical healing or as a prophylactic
measure for hair loss secondary to chemotherapy
HCPCS (E0218, E0236)
Cord blood harvesting and banking
CPT (No specific code)
HCPCS (S2140)
Corneal — computer topography
CPT (92025)
Corneal — collagen cross-linking (CXL) for progressive keratoconus
CPT (0402T)
Corneal — hysteresis
CPT (92145)
Corneal — intrastromal corneal ring segments for keratoconus (Intacs®)
(See also Intrastromal Corneal Ring Segments for Keratoconus)
CPT (65785)
HCPCS (L8610)
Corneal — pachymetry for glaucoma
CPT (76514)
Current Perception Threshold/Sensory Nerve Conduction Threshold Test
(sNCT)
HCPCS (G0255)

Cryoablation — atrial fibrillation
Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

10/13/2017

CPT (64620, 64640, 0441T, 0442T)

Y

Y

Y

Cryoablation — peripheral nerves upper extremity

N

N

N

N

N

N

7/14/2017

Y

Y

Y

10/13/2017

N

N

N

7/14/2017

Y

Y

Y

6/9/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

2/9/2018

(E.g., Arctic Front® Cardiac CryoAblation Catheter)

CPT (93656, 93657)
Cryoablation — Barrett’s esophagus
CPT (43229, 43270)
Cryoablation — bone tumors
CPT (20983)
Cryoablation — breast fibroadenomas
CPT (19105)
Cryoablation — hepatic cancer
(See also Cryosurgery for Liver Tumors)
CPT (47381, 47383, 47371, 76940, 76998, 77013, 77022)
Cryoablation — peripheral nerves for the treatment of knee and
intercostal pain (Iovera cryotherapy)

1/19/2017

CPT (0440T)
Cryoablation — plantar fasciitis
CPT (64640)
Cryoablation — prostate cancer
(See also Cryosurgical Ablation for Prostate Cancer)
CPT (55873)
Cryoablation — pulmonary tumors
CPT (0340T [del. 01/01/2018])
Note: CPT code 32994 is covered for Medicare members only

Cryoablation — renal cancer
(See also Cryosurgical and Radiofrequency Ablation for Renal Tumors)
CPT (50250, 50542, 50593)
Cryoablation — uterine for menorrhagia
(E.g., HerOption)

CPT (58356)
Cryoplasty (aka cryo-balloon angioplasty) for peripheral vascular disease
(E.g., PolarCath [NuCryo; previously Boston Scientific])
CPT (37799 combined with angioplasty codes 36901, 36902, 36905,
36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249)
Cryopreservation — immature oocyte(s)
(See also Assisted Reproductive Technologies)
Note: Refer to Limitations/Exclusion Section within EmblemHealth’s Assisted Reproductive
Technologies Medical Guideline for information pertaining to the cryopreservation of

mature oocytes and sperm for members with iatrogenic infertility.

CPT (0357T)
Cryopreservation — reproductive tissue, ovarian
(See also Assisted Reproductive Technologies)

N

N

N

4/21/2017

N

N

N

7/14/2017

N

N

N

12/12/2017

Y

Y

Y

7/14/2017

Y

Y

Y

6/9/2017

SEE NOTE

SEE NOTE

SEE NOTE

6/9/2017

Y

Y

Y

8/11/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

CPT (0058T)
Cryotherapy — whole body; any indication
(E.g., Asthma, Alzheimer’s, Anxiety, Chronic pain, Depression, Fibromyalgia, Insomnia,
Migraines, Multiple sclerosis, Osteoarthritis, Rheumatoid Arthritis, Weight Loss)

CPT (No specific code)
Cystourethroscopy, with mechanical dilation and urethral therapeutic
drug delivery for urethral stricture or stenosis, including fluoroscopy
CPT (0499T eff. 01/01/2018)
Descemet's Stripping Endothelial Keratoplasty (DSEK)
Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK)
Descemet Membrane Endothelial Keratoplasty (DMEK)
Deep Lamellar Endothelial Keratoplasty (DLEK)
CPT (65756, 65757, 0290T )
Deep brain stimulation — essential tremor/advanced Parkinson’s disease
CPT (61863, 61864, 61867, 61868, 61880, 61885, 61886,61888, 95961,
95962, 95970, 95978)
HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688,
L8689)
Deep brain stimulation — obsessive compulsive disorder (Reclaim™
DBS™ Therapy)
Note: The Reclaim™ DBS™ Therapy is an investigational device that is FDA-approved as a
humanitarian exemption (HDE) for bilateral stimulation of the anterior limb of the internal
capsule, AIC, as an adjunct to medications and as an alternative to anterior capsulotomy for
treatment of chronic, severe, treatment-resistant obsessive compulsive disorder (OCD) in
adult patients who have failed at least three selective serotonin reuptake inhibitors (SSRIs).
Therefore, pre certification requests when presented as such will be reviewed on a case-bycase basis.

CPT (21499, 61863, 61864, 61867, 61885, 61886, 61880, 61888, 95961,
95962)
HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688,
L8689)
Dermabrasion for actinic keratoses (AKs) and superficial basal cell
carcinomas
Note: Click on Medical Guideline link for clinical criteria and coverage
specifics
CPT (15781, 15782, 15783)
DermaClose® RC Continuous External Tissue Expander for wound
management
CPT (No specific code)
Destruction neurofibromata — extensive, (cutaneous, dermal extending

into subcutaneous)
(Face, head and neck, > 50 neurofibromata; trunk and extremities, > 100
neurofibromata)
CPT (0419T, 0420T)
Dexamethasone/fluocinolone acetonide intravitreal implants for FDA
approved indications
(E.g., Ozurdex®, Iluvien®, Retisert)

(See also Intravitreal Injections/Implants)

Y

Y

Y

1/19/2017

Y

Y

Y

3/13/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

3/10/2017

Y

Y

Y

7/14/2017

N

N

N

10/13/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

CPT (67027)
HCPCS (J7311, J7312, J7313)
Dorsal column stimulators for chronic pain management (aka spinal
stimulators)
Note: Considered investigational for stimulation of the dorsal root ganglion.

CPT (63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970,
95971, 95972, 64999)
HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688,
L8689, L8695, L8699)
Double balloon enteroscopy
CPT (No specific code)
Drug eluting ocular implant — lacrimal canaliculus (aka intracanalicular
plugs) (including punctal dilation and implant removal)
CPT (0356T, 0444T, 0445T)
Drug eluting stents — cardiac
CPT (92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944)
Drug eluting stents — sinus
(E.g., Propel® Mometasone Furoate Implant sinus implant, Relieva Stratus™ MicroFlow
spacer and the SinuFoam™ spacer)

(See also Functional Endoscopic Sinus Surgery [FESS])
CPT (0406T, 0407T)
Duopa (carbidopa and levodopa) enteral suspension for the treatment of
motor fluctuations in patients with advanced Parkinson’s disease
CPT (43246, 44373, 49446, 64999, 95999, 99199)
HCPCS (E0781, J7799, J7340)
Dynamic Decompression System for pectus excavatum
(See also Surgical Correction of Chest Wall Deformities)
CPT (No specific code)
Elastography (e.g., FibroScan®) for management of benign liver disease
CPT (0346T, 91200)
Elastography for evaluation of breast lesions (or any other indication)
CPT (0346T)
Note: CPT 0346T and 91200 are allowable for liver elastography

Electrical continence aids, rectal inserts and related accessories
HCPCS (A4335, A4337)
Electrical modulation pain reprocessing — transcutaneous
CPT (0278T)

N

N

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

2/9/2018

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Electrical nerve stimulation — neuromuscular conditions
Note: Eff. October 1, 2013, Medicaid members are no longer eligible for coverage of
functional electrical stimulation (FES) for spinal cord and head injury, cerebral palsy and
upper motor neuron disease.

CPT (64550, 64999)
HCPCS (A4595, A4630, E0720, E0730, E0731, E0745)
Electrical Stimulation — auricular of acupuncture points (aka auricular
electrostimulation)
CPT (S8930)
Electrical stimulation (neurostimulation) — central sleep apnea
(E.g., remedē® System)

CPT (0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T,
0433T, 0434T, 0435T, 0436T)
Electrical stimulation — hypoglossal nerve for obstructive sleep apnea
(E.g., Inspire® Upper Airway Stimulation (UAS)

(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (0466T, 0467T, 0468T, 64999)
Electrical stimulation — pudendal nerve terminal motor latency (PNTML)
for fecal incontinence
(See also Fecal Incontinence Treatment)
CPT (No specific code)
Electrical stimulation — percutaneous tibial nerve (aka
posterior/peripheral) for urinary voiding dysfunction (e.g., Urgent® PC
Neuromodulation System, Stoller afferent nerve system [PerQ SANS
System])
Note: Coverage predicated on the failure of behavioral modification (e.g., pelvic floor
exercise, fluid intake timing, etc.), as well as pharmacological management (e.g.,
anticholinergic, muscle relaxant, etc.)

CPT (64566, 97014, 97032)
HCPCS (L8680)
Electrical stimulation — tibial nerve for fecal incontinence
(See also Fecal Incontinence Treatment)
CPT (64566)
Electrical stimulation/diathermy (pulsed) — knee osteoarthritis
(E.g., BioniCare®BIO-1000, OrthoCor Active Knee System)

HCPCS (E0762)
Electrical stimulation — perianal for fecal incontinence
(See also Fecal Incontinence Treatment)

CPT (No specific code)
Electrical stimulation — transcutaneous electrical nerve stimulation
(TENS) for acute postoperative pain, chronic pain other than low back
pain and chronic low back pain
Note: TENS coverage for Medicaid members is restricted solely to osteoarthritis of the knee.
The above indications are covered for Commercial and Medicare members commensurate
with Noridian LCD for Transcutaneous Electrical Nerve Stimulators (TENS)

Y

Y

SEE NOTE

7/14/2017

N

Y

Y

7/14/2017

N

N

N

7/14/2017

N

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

8/11/2017

N

Y

N

7/14/2017

N

N

N

7/14/2017

N

N

N

1/12/2018

N

N

N

9/8/2017

N

N

N

7/14/2017

CPT (64550)
HCPCS (A4557, A4595, E0730, E0731, E0720)
Electrical stimulation — transcutaneous electrical nerve stimulation
(TENS) for nausea
HCPCS (A4558, E0765)
Electrical stimulation — transcutaneous electrical nerve stimulation
[TENS) for migraine prophylaxis
(E.g., Cefaly® TENS)

HCPCS (No specific code)
Electrical stimulation — wounds
HCPCS (E0769, G0281)
Note: CPT G0282 — Electrical stimulation, (unattended), to one or more areas, for wound
care other than described in G0281 — is not covered

Electrogastrography as a diagnostic tool for gastroparesis or functional
dyspepsia
CPT (91132, 91133)
Electric tumor fields for newly diagnosed or recurrent glioblastoma
following surgery and radiotherapy
(E.g., Optune® [Novocure])
Note: Considered investigational for all other indications

HCPCS (A4555, E0766)
Electromagnetic therapy for wounds
HCPCS (G0295, G0329, E0761)
Electronic nicotine delivery systems for smoking cessation (ENDS)
CPT (No specific code)
Embolization of ovarian and Internal Iliac veins for pelvic congestion
syndrome (PCS)
CPT (36012, 37241, 75894, 75898)
Endomechanical ablative approach for varicose vein
treatment/endovenous mechanochemical ablation (MOCA)
(E.g., ClariVein™ Catheter)

(See also Varicose Vein Treatment)
CPT (36473, 36474)
Endoscope, retrograde imaging/illumination colonoscope device
(implantable)
(E.g., Third Eye® Panoramic™ Device for Colonoscopy)

HCPCS (44799)
Endothelial function assessment, using peripheral vascular response to
reactive hyperemia, non-invasive (e.g., brachial artery ultrasound,
peripheral artery tonometry), unilateral or bilateral

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

3/10/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

(E.g., Endo PAT 2000)

CPT (0337T)
Endovascular Iliac atherectomy for peripheral arterial disease
(E.g., Zenith® Branch Endovascular Graft-Iliac Bifurcation with the H & L-B One-Shot™)

CPT (0254T,[0255T del. 01/01/2018])
Endovascular stent grafts — abdominal aortic aneurysms (AAA) (E.g.,
Aorfix™, AneuRx®, Zenith®, Excluder®, AFX and Powerlink®, Talent™,
OVATION Abdominal Stent Graft System, Endurant®)
Note: Coverage is applicable only FDA-approved grafts utilized per labeled indications. The
plan considers the following investigational:
Fenestrated and branched endografts
Implanted pressure sensors for the detection of endoleaks

CPT ([34701, 34702, 34703, 34705, 34706, 34709 eff. 01/01/2018], 34812,
34820,([34800, 34802, 34803, 34804, 34805,34825, 34826 [del.
01/01/2018])
Note: Non-covered codes pertaining to fenestrated grafts:
CPT (34839, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848)

Endovascular stent grafts — thoracic aortic aneurysms (TAA) (limited to
descending type only)
(E.g., GORE TAG Thoracic Endoprosthesis, Valiant® Thoracic Stent Graft
with the Captiva Delivery System)
Note: Coverage is applicable only FDA-approved grafts utilized per labeled indications.
The following are considered investigational:




Treatment of aneurysms of the ascending aorta/aortic arch
Treatment of aortic dissections/traumatic aortic transections
Implanted pressure sensors for the detection of endoleaks

CPT (33880, 33881, 33883, 33884, 33886, [34806 del. 01/01/2018],
[34710, 34711 eff. 01/01/2018], 75956, 75957, 75958, 75959)
Enfant® Pediatric VEP Vision Testing System for infants > 6 months of age
and pre-school children
(See also Visual Evoked Potential Testing for Pediatric Populations in the
Primary Care Setting)
CPT (95930)
Engauge-Cancer-DLBCL gene expression assay for risk stratification /
treatment of for B-cell lymphoma (measuring expression of LMO2 and
CD137)
CPT (81479, 81599, 84999)
Epidermal nerve fiber density test for the diagnosis of small fiber
neuropathy
CPT (88356)
Epiretinal radiation for wet age-related macular degeneration (placement

of intraocular radiation source applicator)
CPT (0190T)
Erectile dysfunction and penile prostheses
CPT (54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416,
54417)

Y

SEE NOTE

Y

7/14/2017

N

N

N

1/12/2018

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

4/21/2017

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

HCPCS ( [Medicare benefit discontinuance of L7900 and L7902 for the
vacuum pump and ring eff. 07/1/2015])
Exhaled nitric oxide measurement for asthma diagnosis/management
and other respiratory disorders
(E.g., Breathmeter, Insight eNO System™, Nitric Oxide Monitoring System [NIOX®], NIOX
MINO®/VERO)

CPT (95012, 83987)
Extracorporeal immunoabsorption using protein a columns (Prosorba®)
for ITP/rheumatoid arthritis
CPT (36515 [del. 01/01/2018] No specific code)
Extracorporeal liver assist system — oversight of patient care during
extracorporeal liver assist procedure
(Review of status, review of laboratories and other studies, and revision
of orders and liver assist care plan)
CPT (0405T)
Extracorporeal shockwave therapy for chronic epicondylitis
CPT (0102T)
Note: Coverage discontinued for Medicare members eff. 01/01/2016

Extracorporeal shockwave therapy for chronic plantar fasciitis
CPT (28890)
Note: Coverage discontinued for Medicare members eff. 01/01/2016

Extracorporeal shockwave therapy for musculoskeletal indications other
than epicondylitis or plantar fasciitis
CPT (0101T [high energy])
Extra-osseous subtalar joint for talotarsal stabilization
CPT (0335T)
HCPCS (S2117)
Facet joint arthroplasty (replacement)
CPT (0202T)
Fetal fibronectin testing
CPT (82731)
Fecal microbiota transplant (FMI) for recurrent C difficile infection (RCDI)
CPT (44705)
HCPCS (G0455)
FENIX™ Continence Restoration System
Note: The Fenix is an investigational mechanical compression device that is FDA-approved

as a humanitarian device exemption (HDE) for fecal incontinence in patients who are not
candidates for or have previously failed conservative treatment and less invasive therapy
options (e.g., bulking agents, radiofrequency ablation, sacral nerve stimulation). Therefore,
pre certification requests when presented as such will be reviewed on a case-by-case basis.

CPT (43284, 43285)
Fluorescein angiography — anterior segment imaging with interpretation
and report (only when performed by ophthalmologist)

Y

Y

Y

7/14/2017

N

N

N

12/12/2017

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

12/12/2017

N

N

N

12/12/2017

N

N

N

10/13/2017

Y

Y

Y

2/9/2018

CPT (92287)
Fractional ablative laser fenestration of burn and traumatic scars for
functional improvement of infants and children
CPT (0479T, 0480T eff. 01/01/2018)
Gait motion analysis (aka comprehensive motion analysis studies) for
evaluation musculoskeletal function
(E.g., cerebral palsy, meningomyelocele, traumatic brain injury, incomplete quadriplegia,
spastic hemiplegia, spastic diplegia)

CPT (96000, 96001, 96002, 96003)
Galectin-3 testing for congestive heart failure
CPT (82777)
Gastric pacing— Enterra™ Therapy System (aka gastric electrical
stimulation [GES]) for chronic, intractable (drug refractory) nausea and
vomiting secondary to gastroparesis of diabetic or idiopathic etiology
(See also Gastric Electrical Stimulation)
CPT (43647, 43648, 43881, 43882, 64590, 64595)
HCPCS (E0765)
Gene expression profiling — ASXL1
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
myelodysplastic syndrome myeloproliferative neoplasms, chronic
myelomonocytic leukemia), gene analysis; full gene sequence
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
myelodysplastic syndrome myeloproliferative neoplasms, chronic
myelomonocytic leukemia), gene analysis; targeted sequence analysis
(eg, exon 12)
CPT (81175, 81176 eff. 01/01/2018)
Gene expression profiling — brain malformations
(E.g., Comprehensive Brain Malformations Next Generations Sequencing Panel (GeneDx)

(Gene Expression Profiling)
CPT (81405, 81406, 81407, 81408)
Gene expression profiling — breast cancer
Breast Cancer Index [81479], (Biotheranostics), EndoPredict® (Myriad),
MammaPrint® (Agendia), OncoType® DX (Genomic), Prosigna™
[NanoString Technologies], HERmark® (Integrated Oncology LabCorp
Specialty Group — covered for Medicare-covered only)
(See also Gene Expression Profiling and Biomarker Testing for Breast
Cancer)

CPT (81519, [81520, 81521 eff. 01/01/2018] all LOBs)
HCPCS (S3854 for Commercial)
Gene expression profiling — breast cancer (other than Breast Cancer
Index [81479], MammaPrint®], OncoType [81519] and Prosigna [0008M])
(E.g., BreastOncPx™ [Integrated Oncology LabCorp Specialty Group]; BluePrint® [Agendia];
Breast Cancer Gene Expression Ratio [Quest Diagnostics]; HERmark® [Integrated Oncology
LabCorp Specialty Group — not covered for Commercial and Medicaid]; Mammostrat
[Genomic]; Rotterdam Signature; SYMPHONY™ Personalized Breast Cancer Genomic Profile
[Agendia])

(See also Gene Expression Profiling and Biomarker Testing for Breast
Cancer)

N

N

N

2/9/2018

N

SEE NOTE
FOR
SPECIFIC
TESTS

N

2/9/2018

N

Y

N

7/14/2017

N

N

N

12/12/2017

Y

Y

Y

12/12/2017

Y

Y

Y

4/21/2017

N

SEE NOTE

N

10/13/2017

CPT (81519 all LOBs)
HCPCS (S3854 for Commercial)
Note: CPT codes 81432 and 81433 for hereditary breast cancer disorders are not considered
medically necessary

Gene expression profiling — colon cancer (including Septin9 [Sept9] DNA
analysis for early detection of colorectal cancer)
(E.g., ColoVantage [Quest], Epi proColon [Epigenomics], GeneFx® Colon [Precision
Therapeutics], ColoNext™ [Ambry], OncoType® DX [Genomic])
Note: Medicare members are covered for Oncotype only

(See also Oncotype DX Colon Cancer Assay Coding and Billing Guidelines
for Medicare and Gene Expression Profiling)
CPT (81525, 81327)
Gene expression profiling — coronary artery disease
(E.g., Corus® CAD test [CARDIODX])

(See also Corus CAD Test Coding and Billing Guidelines for Medicare and
Gene Expression Profiling)
CPT (84999, 81493)
Gene expression profiling — F9 (coagulation factor IX) (eg, hemophilia B),
full gene sequence
(See also Gene Expression Profiling)
CPT (81238 eff. 01/01/2018)
Gene expression profiling — G6PD (glucose-6-phosphate dehydrogenase)
(eg, hemolytic anemia, jaundice), gene analysis common
variant(s)/known familial variant(s)/full gene sequence
(See also Gene Expression Profiling)
CPT (81247, 81248, 81249 eff. 01/01/2018)
Gene expression profiling — heart transplant rejection
(E.g., AlloMap® [CareDx])

CPT (81595, 86849 unlisted immunology)
Gene expression profiling — melanoma
(E.g., DecisionDx [Castle Biosciences], myPath® [Myriad])

(See also NGS Medicare LCD: Molecular Pathology Procedures and Gene
Expression Profiling of Melanomas)
Note: DecisionDx is covered for Medicare members only. See Gene Expression Profiling of

Melanomas guideline)

CPT (81479, 81504, 81599, 84999, 88299)
Gene expression profiling — microbial pathogens
(E.g., DecodEx Microbial Genetic Identification [PathoGenius ])

(See also Gene Expression Profiling)

N

N

N

9/8/2017

N

N

N

10/13/2017

N

N

N

8/11/2017

N

N

N

12/12/2017

Y

Y

Y

7/14/2017

N

SEE NOTE
FOR
SPECIFIC
TESTS

N

1/12/2018

N

N

N

10/13/2017

CPT (87801)
Gene expression profiling — myeloma
(E.g., MyPRS™ Myeloma Prognostic Risk Signature™ [Signal Genetics])

(See also Gene Expression Profile Testing for Multiple Myeloma)
CPT (81479, 81504, 81599, 84999, 86849, 88299)
Gene expression profiling — narcolepsy
(I.e. HLA-DQB1*06:02 typing)

(See also Palmetto LCD: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy)
CPT (81383)
Gene expression profiling — RUNX1 (runt related transcription factor 1)
(eg, acute myeloid leukemia, familial platelet disorder with associated
myeloid malignancy), gene analysis, targeted sequence analysis (eg,
exons 3-8)
CPT (81334 eff. 01/01/2018)
Gene expression profiling — thyroid nodules of indeterminate cytology
(E.g., Afirma® Thyroid FNA Analysis [Veracyte], ThyGenX [Interpace Diagnostics™, LLC; test
formerly known as the miRInform® from Asuragen], ThyraMIR Thyroid miRNA classifier
[Interpace], Thyroid FNA Cytomorphology with Molecular Reflex [Quest; preferred lab],
ThyroSeq next generation sequencing [University of Pittsburg])

(See also Gene Expression Profiling)
CPT (81545)
Gene/biomarker expression profiling for prostate cancer
(E.g., 4Kscore® Test [OPKO]; ConfirmMDx [MDxHealth]; Decipher [GenomeDX Biosciences
Corp]; OncoType® DX [Genomic]; Prolaris® [Myriad]; ProMark® [Metamark Genetics])
Note:






ConfirmMDx is covered for Medicare members per LCD: ConfirmMDx Epigenetic
Molecular Assay
Decipher is covered for Medicare members per LCD: Decipher® Prostate Cancer
Classifier Assay
Prolaris is covered for Medicare members per LCD: Prolaris™ Prostate Cancer
Genomic Assay
Oncotype is covered for Medicare members per LCD: Oncotype DX® Prostate
Cancer Assay
ProMark is covered for Medicare members per LCD: ProMark Risk Score

(See also Gene Expression Profiling)
CPT (81479, [81539 4Kscore® Test only], [81541, 81551 eff. 01/01/2018],
81599)
Gene therapy — aka CAR T Therapy, cell therapy, embryonic cell therapy,
fresh cell treatment, glandular therapy, organotherapy, and
xenotransplant therapy [Kymriah™, Yescarta™, etc.]) for
lymphoproliferative disorders, hematological malignancies or any other
indications

(Specific to Medicaid members only; see KYMRIAH™ (tisagenlecleucel) for
Acute Lymphoblastic Leukemia — Medicaid)
CPT (No specific code)
Gene therapy — Luxterna™ for biallelic mutation-associated retinal
dystrophy

N

N

N

1/12/2018

N

N

N

4/12/2017

N

N

N

10/13/2017

N

N

N

10/13/2017

Y

Y

Y

2/9/2018

Y

Y

Y

3/10/2017

N

Y

N

3/10/2017

N

SEE NOTE
FOR
SPECIFIC
TESTS

N

7/14/2017

CPT (No specific code)
Genetic testing — amyotrophic lateral sclerosis (ALS) SOD1 mutation
CPT (81404)
HCPSCS (S3800)
(See also Genetic Counseling and Testing)
Genetic testing — Alzheimer’s disease
(E.g., apolipoprotein E [APO E-4], amyloid AB precursor gene, presenilin genes 1 and 2,
ADmark® Alzheimer’s Evaluation [Athena])

(See also Genetic Testing for Alzheimer's Disease)
CPT (81401, 81405, 81406, 83520, 84999)
HCPCS (S3852)
Genetic testing — analysis of PIK3CA status in tumor cells
CPT (81404, 81479)
Genetic testing — breast cancer
(See also BRCA-1 & BRCA- 2 Genetic Testing [Sequence
analysis/rearrangement testing], Gene Expression Profiling)
Note: The BRCAPlus, BREVAGen and BreastNext/CancerNextTM tests (Ambry Genetics) are
not considered medically necessary.

CPT (81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217)
Note: CPT codes 81432 and 81433 for hereditary breast cancer disorders are not considered
medically necessary

Genetic testing — cadherin-1 (CDH1) for hereditary diffuse gastric cancer
(HDGC)
Note: Medically necessary when any of the following criteria is met





2 gastric cases in a family, 1 confirmed diffuse gastric cancer (DGC) diagnosed
before age 50 years
3 confirmed cases of DGC in 1st- or 2nd-degree relatives independent of age
DGC diagnosed before age 40 years without a family history
Personal or family history of DGC and lobular breast cancer, 1 diagnosed before
age 50 years

CPT (81406, 81435, 81479)
Genetic testing — CALR (calreticulin) (e.g., myeloproliferative disorders),
gene analysis, common variants in exon 9
(See also, Gene Expression Profiling, Genetic Counseling and Testing and
NGS Medicare LCD: Molecular Pathology Procedures)
CPT (81219)
Genetic testing — cancer of unknown primary (CUP) (aka tissue origin
testing)
(E.g., ResponseDX [formerly Pathwork®]Tissue Origin Test [Response Genetics], Rosetta
Cancer Origin Test™ [formerly miReview® mets] [Rosetta Genomics])

Note:



Cancer TYPE ID is covered for Medicare members; see bioTheranostics Cancer
TYPE ID
ResponseDX is covered for Medicare members; see ResponseDX Tissue of Origin
Coding and Billing Guidelines

(See also Gene Expression Profiling)
CPT (81479, 81540)
Genetic testing — cardiac ion channelopathies
(i.e., Catecholaminergic Polymorphic Ventricular Tachycardia [CPVT], Long QT syndrome
[LQTS])

Y

Y

Y

3/10/2017

N

N

N

3/10/2017

Y

Y

Y

5/12/2017

Y

Y

Y

2/9/2018

Y

Y

Y

3/10/2017

SEE NOTE

SEE NOTE

Y

2/9/2018

(See also Cardiac Ion Channel Genetic Testing)
CPT (81403, 81405, 81408)
Genetic testing — cardiac ion channelopathies
(I.e., Brugada syndrome, Short QT syndrome [SQTS])

(See also Cardiac Ion Channel Genetic Testing)
CPT (81413, 81414)
HCPCS (S3861 for Brugada)
Genetic testing — acute myeloid leukemia (AML) therapeutic
management
1.

CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha [a]), full gene sequence
analysis FLT3 gene analysis

(See Also Medicare LCD Molecular Pathology Procedures)

CPT (81218) [CEBPA], 81245, 81246 [FLT3]
Genetic testing — cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy (CADASIL) Syndrome
CPT (81406, 81599)
HCPCS (G0452 [Medicare])
Genetic testing — colorectal cancer/Lynch syndrome (aka hereditary
nonpolyposis colorectal cancer HNPCC)
(E.g. tests from Quest Labs, Colaris tests from Myriad Labs):
FAP — testing for APC mutations (exclusive of the mutation at codon 11307K on the APC
gene)
HNPCC— testing for MLH1 & MSH2, MSH6, SH2, PMS2 mutations
HNPCC — microsatellite instability analysis (also known as the replication error test)
MYH-associated neoplasia or MAP (MYH genetic testing) (See also Genetic Testing

for Colorectal Cancer/Lynch Syndrome)
CPT (81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295,
81296, 81297, 81298, 81299, 81300, 81301, 81317,81318, 81319, 81435,
81436)
Genetic testing — colon cancer; fecal DNA (e.g., Cologuard® [Exact
Sciences], ColoSure™ [LabCorp], PreGen-Plus™ [Exact Sciences], QIAamp
DNA Stool Mini Kit [not covered for any line of business])
(See also Genetic Counseling and Testing)
Note: Only Cologuard is covered for Commercial and Medicare members, once every 3
years; all:
Age 50 to 85 years

Asymptomatic (no signs or symptoms of colorectal disease including but not limited to
lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal
immunochemical test)
At average risk of developing colorectal cancer (no personal history of adenomatous polyps,
colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative
colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous
polyposis, or hereditary nonpolyposis colorectal cancer)

CPT (81528)
Genetic testing — comparative genomic hybridization (CGH) microarray
for chromosomal imbalance for the evaluation of chromosomal
imbalances in patients suspected of having a genetic syndrome (i.e. have
congenital anomalies, dysmorphic features, developmental delays,
mental retardation, and/or other developmental disabilities)
Various manufacturers; list not meant to be all-inclusive — Chromosomal Microarray
Analysis (CMA) (Baylor College of Medicine Medical Genetics Laboratories:); Chromosome
Microarray (Laboratory Corporation of America [LabCorp]); Clarisure™ (Quest Diagnostics
Inc.); GenomeDx (GeneDx Inc.); Oligo HD Scan™, BAC HD Scan™, and Prenatal Scan™
(CombiMatrix Molecular Diagnostics [CMDX]); SignatureChipWG™, SignatureChipOS™, and
SignaturePrenatalChip® (Signature Genomic Laboratories) (List not meant to be allinclusive) — Chromosomal Microarray Analysis

Y

Y

Y

10/13/2017

Y

Y

Y

10/13/2017

N

N

N

2/9/2018

N

N

N

2/9/2018

Y

Y

Y

2/9/2018

Y

Y

Y

10/13/2017

Note: Not covered —FirstStepDx PLUS genetic testing service for autism (Lineagen) CPT
(81229, 81479, 81243)

(See also Chromosomal Microarray Analysis)
CPT (81228, 81229, 88230, 88262)
HCPCS (S3870)
Genetic testing — comparative genomic hybridization (CGH) microarray
for chromosomal imbalance (various manufacturers)
(See also Chromosomal Microarray Analysis)
CPT (81228, 81229, 88230, 88262)
HCPCS (S3870)
Genetic testing — craniosynostosis next generation sequencing (NGS)
panel
(E.g., Connective Tissue Gene Tests such as the Skeletal Dysplasia Ciliopathy NGS Panel)

(See also Gene Expression Profiling)
CPT (81479, 81405, 81404)
Genetic testing — cystic fibrosis (general population screening in the
absence of signs/symptoms)
(See also Genetic Testing for Cystic Fibrosis)
CPT (81220, 81221, 81222, 81223, 81224)
Genetic testing — cystic fibrosis (pregnancy-planning and for those in
early stages of pregnancy when results will be used to inform decisions
regarding childbearing or fetal diagnosis)
(See also Carrier Screening for Parents or Prospective Parents)
CPT (81220, 81221, 81222, 81223, 81224)
Genetic testing — cystic fibrosis (diagnostic use for suspected cystic
fibrosis)
(See also Genetic Testing for Cystic Fibrosis)

CPT (81220, 81221, 81222, 81223, 81224)
Genetic testing — dementia
(See also Genetic Testing for Frontotemporal Dementia (FTD)

N

N

N

10/13/2017

N

N

N

2/9/2018

Y

Y

Y

2/9/2018

Y

Y

Y

10/13/2017

N

N

N

2/9/2018

Y

Y

Y

10/13/2017

N

N

N

4/21/2017

Y

Y

Y

10/13/2017

SEE NOTE

SEE NOTE

SEE NOTE

6/9/2017

N

N

N

3/10/2017

N

N

N

12/12/2017

CPT (81406, 81479)
Genetic testing — epilepsy (confirmatory diagnosis to identify familial
mutations to allow carrier testing and prenatal diagnosis)
(See also Genetic Counseling and Testing and Gene Expression Proflling)
(E.g., NGS Epilepsy/Seizure Panel [Greenwood Genetic Center])

CPT (81479)
Genetic testing — Factor V Leiden mutation analysis
CPT (81241)
Genetic testing — familial hypertrophic cardiomyopathy
(See also Hereditary Cardiomyopathy)
CPT (81403, 81405, 81406, 81407, 81479)
HCPCS (S3865, S3866)
Note: CPT codes 81408 and 81439 are not covered (see also Molecular Pathology
Procedures LCD)

Genetic testing — Guanylyl cyclase c (GCC or GUCY2C) lymph node
analysis for colorectal cancer staging
(E.g., Previstage™ GCC)

CPT (No specified code)
Genetic testing — hereditary pancreatitis
CPT (81222, 81223, 81224, 81401, 81404, 81479)
Genetic testing — hereditary retinal disorders
(E.g., sequence analysis ≥ 15 genes including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B,
PRPF31, PRPH2, RDH12, RH0, RP1, RP2, RPE65, RPGR, AND USH2A)

(See also Genetic Counseling and Testing)
CPT (81434)
Genetic testing — Li-Fraumeni syndrome
CPT (81404, 81405, 81479)
Genetic testing — Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
(See also Janus Kinase 2 (JAK2) V617F Gene Mutation Assay)
CPT (81270, 81403)
Genetic testing — age-related macular degeneration (AMD), riskdetermination for
(E.g., Macular Degeneration Mutation Analysis [Quest], Macula Risk PGx [Arctic];
RetnaGene AMD [Sequenom], ARUP lab test offerings)

(See also Genetic Counseling and Testing)
CPT (81401, 81405, 81408)
Genetic testing — infectious agent detection by nucleic acid (DNA or
RNA), human papillomavirus (HPV) for five or more separately reported
high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)

(ie, genotyping)
CPT (0500T eff. 01/01/2018)
Genetic testing — malignant melanoma (CDKN2A)
(E.g., Melaris® [Myriad Genetics])

(See also Gene Expression Profiling of Melanomas)

N

N

N

10/13/2017

N

N

N

9/8/2017

N

N

N

7/14/2017

N

N

N

2/9/2018

N

N

N

4/21/2017

N

N

N

3/10/2017

Y

Y

Y

3/10/2017

N

N

N

7/14/2017

CPT (81404)
Genetic testing — methylenetetrahydrofolate reductase (MTHFR)
genotyping as part of the clinical evaluation for thrombophilia, recurrent
pregnancy loss, coronary artery disease, or any other indication
(See also Genetic Counseling and Testing and Recurrent Pregnancy Loss)
CPT (81291)
Genetic testing — Myeloid Molecular Profile (Genoptix)
(See also Gene Expression Profile Testing for Multiple Myeloma or Gene
Expression Profiling)
CPT (81450)
Genetic testing — next generation sequencing of multiple genes for
hereditary cancers
(E.g., Paradigm Cancer Diagnostics [PCDx] Test; Ambry Genetics Hereditary Cancer Panel
tests such as CancerNext™, myRisk™; FoundationOne; Oncofocus; Guardant 360® Panel;
Molecular Intelligence™ Service or Target Now™ Molecular Profiling Service; GeneKey;
GeneTrails® Solid Tumor Panel; OnkoMatch™; OncInsights™, etc.)

(See also Gene Expression Profiling and Genetic Testing for Cancer
Susceptibility)
CPT (81201*, 81202, 81203, 81211*, 81212, 81213*, 81214, 81215,
81216, 81217, 81292*, 81294*, 81295*, 81297*, 81298*, 81300*, 81317*,
81319*, 81402, 81404, 81406, 84999)
*Denotes CancerNext™ coding
Genetic testing — Noonan spectrum disorders
(Sequence analysis panel, ≥ 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2,
NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1)

(See also Genetic Counseling and Testing)
CPT (81442)
Genetic testing — NOTCH1, SF3B1 and BIRC3 prognostic genetic testing in
chronic lymphocytic leukemia (CLL)
(See also Genetic Counseling and Testing)
CPT (81450, 81455, 81479)
Genetic testing — NRAS mutation testing (neuroblastoma RAS viral, vras,
oncogene homolog) to determine pharmacotherapy candidacy for the
management of colorectal cancer
(See also Genetic Counseling and Testing; for Medicare members, see
NRAS Genetic Testing
CPT (81311)
Genetic testing — Panexia® (Myriad Genetics) for pancreatic
cancer/other oncologic indications

(See also Genetic Testing for Cancer Susceptibility and Gene Expression
Profiling)
CPT (81216, 81406)
Genetic testing — Pediatric Neurology Region of Interest Trio (Claritas
Genomics Inc.)
(See also Gene Expression Profiling)

N

N

N

7/14/2017

N

N

N

10/13/2017

N

N

N

3/10/2017

Y

Y

Y

1/19/2017

N

N

N

10/13/2017

N

N

N

10/13/2017

Y

Y

Y

5/12/2017

CPT (81479)
Genetic testing — peripheral neuropathies
(See also Genetic Testing for Inherited Peripheral Neuropathies)
CPT (81324, 81325, 81326, [81448 eff. 01/01/2018])
Genetic testing — presenilin-1 gene
(See also Genetic Testing for Alzheimer’s Disease and Genetic Counseling
and Testing)
CPT (No specific code)
HCPCS (S3855)
Genetic testing — pregnancy planning (screening for Fragile X Syndrome)
(See also Carrier Screening for Parents or Prospective Parents)
CPT (81243, 81244)
Genetic testing — pregnancy planning (screening for hereditary
hemochromatosis)
(See also Carrier Screening for Parents or Prospective Parents, Genetic
Testing of Hereditary Hemochromatosis, Genetic Counseling and
Testing)
Note: The plan covers prenatal testing for hereditary hemochromatosis when the diseasecausing alleles are first identified in an affected family member or both parents.

CPT (81256)
Genetic testing — pregnancy planning (non-standard universal-type
screening)
(E.g., Counsyl preconception carrier genetic screening test, GeneAware Complete Panel,
Progenity® Pan-Ethnic Panel 3]) Note: Screening for rare diseases is not endorsed by ACOG
as part of standard prenatal testing

(See also Carrier Screening for Parents or Prospective Parents, Genetic
Counseling and Testing, Gene Expression Profiling)
CPT (81200, 81205, 81209, 81220, 81221, 81222, 81223, 81225, 81241,
81242, 81243, 81244, 81250, 81251, 81252, 81253, 81255, 81256, 81257,
81260, 81290, 81291, 81330, 81332, 81400, 81401, 81402, 81403, 81404,
81405, 81406, 81407, 81408, 81479)
Genetic testing — pregnancy planning; cell-free DNA non-invasive
prenatal testing (NIPT) for high risk pregnancies
(E.g., Harmony™ [Ariosa Diagnostics]; MaterniT21™ [Sequenom], Panorama™ [Natera],
Verifi® [Illumina])

(See also Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy)
Note: NIPT is not covered for sex chromosome aneuploidies, low/average risk pregnancies
(e.g., VisibiliT™ [Sequenom]), those with multiple gestations or the analysis of chromosomal
microdeletions for various conditions (e.g., DiGeorge syndrome, Cri-du-chat syndrome, etc.)

CPT (81420, 81422, 81507, 81599, 84999)
Genetic testing — prostate
cancer antigen 3 gene (PCA 3) screening for prostate cancer
(See also Genetic Counseling and Testing)
Note: PCA3 testing is considered medically necessary for Medicare members only when all
biopsies in previous encounter(s) are negative for prostatic cancer, the subsequent prostate
specific antigen (PSA) is rising, and when the patient or physician wants to avoid repeat
biopsy (“watchful waiting”).

N

SEE NOTE

N

3/10/2017

Y

Y

Y

11/10/2017

N

N

N

1/12/2018

N

N

N

8/11/2017

Y

Y

Y

10/13/2017

N

N

N

11/10/2017

N

N

N

2/09/2018

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

4/21/2017

The PROGENSA® PCA3 test (Hologic®) is covered for Medicare members only when all
biopsies in previous encounter(s) are negative and when the patient or physician wants to
avoid repeat biopsy (watchful waiting).

CPT (81313)
HCPCS (S3721)
Genetic testing — PTEN hamartoma tumor syndrome (PHTS)
(Cowden syndrome [CS], Bannayan-Riley-Ruvalcaba syndrome [BRRS]
and Adult Lhermitte Duclos disease (ALDD)
CPT (81321, 81322, 81323)
Genetic testing — Saethre-Chotzen Syndrome (TWIST) Sequencing and
MLPA (Greenwood Genetic Center)
(See also Gene Expression Profiling and Genetic Counseling and Testing)
CPT (81403, 81404)
Genetic testing — SLCO1B1 genotyping for statin dosing or selection
CPT (81328 eff. 01/01/2018)
Genetic testing — SHOX-related short stature
(See also Gene Expression Profiling and Genetic Counseling and Testing)
CPT (81479)
Genetic testing — statin-induced myopathy
CPT (81400)
Genetic testing — whole exome sequencing, whole genome/
mitochondrial sequencing
(See also Genetic Counseling and Testing)
CPT (Exome [81415, 81416, 81417], Genome [81425, 81426, 81427,
81460, 81465], Mitochondrial [81440])
GlucoWatch® Automatic Glucose Biographer (No longer marketed in the
U.S.)
HCPCS (S1030, S1031)
GlycoMark® assay ( Nippon Kayaku, Co., Ltd) for glycemic control
(Aka 1,5-anhydroglucitol [1,5-AG])

(See also Medicare LCD: GlycoMark Testing for Glycemic Control)
CPT (84378, 84999)
Genomic sequencing analysis (at least 9 genes)/duplication deletion
analysis — aortic dysfunction or dilation
(E.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial

tortuosity syndrome)

(See also Genetic Counseling and Testing)
CPT (81410, 81411)
Note: Genetic testing panels for Marfan syndrome, other syndromes associated with thoracic
aortic aneurysms and dissections, and related disorders that are not limited to focused
genetic testing as defined by CPT codes 81405 and 81408 are considered investigational.

Genomic sequencing analysis — acute myelogenous leukemia (AML),
disease management
(See also Medicare LCD Genomic Sequence Analysis Panels in the
Treatment of Acute Myelogenous Leukemia)

N

Y

N

1/19/2017

N

N

N

8/11/2017

N

N

N

1/19/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

SEE NOTE

N

SEE NOTE

9/8/2017

Y

Y

Y

12/12/2017

CPT (81450)
Genomic sequencing analysis (at least 60 genes)/duplication deletion
analysis — hearing loss
(E.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome)

(See also Gene Expression Profiling)
CPT (81252, 81253, 81254, 81430, 81431)
Genomic sequencing analysis — x-linked intellectual disability (XLID)
(E.g., syndromic and non-syndromic XLID)

(See also Gene Expression Profiling)
CPT (81470, 81471)
Guardant 360 liquid biopsy test for advanced solid tumors
CPT (81455)
Heart rate variability testing (Anscore™)
CPT (No specific code)
Heartsbreath test for transplant rejection (aka Tolatile Organic
Compounds Breath Analysis)
Note:
Commercial and Medicaid: The Heartsbreath investigational test is FDA-approved as a
Humanitarian Device Exemption (HDE) for use as an aid in the diagnosis of grade 3 heart
transplant rejection in patients who have received heart transplants within the preceding
year. The Heartsbreath test is intended to be used as an adjunct to, and not as a substitute
for, endomyocardial biopsy. The use of the device is limited to patients who have had
endomyocardial biopsy within the previous month. Therefore, pre certification requests
when presented as such will be reviewed on a case-by-case basis.
Medicare: Not covered per National Coverage Determination (NCD) for Heartsbreath Test
for Heart Transplant Rejection

CPT (0085T)
HBA1/HBA2 (alpha globin 1 and alpha globin 2)(eg, alpha thalassemia, Hb
Bart hydrops fetalis syndrome, HbH disease), gene analysis; known
familial variant
HBA1/HBA2 (alpha globin 1 and alpha globin 2)(eg, alpha thalassemia, Hb
Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene
sequence
HBA1/HBA2 (alpha globin 1 and alpha globin 2)(eg, alpha thalassemia, Hb
Bart hydrops fetalis syndrome, HbH disease), gene analysis;
duplication/deletion variants

CPT (81258, 81259, 81269 eff. 01/01/2018)
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE)
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); known familial variant(s)
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); duplication/deletion variant(s)

N

N

N

12/12/2017

Y

Y

Y

7/14/2017

Y

Y

Y

6/9/2017

N

N

N

1/12/2018

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

N

N

N

9/8/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); full gene sequence
CPT (81361, 81362, 81363, 81364 eff. 01/01/2018)
Hepatitis C virus (HCV) antibody screening for adults at high risk for HCV
infection (defined as persons with a current or past history of illicit
injection drug use, and persons who have a history of receiving a blood
transfusion prior to 1992)
Note: Repeat screening is covered annually only for members who have had continued illicit
injection drug use since prior negative screening test.

CPT (86803)
HCPCS (G0472)
High frequency chest wall oscillation devices (compression vest)
HCPCS (A7025, A7026, E0483)
CPT (94669)
High intensity focused ultrasound (HIFU) for prostate cancer
CPT (55899, 76999)
HCPCS
High resolution anoscopy for detecting anal intraepithelial neoplasia —
diagnostic adjunct in following up on abnormal cytology
CPT (46601, 46607)
High resolution anoscopy for detecting anal intraepithelial neoplasia —
screening of high risk individuals
CPT (46601, 46607)
Diagnosis codes (Z12.12, Z12.89, Z12.89)
High resolution esophageal pressure topography (motility study) standalone or combined with stimulation and/or acid or alkali perfusion
CPT (91299)
HIV genotyping
(E.g., HIV-1 Genotype [Quest Diagnostics]; HIV-1 TrueGene™ [Visible Genetics]; ViroSeq™
[Abbott Laboratories])

CPT (87901, 87906)
HIV phenotyping
(E.g., PhenoSense™, Phenoscript™)

CPT (87903, 87904, 87900)
Note: While CPT code 87900 is relevant to phenotyping, it is also applicable to alternate
viral infections

Holotranscobalamin (HoloTC) biomarker lab test for Vitamin B-12
deficiency

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

N

7/14/2017

Y

Y

Y

4/21/2017

Y

Y

N

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

1/12/2018

N

N

N

8/11/2017

CPT (No specific code)
Home nocturnal penile tumescence testing (RigiScan® Monitor)
CPT (54250)
Home prothrombin time/international normalized ratio (INR) monitoring
for anticoagulation management
CPT (93792, 93793 eff. 01/01/2018)
HCPCS (G0248, G0249, G0250)
Home uterine activity monitoring
CPT (99500, S9001)
Human growth hormone for idiopathic short stature (TEV-TROPIN®)
HCPCS (J2940, J2941, S9558, Q0515)
Human papilloma virus (HPV) DNA testing with cytology co-testing for
cervical cancer
CPT (87623, 87624, 87625)
Human platelet antigen (HPA) genotyping
















Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 [platelet
glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common
variant, HPA-1a/b (L33P)
Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib [platelet],
alpha polypeptide [GPIba]) (eg, neonatal alloimmune thrombocytopenia
[NAIT], post- transfusion purpura), gene analysis, common variant, HPA-2a/b
(T145M)
Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha 2b
[platelet glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb]) (eg,
neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-3a/b (I843S)
Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3 [platelet
glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common
variant, HPA-4a/b (R14)
Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2 [CD49B,
alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common
variant (eg, HPA-5a/b (K505E)
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3 [platelet
glycoprotein IIIa, antigen CD61] [GPIIIa])(eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene analysis, common
variant, HPA-6a/b (R489Q)
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin, alpha 2b
[platelet glycoprotein IIb of IIb/IIIa complex, antigen CD41] [GPIIb]) (eg,
neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-9a/b (V837M)
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109 molecule) (eg,
neonatal alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-15a/b (S682Y)

CPT (81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112 eff.
01/01/2018)
HPV DNA testing as primary screening

(E.g., cobas® HPV)

CPT (87623, 87624, 87625)
Hyaluronate injections for osteoarthritis of the knee
CPT (20610)

Y

Y

N

9/8/2017

Y

Y

Y

5/12/2017

N

N

N

1/12/2018

Y

Y

Y

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

12/12/2017

N

N

N

12/12/2017

Y

Y

Y

1/12/2018

N

N

N

8/11/2017

Y

Y

Y

6/9/2017

HCPCS (J7321, J7323, J7324, J7325, J7326, J7327, J7328)
Hyperbaric Oxygen Therapy
CPT (99183)
HCPCS (G0277)
Hyperthermia (whole-body) for cancer
Note: in addition to whole body, the use of intraluminal, endocavitary, interstitial and
regional deep tissue hyperthermia exceeding 4 cm in depth is investigational

(See also Hyperthermia Treatment for Cancer)
CPT (77605, 77620)
Hypothermia — selective head or total body in neonates ≤ 28 days for
treatment of moderate or severe hypoxic ischemic encephalopathy
(HIE)
CPT (99184)
Hysteroscopic techniques for sterilization
(E.g., Essure™ Coil Sterilization)

(See also FDA Activities: Essure for product warnings)
CPT (58565)
HCPCS (A4264)
iBOT Mobility System® (standard feature)
Note: Additional features for balance, stair-climbing and remote functions are not
considered medically necessary.

HCPCS (K0877)
IDH1 testing — IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg,
glioma), common variants (eg, R132H, R132C)
CPT (81120 eff. 01/01/2018)
IDH2 testing — IDH2 (isocitrate dehydrogenase 2 [NADP+],
mitochondrial(eg, glioma), common variants (eg, R140W, R172M)
CPT (81121 eff. 01/01/2018)
Ilizarov bone lengthening technique
CPT (20690, 20692, 20693, 20694, 20696, 20697)
Imaging — tactile breast by computer-aided tactile sensors
(E.g., Breastview Visual Mapping System, iBreastExam)

CPT (0422T)
Impella RP System for circulatory assistance
Covered for providing circulatory assistance for up to 14 days in pediatric or adult members
with a body surface area ≥ 1.5 m2 who develop acute right heart failure or decompensation
following left ventricular assist device implantation, myocardial infarction, heart transplant,
or open-heart surgery.

(See also The Impella® RP New Way to Treat Right Heart Failure Guide)

CPT (33990, 33991)
For removal or repositioning of the device, utilize CPT code (33992 or
33993)
Implantable infusion pumps for chronic intractable pain
Note: Coverage for Medicaid members is limited to intractable cancer pain only. (This does
not apply to members with pumps in place prior to October 1, 2013). Coverage for
Commercial and Medicare members includes pain attributable to malignant or
nonmalignant origin; as commensurate with the CMS National Coverage Determination
(NCD) for Infusion Pumps

Y

Y

SEE NOTE

7/14/2017

N

Y

N

7/14/2017

N

N

N

9/8/2017

N

N

N

8/11/2017

N

N

N

8/8/2017

N

N

N

7/14/2017

N

N

N

7/14/2017

N

N

N

12/12/2017

N

N

N

10/13/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

CPT (62350, 62351, 62355, 62360, 62360, 62361,62362, 62365, 62367,
62368, 62369, 62370, 95990, 95991, 96523)
HCPCS (E0782, E0783, E0785, E0786, A4220)
Implantable Miniature Telescope™ for macular degeneration
CPT (0308T)
Immune cell function assays
(E.g., Lymphocyte Stimulation, ImmuKnow®, CYLEX®, CU Index®, iSpot Lyme™)

CPT (86352)
Inflow™ intraurethral valve pump
HCPCS (A4335)
Infrared heating pad system and replacement pads
HCPCS (A4639, E0221)
Injectable autologous myoblast cells for fecal incontinence
(See also Fecal Incontinence Treatment)
CPT (0277T, 0377T, 11950, 11951, 11952, 11954)
HCPCS (L8605, L8699)
Injectable autologous mesenchymal stem cells for fecal incontinence
CPT (0277T, 0377T, 11950, 11951, 11952, 11954)
HCPCS (L8605, L8699)
Injectable autologous white blood cell concentrate (autologous protein
solution), any site, including image guidance, harvesting and preparation
CPT (0481T eff. 01/01/2018)
Injectable bulking agents for fecal incontinence
(E.g., Solesta®)

(See also Fecal Incontinence Treatment)
CPT (0377T)
HCPCS (J3490, L8605)
Injectable bulking agents for vocal cord medialization
HCPCS (L8607)
Injection, Alemtuzumab
(See also Alemtuzumab [Campath®] or Alemtuzumab [Lemtrada™])
HCPCS (J0202)

Injection, isavuconazonium sulfate
HCPCS (J1833)

Y

Y

Y

7/14/2017

SEE NOTE

SEE NOTE

SEE NOTE

2/9/2018

N

SEE NOTE

N

2/9/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Insulin — continuous glucose monitoring (CGM) and insulin delivery
devices (aka combination devices)
Insulin — external insulin pumps (standard/programmable wireless, e.g.,
OmniPod®)
Note: See Insulin Delivery Devices and Continuous Glucose Monitoring Systems for coding
and clinical criteria

Insulin — external insulin pumps (transdermal insulin delivery system
[nonprogrammable [no wireless communication capability, e.g., V-Go™
Disposable Insulin Delivery Device]; remote wireless devices with smart
phone capability, e.g., Dexcom G5)
Note: See Insulin Delivery Devices and Continuous Glucose Monitoring Systems

HCPCS (A9274)
Insulin — internal insulin pumps
CPT (49419 [also used for morphine and chemotherapeutic agents
administration, only deny for a diabetic indication])
Insulin — outpatient intravenous insulin treatment/therapy
(Aka Cellular Activation Therapy [CAT], Chronic Intermittent Intravenous Insulin Therapy
[CIIIT], Hepatic Activation Therapy [HAT], Intercellular Activation Therapy [iCAT], Metabolic
Activation Therapy® [MAT®], Pulsatile Intravenous Insulin Treatment [PIVIT], Pulse Insulin
Therapy [PIT] and Pulsatile Therapy [PT])

HCPCS (G9147)
Insulin — insulin potentiation therapy (IPT)
Coding note: No specific CPT; the following series of CPT and HCPCS J codes are used to
describe the various IPT components. Some codes (i.e., code for glucose testing) may be
used more than once during a single session of IPT.

CPT (82948, 96365, 96366, 99070)
HCPCS (J1817, J7030, J7040, J7050)

Intensity modulated radiation therapy (IMRT) — benign conditions
(Specifically: Acoustic neuroma, craniopharyngioma, glomus tumor, hemangioblastoma,
meningioma, pineocytoma, pituitary adenoma, schwannoma and cavernous malformations)

(IMRT) — cancerous conditions
(Specifically: Non-Hodgkin’s lymphoma [disease above the diaphragm], anal cancer, breast
cancer, cervical cancer, endometrial cancer, head and neck cancer, adrenal, kidney, and
bladder cancers, gastric adenocarcinoma [when dose to critical organs such as liver, heart,
lung, kidneys and spinal cord is of concern], hepatobiliary cancer [including primary liver,
intrahepatic bile duct, extrahepatic bile duct, gallbladder], primary malignant gliomas,
primary central nervous system [PCNS] lymphoma, prostate cancer)
Note:
For bone metastasis, IMRT may be approved where overlap with previous radiotherapy
fields is likely to cause complications.
When comparative 3D and IMRT plans demonstrate that a 3D plan does not meet the
“Acceptable” normal tissue constraints (using standard metrics published by the Radiation
Therapy Oncology Group [RTOG]/National Comprehensive Cancer Network [NCCN]), then
IMRT will be approved for the following:
Bladder cancer
Bone Metastasis
Carcinoma of the esophagus/gastroesophageal junction (GEJ)
Gastric adenocarcinoma
Kidney and adrenal cancers
Pancreas adenocarcinoma
For breast cancer, inverse-planned IMRT is not medically necessary for either whole-breast
irradiation (WBI) (with or without nodal irradiation) or the boost. Exceptions will be made
on a case-by-case basis in those unusual clinical situations where inverse-planned IMRT
dosimetry yields clinically meaningful and significant dosimetric improvement over
forward-planned dosimetry.
For lung cancer, IMRT is not medically necessary; case-by-case considerations are as
follows:




Where there is disease in the bilateral mediastinum or bilateral hilar
regions
Where there is disease in the para-spinal region
For superior sulcus tumors

For pancreas adenocarcinoma, IMRT may be considered medically necessary when
acceptable doses to critical organs (i.e., kidney, spinal cord, small bowel, stomach or
liver) cannot be achieved with 3D planning.

CPT (77301, 77338, 77385, 77386, 77387, 77499)
HCPCS (G6015, G6016, G6017)
EmblemHealth does not consider injection/implantation of bulking/spacer material
(with/without image guidance) to be medically necessary in conjunction with IMRT for
prostate cancer (CPT 0438T [del. 01/01/2018] [e.g., SpaceOAR®])

Y

Y

Y

1/12/2018

Intensive behavioral program for diabetes prevention using a
standardized curriculum in a group setting
(See Nutrition Counseling Services for covered services/coding)

N

N

N

1/12/2018

N

N

N

8/11/2017

N

N

N

1/12/2018

SEE NOTE

SEE NOTE

SEE NOTE

7/14/2017

CPT (0403T)
Interferential current stimulator
CPT (S8130, S8131)
Intracellular micronutrient testing — all indications
(Aka intracellular micronutrient analysis/functional intracellular analysis)
Note: This differs from tests for individual micronutrients, which may be considered
medically necessary when used to confirm suspected micronutrient deficiencies

CPT (82136, 82307,82310, 82607, 82725, 82746, 82978, 83735, 84207,
84252, 84255, 84425, 84446, 84591, 84630, 86353, 84999)
Intracranial angioplasty — atherosclerotic post stroke/vasospasm post
aneurysmal subarachnoid hemorrhage
Atherosclerotic stenosis secondary to stroke
(E.g., NEUROLINK® System, including NEUROLINK® Stent & Delivery Catheter and
NEUROLINK® Balloon Dilatation Catheter; Wingspan&Trade Stent System with
Gateway&Trade PTA Balloon Catheter)

Vasospasm post aneurysmal subarachnoid hemorrhage
(E.g., NeuroVasx cPAX Aneurysm Treatment System, ENTERPRISE Vascular Reconstruction
Device and Delivery System, Low-Profile Visualized Intraluminal Support Device, Onyx®
Liquid Embolic System [Onyx® HD-500])
Note: These devices are FDA-approved as Humanitarian Device Exemptions (HDEs);
therefore, pre certification requests when presented as such will receive case-by-case
review for all LOBs EXCEPT for Medicare members with atherosclerotic disease ONLY,
whose costs relating directly to the provision of services related to the Intracranial Stenting
and Angioplasty NCD (that were non-covered services prior to the issuance of the NCD) will
be paid by CMS intermediaries and carriers for cerebral artery stenosis (≥ 50% in patients
with intracranial atherosclerotic disease when furnished in accordance with the FDAapproved protocols governing Category B [Investigational Device Exemption] IDE clinical
trials). (Medicare does not provide vasospasm coverage)

NEUROLINK®
Indicated for the treatment of patients with recurrent intracranial stroke attributable to
atherosclerotic disease refractory to medical therapy in intracranial vessels ranging from 2.5
to 4.5 mm in diameter with > 50% stenosis and that are accessible to the stent system

Wingspan
Indicated for patients between 22 and 80 years old AND who meet ALL of the following
criteria:
≥ 2 strokes despite aggressive medical management most recent stroke occurred > 7 days
prior to planned treatment with Wingspan 70-99 % stenosis due to atherosclerosis of the
intracranial artery related to the recurrent strokes have made good recovery from previous
stroke and have a modified Rankin score of 3 or less prior to Wingspan treatment. The
Rankin scale is used to measure the degree of disability in stroke patients. Lower scores
indicate less disability.

cPax Aneurysm Treatment System
Indicated for adults (≥ 22 years of age) for wide-necked large and giant-sized cerebral
aneurysms (>10) mm that require use of adjunctive assist-devices such as stents or balloons

ENTERPRISE Vascular Reconstruction Device and Delivery System
Indicated for use with embolic coils for the treatment of wide-neck, intracranial, saccular or
fusiform aneurysms arising from a parent vessel with a diameter of >= 3 mm and <= 4 mm

Low-Profile Visualized Intraluminal Support Device

For use with bare platinum embolic coils for the treatment of unruptured, wide-neck (neck
≥ 4 mm or dome to neck ratio < 2 mm), intracranial, saccular aneurysms arising from a
parent vessel with a diameter ≥ 2.5 mm and ≤ 4.5 mm

Onyx® Liquid Embolic System (Onyx® HD-500)
Treatment of intracranial, saccular, sidewall aneurysms that present with a wide neck (>= 4
mm) or with a dome-to-neck ratio < 2 that are not amenable to treatment with surgical
clipping

CPT (61630, 61635, 61640, 61641, 61642)
Intraocular lenses — new technology (multifocal, accommodating or toric
lenses)
(E.g., i.e., Array® Model SA40, ReZoom™, AcrySof® ReStor®, Tecnis ZM900, Crystalens™
Model AT-45, Crystalens HD™, Crystalens Aspheric Optic™, ARTISAN®, STAR Visian ICL™)

N

N

N

8/11/2017

N

N

N

1/19/2017

N

N

N

3/10/2017

N

N

N

6/9/2017

Y

Y

Y

7/14/2017

N

N

N

1/12/2018

N

N

N

2/10/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

HCPCS (Q1004, Q1005)
Intraoperative assessment of surgical margins during breast-conserving
surgery with radiofrequency spectroscopy or optical coherence
tomography
(E.g., MarginProbe®, RS-3000 Advance)

CPT (0351T, 0352T, 0353T, 0354T, 19499)
HCPCS (A4649)
Intra-oral bone conduction prosthetic hearing devices (e.g., SoundBite™)
(See also Bone anchored hearing aids)
CPT (L9900)
Intrapulmonary percussive ventilators (IPV)
(See also High Frequency Chest Wall Oscillation Devices and
Intrapulmonary Percussive Ventilators)
HCPCS (E0481)
Intrathecal opioid therapy for chronic non-malignant pain
CPT (62350, 62351, 62355, 62360, 62361, 62362, 62365, 62367, 62368)
HCPCS (E0785, J3490)
Irreversible electroporation (IRE) for tumors
(E.g., NanoKnife System)

CPT (No specific code)
ketamine (administered via oral, parenteral, sublingual or intranasal
methods) for the treatment of psychiatric disorders
CPT (96365, 96366, 96367, 96368, 96374, 96375, 96376)
HCPCS (J3490)
Know error® system (Strand Diagnostics) to confirm surgical biopsy
samples through bar coding
CPT (81265, 81266)
Koning Breast CT System (KBCT)
CPT (76497)
Kyphoplasty
CPT (22513, 22514, 22515)

Lacrimal duct angioplasty
(E.g., Lacricath®)

Y

Y

Y

7/14/2017

Y

Y

Y

3/10/2017

N

N

N

12/12/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

9/21/2017

N

N

N

9/21/2017

Y

Y

Y

7/14/2017

Y

Y

Y

5/12/2017

N

SEE NOTE

N

7/14/2017

CPT (68816)
Laparoscopic adjustable gastric silicone banding
(E.g., LAP-BAND® Adjustable Gastric Banding [LAGB®] System, REALIZE™ Adjustable Gastric
Band or any other FDA-approved device)

(See also Bariatric Surgery)
CPT (43770, 43771, 43772, 43773, 43774)
Laser — ablative, non-contact, full field and fractional ablation, open
wound
CPT (0491T, 0492T eff. 01/01/2018)
Laser — benign prostatic hypertrophy/interstitial laser coagulation (ILC)
(E.g., Indigo®)

CPT (52647)
Laser — coronary angioplasty
CPT (No specific code)
Laser — in situ for keratomileusis (LASIK)
HCPCS (S0800)
Laser — laparoscopic CO2 laser ablation for endometriosis
CPT (58578)
Laser — low level laser therapy / cold laser
CPT (S8948)
Laser — phototherapy for psoriasis (excimer laser UVB)
(E.g., YAG, Blue light X-Trac)

(See also Photodynamic Therapy for Dermatologic Conditions)
CPT (96920, 96921, 96922)
Laser — phototherapy/ photochemotherapy for vitiligo (excimer laser
UVB)
(E.g., YAG, Blue light X-Trac)

(See also Photodynamic Therapy for Dermatologic Conditions)
Note: Case-by-case consideration will be given for areas of the face, neck and hands only.

CPT (96920, 96921, 96922, 96910, 96912)
Laser — prostate ablation
CPT (52647, 52648)
Laser — pulsed dye for cutaneous vascular lesions
CPT (17106, 17107, 17108)
Laser — spinal (ablation /discectomy [percutaneous or laparoscopic,
laser-assisted disc decompression [LADD], laser disc decompression) —
all levels.
(See also Spinal — minimally invasive [within this document], as well as
CMS Decision Memo for Percutaneous Image-guided Lumbar

Decompression (PILD) for Lumbar Spinal Stenosis
Note: Medicare members, whose costs relating directly to the provision of services related
to the National Coverage Determination (NCD) (that were non-covered services prior to the
issuance of the NCD) will be paid by CMS intermediaries and carriers when beneficiaries are
enrolled in a clinical study that meets the criteria put forth within the NCD.

CPT (62287, 64999)
HCPCS (G0276)
Note: This code must be used for Medicare members when services are provided in a
blinded, randomized, controlled trial with a placebo procedure control arm

Laser — varicose veins (endovenous laser ablation)
(See also Varicose Vein Treatment)
Note: Must be FDA-approved for noncosmetic indication(s); diode/Nd, YAG modalities with
various wavelengths are acceptable)

Y

Y

Y

3/23/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

8/11/2017

N

N

N

10/13/2017

N

SEE NOTE

N

2/9/2018

SEE NOTE

SEE NOTE

SEE NOTE

8/11/2017

CPT (36478, 36479)
Laser-induced thermotherapy for liver cancers
No specific CPT (47399)
Liquid-based cervical cytology
(E.g., Thin Prep)

CPT (88141, 88142)
HCPCS (G0123, G0124)
Lumason contrast agent
HCPCS (Q9950)
Lung volume reduction surgery (reduction pneumoplasty)
CPT (32491)
HCPCS (G0302, G0303, G0304, G0305)
Magnetic Mini Mover Procedure (3MP) for the treatment of pectus
excavatum
(See also Surgical Correction of Chest Wall Deformities)
CPT (No specific code)
Magnetic resonance image guided high intensity focused ultrasound
(MRgFUS), stereotactic ablation lesion, intracranial for movement
disorder including stereotactic navigation and frame placement
MRgFUS
Note: MRgFUs is covered for Medicare members commensurate with the NGS LCD:
Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
(E.g., ExAblate®, Sonotherm®) for bone metastatic pain

CPT (0398T)
Magnetic resonance spectroscopy
Note: Potentially appropriate only in the following clinical scenarios:
Distinguishing low grade from high grade gliomas
Evaluating a brain lesion of indeterminate nature when the MRS findings will be used to
determine whether biopsy/resection can be safely postponed
Distinguishing radiation-induced tumor necrosis from progressive disease within 18 months
of completing radiotherapy.
As an alternative to FDG PET if requested by the patient’s referring epileptologist to assess

intractable epilepsy for which surgical treatment or another interventional modality is
under active consideration

CPT (76390)
Magnetoencephalography (MEG)/magnetic source imaging (MSI) for
operative planning
CPT (95965, 95966, 95967)

Y

Y

Y

7/17/2017

Y

Y

Y

3/10/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

10/13/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

10/13/2017

Y

Y

Y

7/14/2017

HCPCS (S8035)
Mammography — 3D (tomosynthesis for breast cancer screening and
diagnosis [e.g., Selenia® Dimensions® Digital Tomosynthesis System])
CPT (77061, 77062, 77063)
HCPCS (G0279)
Note: Tomosynthesis coverage added to Commercial and Medicaid members, retro to
1/1/2017, per 2/27/2017 letter to insurers from the New York State Department of
Financial Services.

Mammography — digital
CPT (77065, 77066, 77067)
HCPCS (G0202, G0204, G0206 [del. 01/01/2018])
Measurement of spirometric forced expiratory flows and lung volumes
for infants or children < 2yrs of age
CPT (94010, 94011, 94012, 94013)
Mechanical Stretching Devices (see guideline for indications)
Dynamic splinting devices
(E.g., Dynasplint® Systems, EMPI Advance Dynamic ROM®, LMB Pro-Glide™;
extensionators/flexionators (ERMI)/patient-actuated serial stretch [PASS] devices; JAS
Splints [Joint Active Systems]; bidirectional static progressive devices, etc.)

CPT (29126, 29131, 29260, 29280)
HCPCS (E1800, E1801, E1802, E1805, E1806, E1818, E1821, E1825, E1399)
HCPCS (E1810, E1811, E1840, E1816 [covered for Medicare members
only])
Meniett device for Ménière’s disease
CPT (69433)
HCPCS (E2120, A4638)
Merci® Retriever/Merci® Retrieval System for ischemic stroke
CPT (No specific code)
Metal on metal hip resurfacing (total or partial)
(E.g., Birmingham Hip Resurfacing [BHR] System, CONSERVE® Plus Total Resurfacing Hip
System, Cormet Hip Resurfacing System or any other FDA-approved devices)

CPT (27130, 27125, 27132, 27134, 27137, 27138)
HCPCS (S2118)
Microprocessor-controlled prosthetic knees (e.g., C-Leg/ Compact)
(See also Noridian Medicare Local Coverage Determination (LCD) —
Lower Limb Prostheses
HCPCS (L5856, L5857, L5858)

Microvolt T-wave alternans testing for patients at risk for sudden cardiac
death

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

N

N

N

9/8/2017

N

N

N

1/12/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

9/8/2017

N

N

N

8/11/2017

N

N

N

9/8/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

CPT (93025)
Microwave thermotherapy for chest wall recurrence of breast cancer
CPT ([0301T del. 01/01/2018], 19499)
miRview™ meso (Rosetta Genomics) for differentiating malignant pleural
mesothelioma from peripheral adenocarcinomas of the lung or
metastatic carcinomas involving the lung pleura
(See also Gene Expression Profiling)
CPT (81479)
Molecular Intelligence (Caris Life Sciences) tumor profiling
(See also Gene Expression Profiling)
CPT (81599, 81479)
Myocardial sympathetic innervation imaging for the measurement of
radioactive tracer 123Iodine meta-iodobenzylguanidine (MIBG) in heart
failure patients
(E.g., AdreView™ [lobenguane I 123 injection])

CPT (0331T, 0332T)
MRI-guided focal laser ablation for prostate cancer
(E.g., Visualase Laser Ablation System)

CPT (No specific code)
My5-FU™ (Saladax Biomedical) (formerly OnDose™ [Myriad]) for 5fluorouracil (5-FU) dosing guidance
(See also Gene Expression Profiling)
CPT ([84999, prior 01/01/2018], [81232, 81346 eff. 01/01/2018])
HCPCS (S3722)
Multi-component fecal analysis lab testing for the evaluation of intestinal
dysbiosis, irritable bowel syndrome, malabsorption or small intestinal
bacterial overgrowth
(E.g., Comprehensive Stool Analysis [Bio-Reference])

CPT (No specific code)

Nasal endoscopy, surgical; balloon dilation of eustachian tube
(E.g., ACCLARENT AERA™ Eustachian Tube Balloon Dilation System)

CPT (69799)
Near-infrared guidance for vascular access requiring real-time digital
visualization of subcutaneous vasculature for evaluation of potential
access sites and vessel patency
CPT (No specific code)
Near-infrared spectroscopy studies of lower extremity wounds
(E.g., for oxyhemoglobin measurement)

CPT (76499 [prior 01/01/2018], 0493T [eff. 01/01/2018])

NeuRx DPS™, Diaphragm Pacing System for amyotrophic lateral sclerosis
(ALS)
Note: The NeuRX is an investigational device that is FDA-approved as a humanitarian device
exemption (HDE) for use in patients 21 years of age or older with a stimulatable diaphragm
(both right and left portions) as demonstrated by voluntary contraction or phrenic nerve
conduction studies, and who are experiencing chronic hypoventilation (CH), but not
progressed to an FVC less than 45% predicted. (percutaneous, intramuscular, diaphragm
motor point stimulating device)

SEE NOTE

SEE NOTE

SEE NOTE

8/11/2017

N

N

N

8/11/2017

N

N

N

1/12/2018

Y

Y

Y

1/19/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

Y

Y

Y

8/11/2017

Y

Y

Y

1/12/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

Therefore, pre certification requests when presented as such will be reviewed on a case-bycase basis.

CPT (64575, 64580, 64585, 64590, 64595)
HCPCS (C1778, C1816, L8680, L8681, L8682, L8683, L8684, L8685, L8686,
L8687, L8688,L8689)
Neuropsychiatric EEG-based Assessment Aid (NEBA) for the diagnosis of
attention deficit hyperactivity disorder (ADHD)
CPT (the following may be applicable: 95812, 95813, 95816, 95819,
95827, 95957)
Nerve blocks for primary or secondary headache
(E.g., cluster, migraine, cervicogenic [i.e., occipital neuralgia], posttraumatic, etc.)

(See also Pain Management)
CPT (64405)
Neulasta® Onpro™ kit
CPT (96377)
NeuraGen Nerve Guide and NeuraWrap Nerve Protector
CPT (64910, 64911)
Neuroendocrine lab testing of saliva/urine for evaluating
neurotransmitters/hormones
CPT (No Specific Code)
Neuropace® RNS® System for epilepsy
CPT (61850, 61860, 61863, 61864, 61880, 61885, 61886, 61888, 95970,
95971)
(See also Cortical Stimulation for Epilepsy [NeuroPace®])
HCPCS (L8686, L8688)
Neutron beam radiotherapy for cancer for salivary gland cancers that are
inoperable, recurrent, or are resected with gross residual disease or
positive margins
CPT (77423)
Noncontact normothermic wound therapy (e.g., Warm-Up®)
CPT (97610)
HCPCS (A6000, E0231, E0232)
Noninvasive physiologic study of implanted wireless pressure sensor in
aneurysmal sac following endovascular repair, complete study
(E.g., Endosure Wireless Implantable System)

CPT (93982)

Nonpenetrating deep sclerectomy
CPT (66999)
Nuchal translucency screening in 1st trimester pregnancies
CPT (76813, 76814)
Occipital nerve stimulation (ONS) /percutaneous electrical nerve
stimulation (PENS) for occipital neuralgia/cervicogenic headache

N

N

N

8/11/2017

Y

Y

Y

6/9/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

9/8/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

N

N

N

2/9/2018

CPT (64999, 64555, 64575)
Ocular — blood flow measurement
(See also Medicare Local Coverage Article: Ocular Blood Flow Tests)
CPT (0198T [by repetitive intraocular pressure sampling], 92499 [when
used to report ocular flow measurement by other technique])
Ocular — intraocular pressure monitoring ≥ 24 hours
(E.g., SENSIMED Triggerfish®)

CPT (0329T)
Ocular — intraocular tear film imaging
(E.g., Ophtha Vision Imaging System, Tearscope-Plus, LipiView®)

CPT (0330T)
OncoVantage™ Solid Tumor Mutation Analysis (Quest)
(See also Gene Expression Profiling)
CPT (81445)
OP-1™ implant (bone morphogenic protein 1) for recalcitrant long bone
non-union fractures
CPT (No specific code)
OPA1 gene sequencing
(E.g., Optic Atrophy Evaluation [OPA1] Test for autosomal dominant optic atrophy and/or
optic neuropathy [Athena Diagnostics])

(See also Gene Expression Profiling)
CPT (81407)
Opioid antagonists under heavy sedation or general anesthesia as a
technique for opioid detoxification (ultra rapid detoxification [UROD])
CPT (No specific code)
HCPCS (H0047)
Optical coherence tomography — intraoperative axillary lymph node/
breast imaging/anterior segment ophthalmic imaging
(E.g., RS-3000 Advance)

CPT (92132 [anterior segment], 0351T, 0352T, 0353T, 0354T)
Optical coherence tomography — intravascular, coronary native vessel or
graft, diagnostic evaluation and/or therapeutic intervention
(E.g., C7 Xr® Imaging System)

CPT (92978, 92978)

Optical coherence tomography — middle ear, interpretation and report
CPT (0485T, 0486T eff. 01/01/2018)

N

N

N

12/12/2017

Y

Y

Y

2/9/2018

N

N

N

8/11/2017

Y

Y

Y

1/12/2018

N

N

N

8/11/2017

N

N

N

9/8/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

Y

Y

Y

10/13/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

9/8/2017

N

N

N

8/11/2017

Oral appliance therapy for obstructive sleep apnea
(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (E0485, E0486)
OsteoBridge® IDSF — Intramedullary Diaphyseal Segmental Defect
Fixation Rod System for bone loss of either humerus, tibia or femur in
oncology patients
CPT (No specific code)
Osteochondral allografting of the talus
(See also Osteochondral Grafting)
CPT (28446)
OV-Watch®/ovulation predictor kit
CPT/HCPCS (No specific code)
Ovarian cancer — combined ovarian cancer biomarker tests
(E.g., Ova1™ [Vermillion]; OvaNext [Ambry Genetics]; Ovarian Cancer Focus Panel [Fulgent
Genetics]; PreOvar [MiraDx]; ROMA ™ [Fujirebio])

(See also Gene Expression Profiling, Genetic Counseling and Testing and
Medicare LCD: Molecular Pathology Procedures
CPT (81211, 81213, 81292, 81294, 81295, 81297, 81298, 81300, 81317,
81319, 81479, 84999, 83001, 83002, 81503)
Ovarian cancer — proteomic analysis testing
(E.g., OvaCheck™ [Quest Diagnostics]; OvaSure™ [withdrawn by LabCorp])

CPT (83789, 81503)
Palatal implants & stiffening procedures for obstructive sleep apnea
(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (No specific code; may report using 42299 unlisted procedure for the
palate)
Pancreatic islet cell transplantation for chronic pancreatitis
CPT (48160, 48550)
Pancreatic islet cell transplantation for Type 1 diabetes
HCPCS (G0341, G0342, G0343)
Percutaneous sacral augmentation (sacroplasty) (injection with balloon
or mechanical device)
CPT (0200T, 0201T)
Percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis
(DVT)/pulmonary embolism (PE)
CPT (37187, 37188)
Peripheral nerve blocks for diabetic neuropathy
(See also Medicare LCD: Peripheral Nerve Blocks)

CPT (64400-64450)
Periurethral bulking agents for urinary incontinence
CPT (51715)

Y

Y

Y

5/12/2017

N

N

N

8/11/2017

N

SEE NOTE

N

8/11/2017

Y

Y

Y

1/12/2018

Y

Y

Y

10/13/2017

Y

Y

Y

2/9/2018

Y

Y

Y

8/11/2017

HCPCS (L8603, L8604, L8606)
Pervenio™ Lung RS test (Life Technologies)
(See also Gene Expression Profiling)
CPT (84999)
Pharmacogenetic testing for medication sensitivity to any drug (other
than those listed as covered in the pharmacogenetic testing rows below)
(E.g., CYP3A4, CYP3A5; CYP2C19 genotyping to predict response to Voriconazole [Vfend®],
AmpliChip Cytochrome P450 Genotyping Test [Roche]; GeneSight® Psychotropic assay for
neuropsychiatric disorders, etc. [Assurex Health])
Note specific to Medicare members:
Warfarin: See Coverage with Evidence Development for Pharmacogenomic Testing for
Warfarin Response
GeneSight: See LCD GeneSight® Assay for Refractory Depression

CPT (81225, 81226, 81227, 81291, 81355, 81401, 81479, [81230, 81231
eff. 01/01/2018])
HCPCS (G9143)
Pharmacogenetic testing — BCR-ABL1 Mutation Testing in Chronic
Myelogenous Leukemia and Acute Lymphoblastic Leukemia for
tyrosine kinase inhibitor resistance
(E.g., MolecularMD MRDx™ for Tasigna™ [nilotinib])CPT (81170, 81206, 81207,

81208, 81401, 81403)
Pharmacogenetic testing — BRAF mutation analysis for the treatment of
unresectable or metastatic melanoma, metastatic colon cancer, nonsmall cell lung cancer or hairy cell leukemia (BRAF ID™ BRAF V600E/K
test; cobas 4800 BRAF V600)
(E.g,: MEKINIST in combination with Tafinlar® [dabrafenib], [Zelboraf™ [vemurafenib], etc.)

(See also BRAF Mutation Analysis)
CPT (81210, 88363)
Pharmacogenetic testing — BRCA



For women with ovarian cancer who have been treated with ≥ 3 lines of
chemotherapy and under consideration for treatment with Lynparza (olaparib)
For women with deleterious or suspected deleterious gBRCAm human epidermal
growth factor receptor 2 (HER-2)-negative metastatic breast cancer who have
been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic
setting and under consideration for treatment with Lynparza (olaparib)

(E.g., BRACAnalysis CDx™ [Myriad])

CPT (81211, 81213)
Pharmacogenetic testing — BRCA for women with ovarian cancer under
consideration for treatment with rucaparib (Rubraca) after ≥ 2 previous
lines of chemotherapy
(E.g., FoundationFocus CDxBRCA)

CPT (81162, 81211)

Pharmacogenetic testing — epidermal growth factor (EGFR) mutation
testing for non-small lung cancer to predict response to treatment with
tyrosine kinase inhibitors (e.g., erlotinib [Tarceva®], afatinib
[Gilotrif®], gefitinib [Iressa®] and osimertinib [Tagrisso™])
(E.g., cobas® [Roche], therascreen [Qiagen], KRAS Mutation Analysis [Quest])

Y

Y

Y

1/12/2018

Y

Y

Y

7/14/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

(See also Epidermal Growth Factor Receptor Mutation Analysis for
Patients with Non-Small-Cell Lung Cancer)
CPT (81275, 81276, 81235, 81479)
Pharmacogenetic testing — FDA approved test for anaplastic lymphoma
kinase (ALK) fusion gene for members under consideration for treatment
with alectinib (Alecensa® [metastatic ALK + NSCLC]), crizotinib (Xalcori) or
ceritinib (Zykadia) for non-small cell lung cancer
(E.g., ALK 2p23 Rearrangement FISH [Quest Labs], Ventana ALK CDx Assay [Ventana Medical
Systems], Vysis ALK Break Apart FISH Probe Kit)

CPT (88271, 88272, 88273, 88274)
Pharmacogenetic testing — FDA cleared test to detect the following
mutations in the CTFR gene for members with cystic fibrosis under
consideration for treatment with ivacaftor (Kalydeco): G551D, G1244E,
G1349D, G178R, G551S, R117H, S1251N, S1255P, S549N, and S549R
CPT (No specific code)
Pharmacogenetic testing — FDA cleared test to detect the F508del
mutation in the CTFR gene for members with cystic fibrosis under
consideration for treatment with lumacaftor/ivacaftor (Orkambi)
CPT (81222)
Pharmacogenetic testing — FTL3 mutation assay for members with acute
myeloid leukemia (AML) being considered for treatment with
midostaurin (Rydapt)
(E.g., LeukoStrat CDx FLT Mutation Assay)

CPT (81245, 81246)
Pharmacogenetic testing — for the presence of virus with the NS3 Q80K
polymorphism for members with hepatitis C virus (HCV) genotype 1a
infection under consideration for treatment with simeprevir (Olysio)
CPT (87900, 87902,[81283 eff. 01/01/2018])
Pharmacogenetic testing — for the presence of virus with NS5A
resistance-associated polymorphisms for members with hepatitis C virus
genotype 1, 3 and 4 infections being considered for treatment with
daclatasvir (Daklinza) or elbasvir and grazoprevir (Zepatier)
CPT (87900, 87902)
Pharmacogenetic testing — genotyping for CYP2C19 polymorphisms for
members who have been prescribed clopidogrel (Plavix)
Note: One allowable per lifetime

CPT (81225)
Pharmacogenetic testing — genotyping for CYP2D6 polymorphisms for
members who have been prescribed doses of tetrabenazine (Xenazine) >
50 mg per day

Note: One allowable per lifetime

CPT (81226)
Pharmacogenetic testing — genotyping for CYP2D6 polymorphisms for
members with Gaucher disease type 1 who are being considered for
treatment with eliglustat (Cerdelga)

Y

Y

Y

8/11/2017

N

SEE NOTE

N

8/11/2017

Y

Y

Y

10/13/2017

Y

Y

Y

8/11/2017

Y

Y

Y

8/11/2017

Y

Y

Y

10/13/2017

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

Note: One allowable per lifetime

CPT (81226)
Pharmacogenetic testing — genotyping for VKORC1 polymorphism
(diagnostic tests to identify specific genetic variations that may be linked
to reduced/enhanced effect or severe side effects of drugs metabolized
by the vitamin K epoxide reductase complex subunit 1 gene including
warfarin)
For Medicare members see Coverage with Evidence Development for Pharmacogenomic
Testing for Warfarin Response

CPT (83155)
Pharmacogenetic testing — genetic mutation analysis consistent with
FDA approved labeling for Gleevec
(E.g. platelet-derived growth factor receptor, alpha poly peptide [PDGFRA], gastrointestinal
stromal tumor [GIST])

CPT (81272, 81273, 81314)
Specific tests with respective codes
PDGFRB FISH for Gleevec Eligibility in Myelodysplastic Syndrome / Myeloproliferative
Disease (MDS / MPD)
CPT (88271, 88275, 88291)
KIT D816V Mutation Detection by PCR for Gleevec Eligibility in Aggressive Systemic
Mastocytosis (ASM)
CPT (81402)

Pharmacogenetic testing — HLA-B*5701 screening for members infected
with HIV-1 prior to commencing treatment with abacavir (Ziagen)
CPT (81381)
Pharmacogenetic testing — HLA-B*1502 genotyping for members of
Asian ancestry prior to commencing treatment with carbamazepine
(Tegretol)
CPT (81381)
Pharmacogenetic testing — KRAS sequence variant analysis for predicting
response to drug therapy for non-small cell lung cancer, colorectal cancer
or anal adenocarcinoma
(See also Analysis of KRAS Status)
CPT (81275, 81276)
Pharmacogenetic testing — macular degeneration, age-related, dry, for
the selection of eye supplement formulations (AREDS or AREDS without
zinc)
(E.g., VitaRisk™ [Arctic Medical Laboratories])

CPT (81401, 81405, 81408, 81479, 81599)
Pharmacogenetic testing — MGMT (O(6)-methylguanine-DNA

methyltransferase) gene methylation assay for predicting response to
temozolomide (Temodar) in members with glioblastoma
(E.g., PredictMDx for Glioblastoma)

CPT (81287)
Pharmacogenetic testing — measurement of microsatellite instability and
mismatch repair for members with unresectable or metastatic solid
tumors under consideration for treatment with pembrolizumab
(Keytruda)

Y

Y

Y

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

9/21/2017

Y

Y

Y

9/8/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

(See also Keytruda® [pembrolizumab])
CPT (81301)
Pharmacogenetic testing — PD-L1 expression companion diagnostic for
members with non-small cell lung cancer under consideration for
treatment with pembrolizumab (Keytruda®)
(E.g., PD-L1 IHC 22C3 pharmDx [Dako])
(See also Keytruda® [pembrolizumab])
CPT (88342, 88341, 88184, 88185)
Pharmacogenetic testing — PD-L1 expression for members with
urothelial carcinoma under consideration for treatment with durvalumab
(Imfinzi)
(E.g., Ventana PD-L1 [SP263] Assay)

CPT (88360, 88361)
Pharmacogenetic testing — UGT1A1 molecular assay screening test to
determine irinotecan (Camptosar®) dosing for members with colorectal
cancer
(E.g., Invader® assay [Third Wave Technologies])

CPT (81350)
Photodynamic therapy — actinic keratosis
(E.g., BLU-U® Blue Light Photodynamic Therapy Illuminator in combination with Levulan®
Kerastick®)

(See also Phototherapy, Photochemotherapy and Photodynamic Therapy
for Dermatologic Conditions)
CPT (96567)
HCPCS (J7308)
Photodynamic Therapy — Visudyne® Ocular
CPT (67221, 67225)
HCPCS (J3396)
Photoscreening (MTI Photoscreener™) for the detection of eye disorders
in children
CPT (99174, 99177)
Photoselective vaporization of the prostate
(E.g., GreenLight PVP®)

CPT (52648)
Phrenic nerve stimulation for central sleep apnea

CPT (64575, 64590)
HCPCS (L8680, L8682, L8683)
Physical therapy post TMJ surgery
CPT (No specific code)

Y

Y

Y

7/14/2017

N

N

N

2/9/2018

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

N

N

N

7/14/2017

N

N

N

2/9/2018

N

N

N

2/99/2018

N

SEE NOTE

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

HCPCS (E1700, E1701, E1702)
Placental rapid immunoassay for detection of fetal membrane rupture
•
•
•

The AmniSure® ROM Test (AmniSure International, LLC) detects the placental alpha
microglobulin-1 (PAMG-1) protein marker of the amniotic fluid
The ROM Plus® Test (Clinical Innovations, LLC) detects alpha-fetoprotein (AFP) and
placental protein 12 (PP12)
The Actim® PROM Test (Medix Biochemica) detects insulin growth factor binding
protein-1 (IGFBP-1)

CPT (84112)
Plethysmography — cardiac (as part of enhanced external
counterpulsation)
CPT (No specific code)
Plethysmography — lung (as an adjunct to pulmonary function testing)
NOTE: Total body plethysmography is appropriate for this indication.

CPT (94726, 94750)
Plethysmography — penile (for cavernous nerve evaluation prior to
nerve-sparing prostatic or colorectal cancer procedures)
CPT (54240)
Plethysmography (air-displacement) — total body for determining body
composition
CPT (94726, 94750)
Pontocerebellar Hypoplasia Panel
CPT (81479)
Procalcitonin (PCT) measurement
CPT (84145)
Positron emission tomography (PET) — beta amyloid PET in dementia
and neurodegenerative disease
Note: Medicare members, whose costs relating directly to the provision of services related
to the Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease
NCD (that were non-covered services prior to the issuance of the NCD) will be paid by CMS
intermediaries and carriers when beneficiaries are enrolled in a clinical study that meets the
criteria put forth within the NCD.

CPT (78811, 78814)
HCPCS (A9586)
These codes are not only for Beta amyloid positron tomography in
dementia and neurodegenerative disease
Positron emission tomography (PET)/magnetic resonance imaging (MRI)
— combined scanning
CPT (70540, 71550, 72195, 73218, 73718, 74181, 78812)
Positron emission tomography (PET) — NaF-18 scan to identify bone

metastasis of cancer
(See also Positron Emission Tomography (NaF-18) NCD)

CPT (78811, 78814)
HCPCS (G0252)
Post-Op Px™ (formerly the Prostate Px Plus [Aureon]) post prostatectomy
prostate cancer prognostic test

N

N

N

7/14/2017

N

N

N

5/12/2017

N

N

N

9/8/2017

Y

Y

Y

7/14/2017

N

N

N

2/9/2018

N

N

N

7/14/2017

Y

Y

Y

10/13/2017

Y

Y

Y

5/12/2017

CPT (88313, 88346, 88350, 88323, 88399)
Power morcellators in uterine surgery for polyp/fibroid removal (includes
hysteroscopic and laparoscopic techniques)
(E.g., THS® Tower-free Hysteroscopy System, MyoSure® tissue removal system Trueclear
Morcellator System)

(See also Hysterectomy)
CPT (58541–58548, 58550–58554, 58558, 58561, 58570–58573, 58578,
58679)
Powered exoskeleton for ambulation in patients with lower limb
disabilities
(E.g., Ekso™ GT, Indego® powered exoskeleton [aka Vanderbilt exoskeleton], ReWalk, X1
Mina Exoskeleton)

(No specific code)
Praxis Extended RAS Panel (Illumina) next generation sequencing (NGS)
to determine Vetibix treatment eligibility for colorectal cancer patients
CPT (81311, 81275, 81276)
Prolotherapy — all indications
(Aka proliferant therapy, proliferation therapy, joint sclerotherapy, or reconstructive
ligament therapy)

CPT (No specific code)
PROMETHEUS LABS
IBD DIAGNOSTIC SYSTEM Serology 7th to aid in the differentiation of
Crohn’s disease from ulcerative colitis and to aid in diagnosis of
inflammatory bowel disease
CPT (81479, 82397, 83520, 86140, 88346, 88350)
Serologic diagnosis of inflammatory bowel disease – ANCA and ANSA
CPT (83520, 88346, 88350)
Anser ADA™
CPT (84999)
Anser IFX™
CPT (84999)

PROMETHEUS LABS (See also Genetic Counseling and Testing)
PRO‐PredictRx® EnzAct (TPMT enzyme activity) for inflammatory bowel
disease (IBD)
CPT (82657, 82542)
PRO‐PredictRx® Metabolites (metabolite levels) for IBD
CPT (82542)

Prophylactic mastectomy

(See also Risk-Reduction Mastectomy)
CPT (19303, 19304)
Prophylactic (risk-reduction) oophorectomy
CPT (58940, 58661)

Y

Y

Y

7/14/2017

Y

Y

Y

1/19/2017

N

N

N

9/8/2017

N

N

N

1/12/2018

N

Y

N

7/14/2017

Y

Y

Y

7/14/2017

SEE NOTE

SEE NOTE

SEE NOTE

8/11/2017

Y

Y

Y

1/12/2018

N

N

N

1/12/2018

Prostate cancer vaccines (immunotherapy) for the treatment of prostate
cancer (Provenge® [Sipuleucel-T] only)
(See also Provenge® [sipuleucel-T])
Note: ProsVAC-VF will not be covered, as it is investigational

HCPCS (Q2043; no other codes for these vaccines, alternate codes: 96365,
96366)
Proove Opioid Risk Test (Proove Biosciences)
(See also Gene Expression Profiling)
CPT (81291, 81479)
Prostatic artery embolization (PAE) for benign prostatic hypertrophy
(BPH)
CPT (53899, 37242, 75894)
Prostatic urethral lift (PUL) implant for benign prostatic hypertrophy
(BPH)
(E.g., UroLift System)

(See also Medicare LCD: Prostatic Urethral Lift)
CPT (52441, 52442)
Prosthetic replacement of ocular surface ecosystem (PROSE)/Boston
Ocular Surface Prosthesis (BOSP)
CPT (92499, which includes fitting, fabrication, combined with HCPCS
S0515 [PROSE device])
Use HCPCS code V2627 for Medicare
Protégé GPS Self-Expanding Peripheral Stent System for narrowing of iliac
arteries
Note: The Protégé is an investigational device that is FDA approved as a humanitarian
exemption (HDE) for improving luminal diameter in patients with atherosclerotic disease of
the common and/or external iliac arteries up to and including 100 mm in length, with a
reference vessel diameter of 7.5 – 11 mm. Therefore, pre certification requests when
presented as such will be reviewed on a case-by-case basis.

CPT (37220, 37221, 37222, 37223)
Proton beam (particle beam) therapy for various
(See also Stereotactic Radiosurgery and Proton Beam Therapy)
CPT (77520, 77522, 77523, 77525)
HCPCS (S8030)
Proton beam (particle beam) therapy for prostate cancer
(See also Stereotactic Radiosurgery and Proton Beam Therapy
CPT (77520, 77522, 77523, 77525)
HCPCS (S8030)

Pudendal nerve decompression surgery
CPT (64722)

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

9/21/2017

Y

Y

Y

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

5/12/2017

Y

Y

Y

5/12/2017

Y

Y

Y

7/14/2017

Pulmonary artery pressure monitoring — wireless
(E.g., CardioMEMS HF System)

CPT (No specific code)
Quantitative pupillometry
(E.g., NPi™-100 Pupillometer, VIP™-200 Pupillometer)

CPT (0341T)
Quantitative sensory testing (QST) to assess nerve fiber sensation
(multiple stimuli)
CPT (0106T, 0107T, 0108T, 0109T, 0110T)
Radiation — superficial radiation treatment (Grenz ray) for
dermatological conditions
(See also Phototherapy, Photochemotherapy and Photodynamic Therapy
for Dermatologic Conditions)
CPT (77499 unlisted procedure, therapeutic radiology treatment
management)
Localization devices as an alternative to wire localization prior to
excisional breast biopsy or breast conservation surgery
(E.g., SAVI SCOUT® Breast Localization and Surgical Guidance System, Radioactive seed
localization [RSL])

CPT (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288)
Note: Reading of localization device is inclusive in biopsy procedure performed. Placement
of soft tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive
seeds), percutaneous, including image guidance CPT (10035, 10036 eff. 01/01/2016)

Stereotactic breast biopsy
(E.g., Mammotome®)

CPT (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288, 19081,
19082, 19083, 19084, 19085, 19086)
HCPCS (A4649)
Radiofrequency — handheld radiofrequency spectroscopy for
intraoperative assessment of surgical margins during breast-conserving
surgery
(E.g. MarginProbe®)

CPT (19499)
HCPCS (A4649)
Radiofrequency ablation — Barrett’s Esophagus
(E.g., BÂRRX System)

CPT (43229, 43270)
Radiofrequency ablation — benign bone tumors
(See also Radiofrequency Ablation of Tumors)
CPT (20982)
Radiofrequency ablation — cardiac (for atrial fibrillation)

(E.g., Cardioblate®)

CPT (33250, 33251, 33254, 33255, 33256, 33257, 33258, 33259, 33265,
33266)
Radiofrequency ablation — continuous for cervical or lumbar pain (aka
facet denervation, facet neurotomy, facet rhizotomy, articular rhizolysis)
(See also Radiofrequency Ablation for Spinal Pain)

Y

Y

Y

10/13/2017

N

N

N

1/12/2018

Y

Y

Y

7/14/2017

N

N

N

7/14/2017

Y

Y

Y

5/12/2017

Y

Y

Y

5/12/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

6/9/2017

N

N

N

1/12/2018

Y

Y

Y

8/11/2017

CPT (77003, 64635, 64636, 64633, 64634)
Radiofrequency ablation — cooled/pulsed for sacroiliac joint pain
(See also Radiofrequency Ablation for Spinal Pain)
CPT (64999)
Radiofrequency ablation — endometrial
CPT (58353, 58563, 58999)
Radiofrequency ablation — fecal incontinence
(E.g., Secca® procedure)

(See also Fecal Incontinence Treatment)
CPT (46999)
HCPCS (L8699)
Radiofrequency ablation — hepatic cancer
(See also Radiofrequency Ablation of Tumors)
CPT (47370, 47380, 47382, 76940, 77013, 77022)
Radiofrequency ablation — lung cancer
(See also Radiofrequency Ablation of Tumors)
CPT (32998)
Radiofrequency ablation — MRI-guided ultrasound/RFA ablation of
uterine fibroids
(E.g., Acessa™ System, ExAblate®, VizAblate®)

CPT (0071T, 0072T, 0404T, 58674)
Radiofrequency ablation (coblation/microtenotomy) — plantar fasciitis
CPT (No specific code; possible codes: 28899, 64640, 29893)
Radiofrequency ablation — renal cancer
(See also Cryosurgical and Radiofrequency Ablation for Renal Tumors)
CPT (50592)
Radiofrequency ablation — sympathetic (renal) nerve for hypertension
(E.g., Symplicity™ Renal Denervation System, EnligHTN™ Multielectrode Renal Denervation
System, One-Shot Renal Denervation System, V2 Renal Denervation System, Thermocouple
Catheter™)

CPT (0338T, 0339T, 64999)
Radiofrequency ablation — female stress urinary incontinence
(See also Transurethral Radiofrequency Tissue Micro-Remodeling)
(E.g., Lyrette™ Transurethral SUI System [formerly Renessa® System])
Note: Radiofrequency Micro-Remodeling with the SURx System is not coveredCPT

(53860)
Remote real-time interactive video-conferenced critical care evaluation
and management

N

N

N

2/24/2017

Y

Y

Y

7/14/2017

Y

Y

Y

3/23/2017

N

N

N

2/19/2018

N

N

Y

2/9/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

N

N

N

3/10/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

CPT (0188T, 0189T)
Radiofrequency ablation — trigeminal neuralgia
CPT (64600, 64605, 64610)
Radiofrequency ablation — varicosities
(See also Varicose Vein Treatment)
CPT (36475, 36476)
Radiofrequency ablation — wound healing/muscle disuse
atrophy/diabetic neuropathy
(E.g. MicroVas System for stage III or IV pressure ulcers)

CPT (97032, 97139)
HCPCS (G0281, G0282)
Radiofrequency tissue volume reduction somnoplasty for upper airway
obstruction
(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (41530)
Radiostereometric analysis
CPT (0347T, 0348T, 0349T, 0350T)
Red blood cell long chain fatty acid chromatography analysis
CPT (0111T)
Relizorb™ point-of-care digestive enzyme cartridge
(Aka enteral feeding in-line cartridge [EFIC])

HCPCS (B9998)
ReShape® Integrated Dual Balloon System for obesity
(See also Bariatric Surgery)
CPT (No specific code)
Rhinomanometry/acoustic rhinometry
CPT (92512)
Rhizotomy (dorsal) for spastic cerebral palsy
(See also Selective Dorsal Rhizotomy for Cerebral Palsy)
CPT (63185, 63190)
Robotically-assisted adrenalectomy*
HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g., 60540 adrenalectomy, partial or complete, or exploration of adrenal gland with or
without biopsy, transabdominal, lumbar or dorsal in addition to HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Retinal polarization scan, ocular screening with on-site automated
results, bilateral

N

N

N

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

(CPT 0469T [new eff. 07/01/17])
Robotically-assisted cardiac surgery (inclusive of coronary artery bypass
graft)*
HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g.,33510 Coronary artery bypass, vein only; single coronary venous graft in addition to
HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Robotically-assisted gastrointestinal surgery
(E.g. gastroesophageal reflux disease, gallbladder indications)*

HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g., 43280 laparoscopy, surgical, esophagogastric fundoplasty in addition to HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Robotically-assisted gynecological surgery (inclusive of hysterectomy)*
HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g., 58541 laparoscopy, surgical, supracervical hysterectomy, for uterus ≤ 250g in addition
to HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Robotically-assisted prostatectomy*
HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g., 55866 laparoscopy, surgical prostatectomy in addition to HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Robotically-assisted urological procedures*
HCPCS (S2900)
Report the code that best describes the basic surgery being performed
(E.g., 50546 laparoscopy, surgical; nephrectomy, including partial ureterectomy in addition
to HCPCS S2900)
Note: EmblemHealth does not provide additional reimbursement for the use of robotic
surgical devices, as the Plan regards these as incidental to the primary surgical procedure
and therefore not separately billable. Robotically assisted surgeries are also not considered
medically necessary in the absence of an FDA approval for a requested indication.

Sacral nerve stimulators for fecal incontinence, urinary urge

incontinence, urinary frequency, and urinary retention
(E.g., Medtronic® InterStim®)

(See also Fecal Incontinence Treatment)
CPT (64561, 64581, 64585, 64590, 64595, 95970, 95971, 95972)
HCPCS (A4290, L8680, L8681, L8685, L8686, L8687, L8688, L8689, L8695)
Salivary hormone testing — screening, diagnosis, monitoring, all
indications
(E.g., hormones such as cortisol, dehydroepiandrosterone [DHEA], estrogen, melatonin,
progesterone, testosterone for conditions such as adrenal insufficiency, bipolar disorder,
depression, or eating disorders, menopause, diseases related to aging, etc.)
Note: Late night salivary cortisol is considered medically necessary for diagnosing Cushing's
syndrome.

N

N

N

2/9/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

3/23/2017

N

N

N

4/21/2017

Y

Y

Y

9/8/2017

N

N

N

8/11/2017

CPT (82530, 82533, 82530, 82626, 82627, 82670, 82671, 82672, 82677,
82679, 83516, 83520, 84144, 84402, 84403, 84436, 84437, 84439, 84443,
84479, 84480, 84481, 86316, 88341, 88342, 88344)
HCPCS (S3650)
Scintimammography for breast lesions (radiotracer nuclear imaging)/low
dose breast-specific gamma imaging (BSGI)/molecular breast imaging
(MBI)
(E.g., Miraluma Scan)

CPT (78800, 78801)
HCPCS (A9500, S8080)
Sclera fistulization for glaucoma
CPT (66999)
Sclerotherapy for esophageal varices
CPT (43204, 43243)
Sclerotherapy for varicose veins (endovenous chemical ablation)
(I.e., liquid or foam [e.g., Varithena®])
(See also Varicose Vein Treatment)
CPT ([36465, 36466, 36482, 36483 eff. 01/01/2018], 36470, 36471)
ScoliScore™ AIS Prognostic Test and other genetic testing for the
prediction of adolescent idiopathic scoliosis
(E.g., CHD7 gene, the matrilin-1 gene (MATN1), melatonin receptor 1B gene (MTNR1B)
rs4753426 and rs10830963 polymorphism testing, and the transforming growth factor beta
1 (TGFB1) gene; not an all-inclusive list])

(See also Gene Expression Profiling)
CPT (0004M)
Selective internal radiation therapy (SIRT) for primary hepatocellular
carcinoma, hepatoma or metastatic liver tumors
SIR-Spheres®
CPT (37243, 75894, 79445, 77778)
SelectMDx for prostate cancer (MDxHealth Inc.)
(See also Gene Expression Profiling)
CPT (81479)

Sentinel lymph node biopsy for breast cancer
CPT (38792, 38500, 38525, 38530, 78195)

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

2/9/2018

Y

Y

Y

3/10/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

N

N

N

2/9/2018

Sentinel lymph node biopsy for melanoma
CPT (38792, 38500, 38510, 38525, 38530,78195)
Note: If metastatic disease is confirmed, these are other CPT codes related (38510, 38525,
and 38530). When a complete lymphadenectomy is performed as a result of a positive
lymph node biopsy, do not code the biopsy, only code the injection procedure; for the
identification of sentinel node plus a complete lymphadenectomy, please check AMA/CPT
for appropriate codes.

Serum markers for liver disease
(E.g., ASH FibroSURE™, FibroMAX™, FIBROSpect II®, HCV FibroSURE™ [Quest], FibroTest +
ActiTest, HepaScore™, NASH FibroSURE™)

CPT (No specific code)
Shoulder resurfacing
(E.g., Copeland™ Extended Articulating Surface [EAS] ™ Resurfacing Heads, DePuy Global
CAP™ CTA Resurfacing Shoulder Humeral Head, Axiom Shoulder Resurfacing System,
HemiCAP® [also referred to as Contoured Articular Prosthetic [CAP] Humeral Head
Resurfacing Prosthesis)

CPT (23470, 23472, 23929)
Sleep monitoring (home attended or unattended)
(E.g., NovaSom QSG™ [Sleep Solution™], SNAP™ System [only those systems measuring ≥ 3
channels)

(See also Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (95800, 95801)
HCPCS (G0398, G0399, G0400)
Sleeve gastrectomy
(See also Bariatric Surgery)
CPT (43775)
SpaceOar System — rectal protection from radiation therapy for prostate
cancer
CPT (45999)
HCPCS (A4649)
Spectroscopy — intravascular catheter-based coronary vessel or graft
(E.g., infrared)

CPT (0205T)
Spectroscopy — multi-wavelength fluorescent measurement of advanced
glycation products (AGE) to replace skin biopsy for risk assessment
CPT (88749)
Spectroscopy — real time spectral analysis of prostate tissue by
fluorescence spectroscopy
(E.g., Precision Biopsy ClariCore Optical Biopsy System®)

CPT (0443T)
Speculoscopy for the screening or diagnosis of cervical cancer
(Aka cervicography; e.g., PapSure®)

CPT (58999)
Spinal — artificial disc replacement (multiple-level cervical or lumbar)
(E.g., Mobi-C® Cervical Disc Prosthesis [two-level])

(See also Artificial Intervertebral Discs)
CPT (22861, 22862, 22864, 22865, 0095T, 0098T, 0163T, 0164T, 0165T,
0375T)

N

N

Y

9/8/2017

Y

Y

Y

9/8/2017

Y

Y

Y

7/14/2017

Y

Y

N

7/14/2017

N

N

N

8/11/2017

N

N

Y

8/11/2017

Y

Y

Y

5/12/2017

Y

Y

Y

3/10/2017

N

N

N

8/11/2017

SEE NOTE

SEE NOTE

SEE NOTE

3/10/2017

Note: CPT 22858 is covered for Medicaid only

Spinal — artificial disc replacement (single-level cervical or lumbar) and
only if FDA-approved
(See also Artificial Intervertebral Discs)
E.g., Cervical — Bryan®, Prestige® Cervical Disc System, Prestige LP Cervical Disc, ProDisc-C®,
SECURE®-C Artificial Cervical Disc
E.g., Lumbar — Charité™, ProDisc-L®

CPT (22856, 22857, 22858)
Spinal — cervical traction (e.g., freestanding over-the-door mechanism or
attached to headboard)
HCPCS (E0840, E0849, E0850)
Spinal — continuous or intermittent traction for low back pain
HCPCS (E0830)
Spinal — dynamic spinal visualization (including
cineradiography/videoradiography)
CPT (76120, 76125)
Spinal — endoscopy (epiduroscopy)
(See also “Spinal minimally invasive” below)
CPT ([20939 eff. 01/01/2018], 64999)
Spinal — interspinous distraction devices
(E.g. X-Stop® Interspinous Process Decompression System)

CPT (22867, 22868, 22869, 22870)
Spinal — intervertebral stabilization devices (e.g., Dynesys® Spinal
System, SATELLITE™ Spinal System, Stabilimax NZ®)
Note: These differ from interspinal distraction devices/spacers such as the X-Stop

(See also Lumbar Fusion and Intervertebral Fusion Devices for medically
necessary fusion procedures/fixation devices)
CPT (22853, 22854, 22859)
Spinal — intrafacet implant(s), single/multi-level (inclusive of imaging
and bone graft/device placement)
(E.g., NuFix, TruFUSE®)

CPT (0219T, 0220T, 0221T, 0222T)
Spinal — lumbar fusion
(See also Lumbar Fusion and Intervertebral Fusion Devices for covered
fusion procedures and covered CPT coding)
Spinal — lumbar fusion arthrodesis pre-sacral interbody technique

(Aka transsacral interbody fusion, axial lumbar interbody fusion, or AxiaLIF)

(See also Lumbar Fusion and Intervertebral Fusion Devices for descriptive
of medical procedures)
CPT (0195T, 0196T)
Considered investigational and not medically necessary

Spinal — lumbar discography for chronic low back pain (to confirm that
symptoms are attributable to a particular disc prior to therapeutic
intervention)

Y

Y

N

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

6/9/2017

N

Y

Y

6/9/2017

N

N

N

8/11/2017

CPT (62290, 72295)
Spinal — manipulation under anesthesia for acute spinal injury
(E.g., vertebral fracture, complete dislocation or acute traumatic incomplete dislocation
[subluxation])

CPT (22505, 00640)
Spinal — manipulation under anesthesia when services rendered by a
chiropractor
CPT (22505, 00640)
Spinal — minimally invasive procedures
(See also Radiofrequency Ablation of Spinal Pain)
List not meant to be all-inclusive:








Automated percutaneous lumbar discectomy (APLD)/automated percutaneous
nucleotomy
Coblation® Nucleoplasty™, disc nucleoplasty, decompression nucleoplasty
plasma disc decompression cryoneurolysis devices for anular repair (e.g.,
Inclose™ Surgical Mesh System, Xclose™ Tissue Repair System )
Endoscopic epidural adhesiolysis
Intervertebral disc biacuplasty
Intradiscal electrothermal annuloplasty (IDET)/ percutaneous intradiscal
radiofrequency thermocoagulation (e.g., SpineCATH™)
Percutaneous decompression laminotomy (e.g., Vertos mild®)/percutaneous
image-guided lumbar decompression (PILD) (For Medicare coverage, see
Percutaneous Image-guided Lumbar Decompression for Lumbar Spinal Stenosis
NCD)
Note: Medicare members, whose costs relating directly to the provision of
services related to the National Coverage Determination (NCD) (that were noncovered services prior to the issuance of the NCD) will be paid by CMS
intermediaries and carriers when beneficiaries are enrolled in a clinical study
that meets the criteria put forth within the NCD.



Endoscopic and Percutaneous Epidural Lysis of Adhesions (RACZ procedure)
(Approved Medicare ONLY – CPT codes 62263 and 62264)

CPT (0274T, 0275T, [0309T del. 01/01/2018], [20939 eff. 01/01/2018],
22526, 22527, 22586, 22899, 62263, 62264, 62287, 62380, 64999)
HCPCS (G0276, S2348)
Spinal — sacroiliac joint (SIJ) fusion (open)
CPT (27280, 27299)
Spinal — sacroiliac joint (SIJ) fusion (minimally invasive)
(E.g., iFuse Implant System® [SI-BONE])

CPT (27279)
Spinal — vertebral axial decompression devices/mechanical spinal

distraction therapy for low back pain
(E.g., VAX-D® table, DRX9000™, the DRS System, the Alpha-Spina System, the Lordex
Lumbar Spine System, or the Internal Disc Decompression [IDD] Therapy)

HCPCS (S9090)
Spinal — vertebral stapling for idiopathic scoliosis
CPT (22899)
Spinal — vertebroplasty
CPT (22510, 22511, 22512, 22513, 22514, 22515)

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

3/10/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

1/12/2018

N

Y

N

3/23/2017

N

N

N

2/9/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

SPOT-Light® HER2 CISH™ Kit for breast cancer to determine Herceptin®
treatment candidacy
(See also Genetic Counseling and Testing)
CPT (88368)
ST2 Assay as a prognostic indicator for acute dyspnea and acute or
chronic heart failure
CPT (83520)
Stereotactic placement of infusion catheter(s) in the brain for delivery of
therapeutic agent(s)
CPT (64999)
Stereotactic radiosurgery — multiple indications; click on Medical
Guideline link for clinical criteria
CPT (61796, 91797, 61798, 61799, 63620, 63621, 77371, 77372, 77373,
77432, 77435, 77520, 77522, 77523, 77525)
HCPCS (G0340)
Subfascial endoscopic perforator surgery for chronic venous insufficiency
(SEPS)
(See also Varicose Vein Treatment)
CPT (37500)
Suprachoroidal injection of pharmacologic agents for the treatment of
ophthalmological conditions
(E.g., iScience Surgical Ophthalmic Microcannula [aka iTrack])

(See also Intravitreal Injections/Implants)
CPT (0465T)
Sural nerve graft with radical prostatectomy
CPT (64999, 55840, 55842, 55845)
Surface electromyography for the evaluation of segmental spinal joint
dysfunction and muscle tone
CPT (96002, 96004)
HCPCS (S3900)
Surgical decompression for peripheral polyneuropathy
CPT (01470, 28035, 64702, 64704, 64708, 64712, 64714, 64722, 64726,
64727)
Note: The above CPT codes are not covered when rendered for non-compressive peripheral

neuropathy syndromes due to insufficient evidence of therapeutic value.

Sympathectomy/ endoscopic thoracic sympathectomy for hyperhidrosis
CPT (32664)

Y

Y

Y

5/12/2017

N

N

N

9/8/2017

y

y

y

7/14/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

N

N

N

10/27/2017

N

N

N

8/11/2017

N

N

N

2/9/2018

N

N

N

3/10/2017

N

N

Y

9/8/2017

Target Now™ molecular profiling test
(Aka MI Profile, MI Profile X)

(See also Gene Expression Profiling)
CPT (88360, 88368, 81599)
Tear osmolarity measurement for the dry eye diagnosis (e.g., TearLab®
Osmolarity System)
CPT (83861)
Tele-retinal imaging/digital photography computer programs (i.e.,
algorithms) designed to automatically detect or diagnose diabetic
retinopathy by nonspecialists
(E.g., DigiScope Diabetic Retinal Evaluation Service, Inoveon Diabetic Retinopathy
Evaluation Service)

CPT (92227)
Thermal shrinkage of capsules, ligaments, tendons (e.g., lasers,
radiofrequency ablation) for indications including but not limited to the
shoulder, knee, hip, thumb, wrist and ankle
(Aka electrothermal arthroscopy, electrothermally-assisted capsule shift and
electrothermally-assisted capsulorrhaphy [ETAC])

CPT (29999)
HCPCS (S2300)
Thermography (indications other than breast)
CPT (93740)
Thermography — breast
(See also FDA Consumer Posting — Breast Cancer Screening: Thermogram
No Substitute for Mammogram)
CPT (No specific code)
Tinnitus retraining therapy (TRT)
CPT (No specific code; evaluation and management codes may be used or
possibly physical medicine and rehabilitation codes. TRT may also be
billed as physical or speech therapy using V5299, 97039, E1399)
Tongue suspension/suturing procedures for the obstructive sleep apnea
(E.g., AIRvance System [formerly Repose™ System], Encore™ )

(See Obstructive Sleep Apnea Diagnosis and Treatment)
CPT (41512)
TOP2A FISH (topoisomerase II Alpha) pharmDX (Dako Agilent
Technologies company) for breast cancer prognosis
(See also Genetic Counseling and Testing)
CPT (88365, 88368)
Topical oxygen wound therapy (TOWT) (aka continuous diffusion of

oxygen therapy [CDO])
(See also Topical Oxygen Wound Therapy [Medicaid/FHP])
HCPCS (A4575, E1390)
Topographic genotyping — PancraGEN (Interpace) (formerly PathFinder
TG® [RedPath]
(See also Genetic Counseling and Testing; Medicare LCD: Loss-ofHeterozygosity Based Topographic Genotyping with PathfinderTG ®)

N

Y

N

9/8/2017

Y

Y

Y

9/8/2017

Y

Y

Y

5/12/2017

N

N

N

5/12/2017

N

SEE NOTE

N

5/12/2017

Y

Y

Y

6/9/2017

N

N

N

8/11/2017

N

N

N

8/11/2017

CPT (81479)
Total ankle replacement
(E.g., Scandinavian Total Ankle Replacement System [STAR Ankle] or any other FDAapproved device)

CPT (27702, 27703)
Trabeculectomy for glaucoma (ab externo)
(See also Glaucoma Surgery)
CPT (65820, 66170, 66172)
Trabectome® for glaucoma (ab interno)
(See also Glaucoma Surgery)
CPT (65820, 65850, 66999)
Transcatheter mitral valve repair (TMVR), percutaneous approaches
(E.g., MitraClip®)
Note: Medicare members, whose costs relating directly to the provision of services related
to the NCD for Transcatheter Mitral Valve Repair (TMVR) (that were non-covered services
prior to the issuance of the NCD) will be paid by CMS intermediaries and carriers, as part of
the Coverage with Evidence Development (CED) program, when beneficiaries are enrolled in
a clinical study that meets the criteria put forth within the NCD for the treatment of
significant symptomatic degenerative mitral regurgitation when furnished according to an
FDA approved indication and when the conditions put forth within the NCD are met.
For information on the 2016 FDA recall of the Abbott Vascular MitraClip Delivery System
click here.

CPT (0345T, 33418, 33419, 93590, 93592, [0483T, 0484T eff. 01/01/2018])
Transcranial magnetic stimulation for Major Depressive Disorder (MDD)
(NeuroStar®TMS Therapy System)
Note: Coverage will be considered for chronic refractory depression in members diagnosed
with MDD (without psychoses) who have failed psychotherapy with pharmacotherapy
(prerequisite of 4 antidepressants from 2 different classes), as well as electroconvulsive
therapy (unless contraindicated).

CPT codes (90867, 90868, 90869)
Transcranial magnetic stimulation for neurologic or psychological
indications other than depression
(E.g., migraines [including Cerena Single-Pulse Transcranial Magnetic Stimulator], strokes,
Parkinson's disease, dystonia, tinnitus and auditory hallucinations)

CPT (90867, 90868, 90869, [0310T del. 01/01/2018])
Note: CPT 0310T (e.g., Nextstim® Navigated Brain Stimulation [NBS] System 4 with
NexSpeech®)— motor function mapping using non-invasive navigated transcranial magnetic
stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity — is not
separately reimbursable as there is insufficient evidence of therapeutic value.

Transendoscopic therapies for dysphagia and gastrointestinal reflux

disease (GERD)
(E.g., Bard EndoCinch™ Suturing System, Enteryx™, EsophyX™, LINX Reflux Mgmt. System,
Stretta® radiofrequency ablation)
(See also Medicare LCD: Endoscopic Treatment of GERD)

Natural orifice transoral endoscopic surgery (NOTES) for bariatric
surgery/transoral gastroplasty (TOGA)
(E.g., Apollo OverStitch endoscopic suturing system, StomaphyX™ endoluminal fastener and
delivery system, etc.)

CPT (0392T, 0393T, 43210, 43257, 43284, 43285,43289, 43499, 43999,
49999)
Transhemorrhoidal dearterialization (THD)
CPT (0249T)

Y

Y

Y

7/14/2017

Y

Y

Y

3/23/2017

Y

Y

Y

7/14/2017

N

N

N

9/8/2017

Y

Y

Y

1/19/2017

Y

N

Y

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

7/14/2017

N

N

N

3/10/2017

N

N

N

8/11/2017

N

N

N

6/9/2017

Y

Y

Y

10/13/2017

Transilluminated powered phlebectomy (TriVex System) for varicosities
(See also Varicose Vein Treatment)
CPT (No specific code)
Transmyocardial revascularization
CPT (33140, 33141)

Transperineal implantation of permanent adjustable balloon
continence device, with cystourethroscopy, when performed
and/or fluoroscopy, when performed
CPT (No specific code)
Tranpupillary thermotherapy for retinoblastoma
CPT (67299)
Transtelephonic spirometry for monitoring pulmonary function following
lung or heart-lung transplantation. CPT (94014, 94015, 94016)
Transurethral microwave thermotherapy
CPT (53850)
Transurethral needle ablation of the prostate
CPT (53852)
Transvascular Autonomic Modulation (TVAM) for the treatment of
autonomic dysfunction using balloon angioplasty devices
(See also FDA MedWatch Safety Alert)
CPT (No specific code)
Tremor analysis device
(E.g., Physiologic recording of tremor using accelerometers)

CPT (95999)
Triggerfish® System for continuous intraocular pressure monitoring for
glaucoma (Sensimed)
CPT (0329T)
Tropism testing for HIV
(E.g., Trofile™ co-receptor assay for HIV [Monogram Biosciences], HIV-1 Coreceptor Tropism
Testing [Quest Diagnostics]

(See also Genetic Counseling and Testing)
CPT (No specific code)
Ultrasound — intravascular noncoronary vessel
CPT (37252, 37253)

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

11/10/2017

Y

Y

Y

8/11/2017

N

N

N

1/12/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

7/8/2017

Y

Y

Y

7/14/2017

Y

Y

Y

2/9/2018

N

N

N

10/13/2017

N

SEE NOTE

N

07/14/2017

Y

Y

Y

5/12/2017

Ultrasound — low frequency for wounds
(E.g., MIST Therapy System)

CPT (97610)
Ultrasound — obstetric
(See also Obstetric Ultrasonography for coding and criteria)
Ultrasound-guided ligation of hemorrhoidal vascular bundle(s)
CPT (0249T)
Ultrasound-guided spinal injection(s), single/multilevel),
diagnostic/therapeutic agent
(See also Pain Management)
CPT (0213T, 0214T, 0215T)
Unicondylar interpositional spacer
(E.g., UniSpacer™ Knee System)

CPT (No specific code)
Urine cytology for bladder cancer screening or as a primary detection
modality (without cystoscopy)
(E.g., UroVysion™)

CPT (88112, 88120, 88121)
Uterine artery embolization for symptomatic fibroids
CPT (37243)
Vacuum-Assisted Socket System™ for artificial limbs
HCPCS (L5781, L5782)
Vacuum assisted wound closure (VAC) (aka negative-pressure wound
therapy [NPWT])
Note: SNAP® Wound Care System is considered investigational

CPT (97605, 97606, 97607, 97608)
HCPCS (A6550, A9272, E2402, K0743, K0744, K0745, K0746)
Vacuum bell for treatment of pectus excavatum
(See also Surgical Correction of Chest Wall Deformities)
CPT (No specific code)
Vaginal bowel control for fecal incontinence
(E.g., Eclipse™ Vaginal Insert System)

(See also Fecal Incontinence Treatment)
Note: The eclipse system is covered for Medicare members per Noridian LCD.

CPT (A4335)
Vagus nerve stimulation — epilepsy

CPT (61885, 61886, 61888, 64553, 64568, 64569, 64570, 95970, 95974,
95975)
HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688,
L8689)
Vagus nerve stimulation — multiple conditions
(E.g., Addictions, Alzheimer disease, anxiety disorders, atrial fibrillation, autism spectrum
disorders, back pain, bipolar disorder, cerebral palsy, chronic pain syndrome, eating
disorders, headaches, cognitive impairment associated with Alzheimer’s disease, coma,
depression, essential tremor, fibromyalgia, heart failure, hemicrania continua, impaired
glucose tolerance, morbid obesity [aka nerve blocking therapy, i.e., vBloc® Maestro®
System], mood disorders, narcolepsy, neck pain, obsessive compulsive disorder, paralysis
agitans, sleep disorder, stroke, tinnitus, Tourett’s syndrome, traumatic brain injury [TBI]
including post-TBI pneumonia, etc.)

N

N

N

2/9/2018

N

N

N

8/11/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

3/10/2017

Y

Y

Y

7/14/2017

Y

Y

Y

1/12/2018

N

N

N

4/21/2017

Y

Y

Y

N

N

N

CPT (0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 61885, 61886, 61888,
64553, 64568, 64569, 64570, 64585, 64590, 64595, 95970, 95974, 95975)
HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L6868,
L8689)
Venoplasty for relapsing remitting multiple sclerosis
CPT (36901, 36902, 36903, 36904, 36905, 36906)
VerifyNow™ Aspirin Plus Assay (point-of-care platelet aggregation device)
(Accumetrics)
CPT (85576)
VeriStrat® proteomic expression profiling for non-small cell lung cancer
treatment (Biodesix)
(See also Medicare Coverage Article: Biomarkers for Oncology)
CPT (84999, 81538)
Vertical expandable prosthetic titanium rib
(See also Vertical Expandable Prosthetic Titanium Rib [VEPTR])
CPT (No specific code)
Viadur® (leuprolide acetate implant) for advanced prostate cancer
CPT (11981, 11982, 11983)
HCPCS (J9219)
Virtual colonoscopy
CPT codes ([74261, 74262 for diagnostic], [74263 for screening])
Viscocanalostomy
(See also Canaloplasty and Viscocanalostomy)
CPT (66174, 66175)
Visual electrophysiology testing
CPT (92275, 95930)

7/14/2017

Visual evoked potential, screening of visual acuity, automated
(See also Visual Evoked Potential Testing for Pediatric Populations in the
Primary Care Setting)
CPT (0333T)

8/11/2017

Visual evoked potential testing for glaucoma
(See also Visual Electrophysiology Testing)

N

N

N

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

6/26/2017

Y

Y

Y

7/14/2017

N

N

N

8/11/2017

Y

Y

Y

7/14/2017

Y

Y

Y

1/12/2018

Y

Y

Y

CPT (0464T)
Visual field assessment — real time, remote surveillance data
transmission
(E.g., ForeseeHome™ AMD Monitoring Program)

CPT (0378T, 0379T)
Vitamin D Deficiency Testing
(See Vitamin D Deficiency Testing for coding)
Water-induced thermotherapy
CPT (55899)
Waterjet ablation — prostate, transurethral
(E.g. PROCEPT Aquablation™ System)

CPT (0421T)
Wireless Esophageal pH Monitoring (Bravo™ System)
CPT (91035)
Xofigo® (radium Ra 223 dichloride injection)
CPT (79101)
HCPCS (A9606)
Zika virus diagnostic testing
(E.g., Zika Virus Antibody [IgM], Zika Virus Qualitative Real-Time PT-PCR Panel
[serum/urine], [Quest], Zika Virus RNA Qualitative Real-Time RT-PCR test [Focus
Diagnostics; subsidiary of Quest, EmblemHealth’s preferred lab])

See also:




7/14/2017

FDA web page on Emergency Use Authorizations
Medicare coverage for Zika Virus and Testing
Quest Zika Virus Infection web page

CPT (86790, 87798)
Zika virus general population screening

N

N

N



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