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

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])

SEE NOTE

7/14/2017

Acticon™ Neosphincter artificial bowel sphincter

(See also Fecal Incontinence Treatment)

CPT (No specific code)

7/14/2017

Actigraphy as a stand-alone measurement parameter for the diagnosis of

obstructive sleep apnea

(See also Obstructive Sleep Apnea Diagnosis and Treatment)

CPT (95803)

2/9/2018

Agilium Freestep for unicompartmental osteoarthritis

12/9/2016

HCPCS (A9285)

Alcohol septal ablation for hypertrophic cardiomyopathy

CPT (93583, 93799)

4/21/2017

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 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)

SEE

Transplant

Program Case

Management

SEE

CMS

NOTE

SEE

Transplant

Program Case

Management

7/14/2017

AlloSure® Donor-Derived Cell-Free DNA Test to assess probability of

allograft rejection in kidney transplant recipients

CPT (81479)

7/14/2017

Altered auditory feedback devices

(E.g., SpeechEasy®/FluencyMaster)

CPT (No specific code)

HCPCS (E1399)

7/14/2017

Amniotic membrane transplantation for ocular reconstruction

CPT (65778, 65779, 65780, 65781, 65782, V2790)

4/21/2017

Apheresis therapy with selective high density lipoprotein (HDL)

delipidation and plasma reinfusion

CPT (0342T)

7/14/2017

Atherectomy — peripheral, open or percutaneous, infrainguinal

atherosclerotic arterial occlusive disease

CPT (37225, 37227, 37229, 37231)

1/19/2017

Atherectomy — peripheral, open or percutaneous, of arterial vasculature

(E.g., abdominal aorta, brachiocephalic, iliac, renal, etc.)

CPT (0234T, 0235T, 0236T, 0237T, 0238T)

7/14/2017

Aqueous Shunts/implants for primary open angle glaucoma (FDA-

approved 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)

5/12/2017

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

5/12/2017

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.

CPT (0100T, [0472T, 0473T new eff. 07/01/17])

SEE NOTE

7/14/2017

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)

4/21/2017

Antibody assay testing for detecting neutralizing antibodies against

interferon beta (Betaseron) for multiple sclerosis patients

(E.g., Bab Sreen, NabFeron®)

CPT (86382)

2/9/2018

Assisted Embryo Hatching

(See also Assisted Reproductive Technologies for case-by-case

consideration)

CPT (89253)

2/10/2017

Audiometry — pure tone/speech (threshold), automated

CPT (0208T, 0209T, 0210T, 0211T, 0212T)

7/14/2017

Autologous adipose-derived regenerative cell therapy for scleroderma in

the hands

CPT (0489T, 0490T eff. 01/01/2018)

12/12/2017

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)

SEE NOTE

7/14/2017

Autologous bone marrow cell therapy, intramuscular, with preparation of

harvested cells, multiple injections, one, leg, including ultrasound

guidance (if performed)

7/8/2017

CPT (0263T, 0264T, 0265T)

Autologous chondrocyte implantation (aka transplantation)

CPT (27412)

HCPCS (J7330, S2112)

10/13/2017

Automated evacuation of meibomian glands — heat and intermittent

pressure

(E.g., LipiFlow [TearScience®])

CPT (0207T)

7/14/2017

Avise MCV™ for the diagnosis and prognosis of rheumatoid arthritis

(See also Gene Expression Profiling)

CPT (83520)

2/9/2018

MCV+

CPT (83520, 86200)

2/9/2018

Avise® MTX (aka Avise PG) for measuring methotrexate polyglutamates

for rheumatoid arthritis (metabolite marker testing)

(See also Gene Expression Profiling)

CPT (81479)

2/9/2018

Avise® Lupus (aka Avise SLE) diagnostic biomarker panel for diagnosis of

systemic lupus erythematosus (SLE)

(See also Gene Expression Profiling)

CPT (83520, 86039, 86225, 88184, 88185, 88187)

2/9/2018

Avise® CTD (aka Avise SLE+)

(See also Gene Expression Profiling)

CPT (83520, 86039, 86225, 88184, 88185, 88187, 86235, 86200)

2/9/2018

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

CPT (31295, 31296, 31297, [31298 eff. 01/01/2018])

10/13/2017

Behavioral prevention program for diabetes — online/electronic

(See also Nutritional Counseling Services)

CPT (0488T eff. 01/01/2018)

12/12/2017

Biliopancreatic diversion (BPD) (Scopinaro procedure) for clinically severe

obesity

(See also Bariatric Surgery)

CPT (43847)

3/10/2017

Biliopancreatic diversion (BPD) with duodenal switch (DS) for clinically

severe obesity

(See also Bariatric Surgery)

CPT (43845)

3/10/2017

Bioelectrical impedance (whole body)

CPT (0358T)

7/8/2017

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

7/8/2017

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

Note: Not considered medically necessary for any

other condition

Q4112

DermaMatrix (discontinued 6/2014)

N/A

FlexHD

Q4128

7/14/2017

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™

Neox® Wound Matrix

Q4155

Q4148, Q4156

Repriza

Q4143

Strattice™ Reconstructive

Q4130

SurgiMend®

(No specific code)

XCM BIOLOGIC® Tissue Matrix

Q4142

XenMatrix™

No specific code

1/12/2018

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

AmnioBand 1mg

Q4151 (AmnioBand Viable and

AmnioBand SL)

Q4168 (AmnioBand

Particulate)

AmnioExcel or BioDExCel

Q4137

10/13/2017

Amniopro, Bioskin, Biorenew, Woundex, Amniogen-

45, 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)

PuraPly™ Antimicrobial Wound Matrix (PuraPly AM)

PuraPly™ Wound Matrix (PuraPly)

Q4172

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

(New commercial name for MariStem is Cytal)

Q4118, Q4166 for Cytal

Mediskin

Q4135

MemoDerm™, DermaSpan, TranZgraft or InteguPly

Q4126

MIRODERM™

Q4175

Nushield

Q4160

OASIS® Wound Matrix, Oasis Burn Matrix,Ultra Tri-

layer Matrix

Q4102, Q4103, Q4124

PalinGen or PalinGen XPlus, per square centimeter (to

identify PalinGen®) Membrane and PalinGen®

Hydromembrane

PalinGen or ProMatrX (to identify ProMatrX, PalinGen

Flow and PalinGen SportFlow

Q4173

Q4174

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®

Q4107

10/13/2017

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)

10/13/2017

Biomagnetic Therapy

CPT (97799)

6/9/2017

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)

1/19/2017

Biomarker testing — Des-gamma-carboxy prothrombin (DCP) for

diagnosing and monitoring hepatocellular carcinoma (HCC) and

other indications

1/19/2017

(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

CPT (No specific code)

7/14/2017

Biomarker testing for assessing cardiac disease risk — secretory type II

phospholipase A2 (sPLA2-IIA)

(E.g., AccuCardia [Zeus Scientific])

CPT (0423T )

7/14/2017

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)

2/10/2017

Biomarker testing for Alzheimer’s disease (cerebrospinal fluid or urine-

based)

(E.g., ADmark® Alzheimer’s Evaluation [Athena])

CPT (83520 )

7/8/2017

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)

2/10/2017

Biomechanical mapping, transvaginal, with report

CPT (0487T eff. 01/01/2018)

12/12/2017

Bioness L300 Foot Drop System for traumatic brain Injury (TBI) (aka

functional electrical stimulation)

HCPCS (E0770)

7/14/2017

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)

1/19/2017

Biosynthetic Implant for ventral hernia repair/abdominal wall fascial

defect

CPT (0437T)

1/19/2017

Blood coagulation home testing devices

HCPCS (E1399, G0248, G0249, G0250)

8/11/2017

Body photography — “total” body or “whole” body/computer-based

optical diagnostic devices/imaging techniques for evaluating pigmented

7/14/2017

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)

3/10/2017

Bone growth stimulators

(See Osteogenesis Stimulators for covered/noncovered indications)

CPT (20974, 20975, 20979)

HCPCS (E0747, E0748, E0749, E0760, A4559)

SEE NOTE

5/12/2017

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)

7/14/2017

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)

7/14/2017

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)

7/14/2017

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)

7/14/2017

Brachytherapy — intracoronary for stent restenosis

CPT (77770, 77771, 77772, 92974)

HCPCS (Q3001)

7/14/2017

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)

7/14/2017

Breast ductal endoscopy (aka fiberoptic ductoscopy or mammary

ductoscopy) for breast cancer screening

3/10/17

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.)

CPT (19499)

3/10/17

Bronchial thermoplasty for severe asthma

CPT (31660, 31661, 31899)

7/14/2017

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 post-

operative 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

SEE NOTE

7/14/2017

Cadaver lung organ perfusion system — initiation, monitoring, surgical

preparation

CPT (0494T, 0495T, 0496T eff. 01/01/2018)

12/12/2017

Camera pill — esophageal and small bowel indications

(E.g., PillCam ESO, PillCam SB, Olympus Capsule Endoscope System)

(See also Capsule Endoscopy)

CPT (91110, 91111)

5/12/2017

Camera pill — colon (PillCam® Colon)

(See also Capsule Endoscopy)

CPT (0355T)

5/12/2017

Camera pill accessory systems to determine gastrointestinal patency

(E.g., Given® AGILE Patency System for Given® PillCam™)

5/12/2017

(See also Capsule Endoscopy)

CPT (91299)

Canaloplasty

(See also Canaloplasty and Viscocanalostomy)

CPT (66174, 66175)

4/21/2017

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)

7/14/2017

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)

1/12/2018

Cardiac — central arterial pressure waveforms analysis

(E.g., SphygmoCor® System)

CPT (93050 )

7/14/2017

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)

1/12/2018

Cardiac — counterpulsation (external)

(See also Enhanced External Counterpulsation for Chronic Stable Angina)

CPT (92971)

HCPCS (G0166)

8/11/2017

Cardiac — counterpulsation (implanted extra-aortic counterpulsation

device [EACD])

CPT (0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T,

0460T, 0461T, 0462T, 0463T)

1/12/2018

Cardiac — HeartFlow® digital 3D modeling

CPT ([0501T, 0502T, 0503T, 0504T eff. 01/01/2018], 93799)

3/10/2017

Cardiac — hemodynamic monitors, implantable left atrial

(E.g., HeartPOD System, Promote LAP System)

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

7/14/2017

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

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

(0387T, 0388T, 0389T, 0390T, 0391T)

SEE NOTE

1/12/2018

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)

SEE NOTE

1/12/2018

Cardiac — left partial ventriculectomy (Batista procedure/ventricular

reduction surgery)

CPT (33542, 33548, 33999)

1/12/2018

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)

6/9/2017

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

1/12/2018

Cardiac — resynchronization therapy/biventricular pacing for congestive

heart failure

(E.g., InSync®, St. Jude Frontier™ Biventricular Cardiac Pacing System or any other FDA-

approved 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)

3/10/2017

Cardiac — septal closure devices

7/14/2017

(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)

Note: Percutaneous closure of paravalvular leakage (CPT 93591, 93592) is considered

investigational. Requests for this service will receive case-by-case review.

11/10/2017

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.

7/14/2017

Cardiac —transcatheter heart valve implantation within an existing

bioprosthetic valve

CPT (No specific code)

7/14/2017

Cardiac — ventricular assist devices (VADs) — adult (e.g., Thoratec®,

HeartMate II®)

CPT (33975–33983, 33990, 33991, 33992,33993 )

HCPCS (Q0478–Q0508)

7/14/2017

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)

SEE NOTE

7/14/2017

Cardiac defibrillators — automatic external (home use, wearable)

(See also Automatic External Defibrillators)

CPT (93292, 93745)

HCPCS (K0606, K0607, K0608, K0609)

4/21/2017

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)

5/12/2017

Cardiac defibrillators — subcutaneous implantable (S-ICD)

(E.g. S-ICD™ System)

(See also Implantable Cardioverter Defibrillators)

CPT (33270, 33271, 33272, 33273, 93260, 93261, 93644)

5/12/2017

Cardiac monitoring — ECG remote algorithm analysis, computerized

1/12/2018

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)

CPT (93268, 93270, 93271, 93272)

7/14/2017

Cardiac monitoring — external electrocardiographic recording up to 48

hours

(See also Cardiac Event Monitors)

CPT (93224, 93225, 93226, 93227)

7/14/2017

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)

7/14/2017

Cardiac monitoring — external patient-activated, physician- or other

qualified health care professional-prescribed, electrocardiographic

rhythm derived event recorder without 24 hour attended monitoring; in-

office connection/review and interpretation by a physician or other

qualified health care professional per 30 days with at least one patient-

generated triggered event

(See also Cardiac Event Monitors)

CPT (0497T, 0498T eff. 01/01/2018)

12/12/2017

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)

7/14/2017

Cardiac monitoring — fetal magnetic cardiac, at least 3 channels

CPT (0475T, 0476T, 0477T, 0478T eff. 07/01/2017)

7/14/2017

Cardiac monitoring — hemodynamic, left atrial

(E.g., HeartPOD System, Promote LAP System)

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

12/21/2016

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)

7/14/2017

Cardiac monitoring — intracardiac ischemic to detect potential heart

attack

(E.g., AngelMed Guardian System)

12/21/2016

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

(See also Cardiac Event Monitors)

CPT (93228, 93229)

7/14/2017

Cardiography — combined acoustic and electrical

(Aka, acoustic heart sound recording, computer analysis and interpretation; e.g., Zargis

Acoustic Cardioscan)

CPT (93799)

1/12/2018

Cardiophysiologic mapping/multichannel electrocardiography (≤ 64-

leads)

(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)

1/12/2018

Carotid artery stenting

(E.g., Enroute Transcarotid Neuroprotection System)

CPT (37215, 37216, 37217, 37218)

Note: CPT codes 0075T and 0076T are not reimbursable

7/14/2017

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)

7/14/2017

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)

7/14/2017

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)

7/14/2017

Chelation therapy for heavy metal toxicity and overload conditions

HCPCS (J0470, J0600, J0895, J3520)

2/10/2017

Chemical peels for actinic keratoses (AKs)/premalignant skin lesions

Note: Click on Medical Guideline link for clinical criteria and coverage

specifics

CPT (15788, 15789, 15792, 15793)

8/11/2017

Chemoembolization for hepatic cancer

CPT (37243, 75894)

7/14/2017

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)

4/21/2017

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])

3/10/2017

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)

7/14/2017

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)

6/9/2017

Cognitive rehabilitation

CPT (97532)

3/10/2017

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)

7/14/2017

Coil embolization for arterio-venous malformations (AVMs)/aneurysm

10/13/2017

and splenic artery aneurysm

CPT (37241, 37242, 37243, 37244, 61624, 61635, 75894)

Collagen meniscus implant

(E.g., Menaflex™)

HCPCS (G0428)

7/14/2017

Common carotid intima-media thickness (IMT) study for evaluation of

atherosclerotic burden or coronary heart disease risk factor assessment

CPT (93895, 0126T)

7/14/2017

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

10/13/2017

Computed tomography (CT) — low dose for lung cancer detection

CPT (No specific code)

HCPCS (G0296, G0297)

7/14/2017

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)

7/14/2017

Computed tomographic angiography (CTA) for coronary diagnostics via

multislice or multidetector CT modalities

CPT (75574)

7/14/2017

Computer-aided animation and analysis of time series retinal images for

disease-progression monitoring

CPT (0380T)

7/14/2017

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)

7/14/2017

Computer-assisted detection breast MRI

CPT (0159T)

7/14/2017

Computer-assisted detection breast ultrasound

CPT (76999)

7/14/2017

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)

7/14/2017

Computer-assisted detection mammography (e.g., MammoReader or any

other FDA-approved device)

CPT (No specific code)

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

mammography

7/14/2017

Computer-assisted orthopedic surgery

CPT (20985, 0054T, 0055T, 0396T)

7/14/2017

Confocal laser endomicroscopy (CLE) (aka confocal fluorescent

endomicroscopy and optical endomicroscopy)

CPT (43206, 43252, 88375, 0397T)

7/14/2017

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)

7/14/2017

Continuous passive motion devices

HCPCS (E0935)

5/12/2017

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)

7/14/2017

Cord blood harvesting and banking

CPT (No specific code)

HCPCS (S2140)

7/14/2017

Corneal — computer topography

CPT (92025)

7/14/2017

Corneal — collagen cross-linking (CXL) for progressive keratoconus

CPT (0402T)

7/14/2017

Corneal — hysteresis

CPT (92145)

7/14/2017

Corneal — intrastromal corneal ring segments for keratoconus (Intacs®)

(See also Intrastromal Corneal Ring Segments for Keratoconus)

CPT (65785)

HCPCS (L8610)

6/9/2017

Corneal — pachymetry for glaucoma

CPT (76514)

7/14/2017

Current Perception Threshold/Sensory Nerve Conduction Threshold Test

(sNCT)

HCPCS (G0255)

7/14/2017

Cryoablation — atrial fibrillation

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

CPT (93656, 93657)

7/14/2017

Cryoablation — Barrett’s esophagus

CPT (43229, 43270)

7/14/2017

Cryoablation — bone tumors

CPT (20983)

7/14/2017

Cryoablation — breast fibroadenomas

CPT (19105)

7/14/2017

Cryoablation — hepatic cancer

(See also Cryosurgery for Liver Tumors)

CPT (47381, 47383, 47371, 76940, 76998, 77013, 77022)

10/13/2017

Cryoablation — peripheral nerves for the treatment of knee and

intercostal pain (Iovera cryotherapy)

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

Cryoablation — peripheral nerves upper extremity

CPT (0440T)

1/19/2017

Cryoablation — plantar fasciitis

CPT (64640)

7/14/2017

Cryoablation — prostate cancer

(See also Cryosurgical Ablation for Prostate Cancer)

CPT (55873)

10/13/2017

Cryoablation — pulmonary tumors

CPT (0340T [del. 01/01/2018])

Note: CPT code 32994 is covered for Medicare members only

7/14/2017

Cryoablation — renal cancer

(See also Cryosurgical and Radiofrequency Ablation for Renal Tumors)

CPT (50250, 50542, 50593)

6/9/2017

Cryoablation — uterine for menorrhagia

(E.g., HerOption)

CPT (58356)

7/14/2017

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)

7/14/2017

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

2/9/2018

mature oocytes and sperm for members with iatrogenic infertility.

CPT (0357T)

Cryopreservation — reproductive tissue, ovarian

(See also Assisted Reproductive Technologies)

CPT (0058T)

4/21/2017

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)

7/14/2017

Cystourethroscopy, with mechanical dilation and urethral therapeutic

drug delivery for urethral stricture or stenosis, including fluoroscopy

CPT (0499T eff. 01/01/2018)

12/12/2017

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 )

7/14/2017

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)

6/9/2017

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-by-

case basis.

CPT (21499, 61863, 61864, 61867, 61885, 61886, 61880, 61888, 95961,

95962)

HCPCS (L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688,

L8689)

SEE NOTE

6/9/2017

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)

8/11/2017

DermaClose® RC Continuous External Tissue Expander for wound

management

CPT (No specific code)

7/14/2017

Destruction neurofibromata — extensive, (cutaneous, dermal extending

7/14/2017

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)

CPT (67027)

HCPCS (J7311, J7312, J7313)

1/19/2017

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)

3/13/2017

Double balloon enteroscopy

CPT (No specific code)

7/14/2017

Drug eluting ocular implant — lacrimal canaliculus (aka intracanalicular

plugs) (including punctal dilation and implant removal)

CPT (0356T, 0444T, 0445T)

7/14/2017

Drug eluting stents — cardiac

CPT (92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944)

7/14/2017

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)

3/10/2017

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)

7/14/2017

Dynamic Decompression System for pectus excavatum

(See also Surgical Correction of Chest Wall Deformities)

CPT (No specific code)

10/13/2017

Elastography (e.g., FibroScan®) for management of benign liver disease

CPT (0346T, 91200)

7/14/2017

Elastography for evaluation of breast lesions (or any other indication)

CPT (0346T)

Note: CPT 0346T and 91200 are allowable for liver elastography

7/14/2017

Electrical continence aids, rectal inserts and related accessories

HCPCS (A4335, A4337)

7/14/2017

Electrical modulation pain reprocessing — transcutaneous

CPT (0278T)

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)

7/14/2017

Electrical Stimulation — auricular of acupuncture points (aka auricular

electrostimulation)

CPT (S8930)

7/14/2017

Electrical stimulation (neurostimulation) — central sleep apnea

(E.g., remedē® System)

CPT (0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T,

0433T, 0434T, 0435T, 0436T)

7/14/2017

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)

2/9/2018

Electrical stimulation — pudendal nerve terminal motor latency (PNTML)

for fecal incontinence

(See also Fecal Incontinence Treatment)

CPT (No specific code)

7/14/2017

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)

7/14/2017

Electrical stimulation — tibial nerve for fecal incontinence

(See also Fecal Incontinence Treatment)

CPT (64566)

7/14/2017

Electrical stimulation/diathermy (pulsed) — knee osteoarthritis

(E.g., BioniCare®BIO-1000, OrthoCor Active Knee System)

HCPCS (E0762)

7/14/2017

Electrical stimulation — perianal for fecal incontinence

(See also Fecal Incontinence Treatment)

7/14/2017

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)

CPT (64550)

HCPCS (A4557, A4595, E0730, E0731, E0720)

SEE NOTE

7/14/2017

Electrical stimulation — transcutaneous electrical nerve stimulation

(TENS) for nausea

HCPCS (A4558, E0765)

7/14/2017

Electrical stimulation — transcutaneous electrical nerve stimulation

[TENS) for migraine prophylaxis

(E.g., Cefaly® TENS)

HCPCS (No specific code)

7/14/2017

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

7/14/2017

Electrogastrography as a diagnostic tool for gastroparesis or functional

dyspepsia

CPT (91132, 91133)

7/14/2017

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)

8/11/2017

Electromagnetic therapy for wounds

HCPCS (G0295, G0329, E0761)

7/14/2017

Electronic nicotine delivery systems for smoking cessation (ENDS)

CPT (No specific code)

7/14/2017

Embolization of ovarian and Internal Iliac veins for pelvic congestion

syndrome (PCS)

CPT (36012, 37241, 75894, 75898)

1/12/2018

Endomechanical ablative approach for varicose vein

treatment/endovenous mechanochemical ablation (MOCA)

(E.g., ClariVein™ Catheter)

(See also Varicose Vein Treatment)

CPT (36473, 36474)

9/8/2017

Endoscope, retrograde imaging/illumination colonoscope device

(implantable)

(E.g., Third Eye® Panoramic™ Device for Colonoscopy)

7/14/2017

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

(E.g., Endo PAT 2000)

CPT (0337T)

7/14/2017

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])

7/14/2017

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)

7/14/2017

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)

7/14/2017

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)

3/10/2017

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)

7/14/2017

Epidermal nerve fiber density test for the diagnosis of small fiber

neuropathy

CPT (88356)

7/14/2017

Epiretinal radiation for wet age-related macular degeneration (placement

7/14/2017

of intraocular radiation source applicator)

CPT (0190T)

Erectile dysfunction and penile prostheses

CPT (54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416,

54417)

HCPCS ( [Medicare benefit discontinuance of L7900 and L7902 for the

vacuum pump and ring eff. 07/1/2015])

SEE NOTE

7/14/2017

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)

1/12/2018

Extracorporeal immunoabsorption using protein a columns (Prosorba®)

for ITP/rheumatoid arthritis

CPT (36515 [del. 01/01/2018] No specific code)

7/14/2017

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)

7/14/2017

Extracorporeal shockwave therapy for chronic epicondylitis

CPT (0102T)

Note: Coverage discontinued for Medicare members eff. 01/01/2016

7/14/2017

Extracorporeal shockwave therapy for chronic plantar fasciitis

CPT (28890)

Note: Coverage discontinued for Medicare members eff. 01/01/2016

7/14/2017

Extracorporeal shockwave therapy for musculoskeletal indications other

than epicondylitis or plantar fasciitis

CPT (0101T [high energy])

7/14/2017

Extra-osseous subtalar joint for talotarsal stabilization

CPT (0335T)

HCPCS (S2117)

7/14/2017

Facet joint arthroplasty (replacement)

CPT (0202T)

7/14/2017

Fetal fibronectin testing

CPT (82731)

7/14/2017

Fecal microbiota transplant (FMI) for recurrent C difficile infection (RCDI)

CPT (44705)

HCPCS (G0455)

4/21/2017

FENIX™ Continence Restoration System

Note: The Fenix is an investigational mechanical compression device that is FDA-approved

SEE NOTE

7/14/2017

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)

CPT (92287)

7/14/2017

Fractional ablative laser fenestration of burn and traumatic scars for

functional improvement of infants and children

CPT (0479T, 0480T eff. 01/01/2018)

12/12/2017

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)

7/14/2017

Galectin-3 testing for congestive heart failure

CPT (82777)

7/14/2017

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)

12/12/2017

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)

12/12/2017

Gene expression profiling — brain malformations

(E.g., Comprehensive Brain Malformations Next Generations Sequencing Panel (GeneDx)

(Gene Expression Profiling)

CPT (81405, 81406, 81407, 81408)

10/13/2017

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)

2/9/2018

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)

CPT (81519 all LOBs)

HCPCS (S3854 for Commercial)

Note: CPT codes 81432 and 81433 for hereditary breast cancer disorders are not considered

medically necessary

2/9/2018

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)

SEE NOTE

FOR

SPECIFIC

TESTS

2/9/2018

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)

7/14/2017

Gene expression profiling — F9 (coagulation factor IX) (eg, hemophilia B),

full gene sequence

(See also Gene Expression Profiling)

CPT (81238 eff. 01/01/2018)

12/12/2017

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)

12/12/2017

Gene expression profiling — heart transplant rejection

(E.g., AlloMap® [CareDx])

CPT (81595, 86849 unlisted immunology)

4/21/2017

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

SEE NOTE

10/13/2017

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)

CPT (87801)

9/8/2017

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)

10/13/2017

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)

8/11/2017

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)

12/12/2017

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)

7/14/2017

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)

SEE NOTE

FOR

SPECIFIC

TESTS

1/12/2018

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

10/13/2017

(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

CPT (No specific code)

1/12/2018

Genetic testing — amyotrophic lateral sclerosis (ALS) SOD1 mutation

CPT (81404)

HCPSCS (S3800)

(See also Genetic Counseling and Testing)

4/12/2017

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)

10/13/2017

Genetic testing — analysis of PIK3CA status in tumor cells

CPT (81404, 81479)

10/13/2017

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

2/9/2018

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)

3/10/2017

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)

3/10/2017

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])

SEE NOTE

FOR

SPECIFIC

TESTS

7/14/2017

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])

(See also Cardiac Ion Channel Genetic Testing)

CPT (81403, 81405, 81408)

3/10/2017

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)

3/10/2017

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]

5/12/2017

Genetic testing — cerebral autosomal dominant arteriopathy with

subcortical infarcts and leukoencephalopathy (CADASIL) Syndrome

CPT (81406, 81599)

HCPCS (G0452 [Medicare])

2/9/2018

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)

3/10/2017

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

SEE NOTE

2/9/2018

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 all-

inclusive) — Chromosomal Microarray Analysis

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)

10/13/2017

Genetic testing — comparative genomic hybridization (CGH) microarray

for chromosomal imbalance (various manufacturers)

(See also Chromosomal Microarray Analysis)

CPT (81228, 81229, 88230, 88262)

HCPCS (S3870)

10/13/2017

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)

2/9/2018

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)

2/9/2018

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)

2/9/2018

Genetic testing — cystic fibrosis (diagnostic use for suspected cystic

fibrosis)

(See also Genetic Testing for Cystic Fibrosis)

10/13/2017

CPT (81220, 81221, 81222, 81223, 81224)

Genetic testing — dementia

(See also Genetic Testing for Frontotemporal Dementia (FTD)

CPT (81406, 81479)

10/13/2017

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)

2/9/2018

Genetic testing — Factor V Leiden mutation analysis

CPT (81241)

2/9/2018

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)

10/13/2017

Genetic testing — Guanylyl cyclase c (GCC or GUCY2C) lymph node

analysis for colorectal cancer staging

(E.g., Previstage™ GCC)

CPT (No specified code)

2/9/2018

Genetic testing — hereditary pancreatitis

CPT (81222, 81223, 81224, 81401, 81404, 81479)

10/13/2017

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)

4/21/2017

Genetic testing — Li-Fraumeni syndrome

CPT (81404, 81405, 81479)

10/13/2017

Genetic testing — Janus Kinase 2 (JAK2) V617F Gene Mutation Assay

(See also Janus Kinase 2 (JAK2) V617F Gene Mutation Assay)

CPT (81270, 81403)

SEE NOTE

6/9/2017

Genetic testing — age-related macular degeneration (AMD), risk-

determination 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)

3/10/2017

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)

12/12/2017

(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)

CPT (81404)

10/13/2017

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)

9/8/2017

Genetic testing — Myeloid Molecular Profile (Genoptix)

(See also Gene Expression Profile Testing for Multiple Myeloma or Gene

Expression Profiling)

CPT (81450)

7/14/2017

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

2/9/2018

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)

4/21/2017

Genetic testing — NOTCH1, SF3B1 and BIRC3 prognostic genetic testing in

chronic lymphocytic leukemia (CLL)

(See also Genetic Counseling and Testing)

CPT (81450, 81455, 81479)

3/10/2017

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)

3/10/2017

Genetic testing — Panexia® (Myriad Genetics) for pancreatic

cancer/other oncologic indications

7/14/2017

(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)

CPT (81479)

7/14/2017

Genetic testing — peripheral neuropathies

(See also Genetic Testing for Inherited Peripheral Neuropathies)

CPT (81324, 81325, 81326, [81448 eff. 01/01/2018])

10/13/2017

Genetic testing — presenilin-1 gene

(See also Genetic Testing for Alzheimer’s Disease and Genetic Counseling

and Testing)

CPT (No specific code)

HCPCS (S3855)

3/10/2017

Genetic testing — pregnancy planning (screening for Fragile X Syndrome)

(See also Carrier Screening for Parents or Prospective Parents)

CPT (81243, 81244)

1/19/2017

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 disease-

causing alleles are first identified in an affected family member or both parents.

CPT (81256)

10/13/2017

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)

10/13/2017

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.)

5/12/2017

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”).

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)

SEE NOTE

3/10/2017

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)

11/10/2017

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)

1/12/2018

Genetic testing — SLCO1B1 genotyping for statin dosing or selection

CPT (81328 eff. 01/01/2018)

8/11/2017

Genetic testing — SHOX-related short stature

(See also Gene Expression Profiling and Genetic Counseling and Testing)

CPT (81479)

10/13/2017

Genetic testing — statin-induced myopathy

CPT (81400)

11/10/2017

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])

2/09/2018

GlucoWatch® Automatic Glucose Biographer (No longer marketed in the

U.S.)

HCPCS (S1030, S1031)

7/14/2017

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)

7/14/2017

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

4/21/2017

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)

CPT (81450)

1/19/2017

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)

8/11/2017

Genomic sequencing analysis — x-linked intellectual disability (XLID)

(E.g., syndromic and non-syndromic XLID)

(See also Gene Expression Profiling)

CPT (81470, 81471)

1/19/2017

Guardant 360 liquid biopsy test for advanced solid tumors

CPT (81455)

7/14/2017

Heart rate variability testing (Anscore™)

CPT (No specific code)

7/14/2017

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)

SEE NOTE

9/8/2017

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

12/12/2017

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)

HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,

hemoglobinopathy); full gene sequence

CPT (81361, 81362, 81363, 81364 eff. 01/01/2018)

12/12/2017

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)

7/14/2017

High frequency chest wall oscillation devices (compression vest)

HCPCS (A7025, A7026, E0483)

CPT (94669)

6/9/2017

High intensity focused ultrasound (HIFU) for prostate cancer

CPT (55899, 76999)

HCPCS

1/12/2018

High resolution anoscopy for detecting anal intraepithelial neoplasia —

diagnostic adjunct in following up on abnormal cytology

CPT (46601, 46607)

7/14/2017

High resolution anoscopy for detecting anal intraepithelial neoplasia —

screening of high risk individuals

CPT (46601, 46607)

Diagnosis codes (Z12.12, Z12.89, Z12.89)

7/14/2017

High resolution esophageal pressure topography (motility study) stand-

alone or combined with stimulation and/or acid or alkali perfusion

CPT (91299)

9/8/2017

HIV genotyping

(E.g., HIV-1 Genotype [Quest Diagnostics]; HIV-1 TrueGene™ [Visible Genetics]; ViroSeq™

[Abbott Laboratories])

CPT (87901, 87906)

7/14/2017

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

7/14/2017

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

deficiency

CPT (No specific code)

8/11/2017

Home nocturnal penile tumescence testing (RigiScan® Monitor)

CPT (54250)

7/14/2017

Home prothrombin time/international normalized ratio (INR) monitoring

for anticoagulation management

CPT (93792, 93793 eff. 01/01/2018)

HCPCS (G0248, G0249, G0250)

7/14/2017

Home uterine activity monitoring

CPT (99500, S9001)

4/21/2017

Human growth hormone for idiopathic short stature (TEV-TROPIN®)

HCPCS (J2940, J2941, S9558, Q0515)

7/14/2017

Human papilloma virus (HPV) DNA testing with cytology co-testing for

cervical cancer

CPT (87623, 87624, 87625)

7/14/2017

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)

1/12/2018

HPV DNA testing as primary screening

8/11/2017

(E.g., cobas® HPV)

CPT (87623, 87624, 87625)

Hyaluronate injections for osteoarthritis of the knee

CPT (20610)

HCPCS (J7321, J7323, J7324, J7325, J7326, J7327, J7328)

9/8/2017

Hyperbaric Oxygen Therapy

CPT (99183)

HCPCS (G0277)

5/12/2017

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)

1/12/2018

Hypothermia — selective head or total body in neonates ≤ 28 days for

treatment of moderate or severe hypoxic ischemic encephalopathy

(HIE)

CPT (99184)

8/11/2017

Hysteroscopic techniques for sterilization

(E.g., Essure™ Coil Sterilization)

(See also FDA Activities: Essure for product warnings)

CPT (58565)

HCPCS (A4264)

7/14/2017

iBOT Mobility System® (standard feature)

Note: Additional features for balance, stair-climbing and remote functions are not

considered medically necessary.

HCPCS (K0877)

7/14/2017

IDH1 testing — IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg,

glioma), common variants (eg, R132H, R132C)

CPT (81120 eff. 01/01/2018)

12/12/2017

IDH2 testing — IDH2 (isocitrate dehydrogenase 2 [NADP+],

mitochondrial(eg, glioma), common variants (eg, R140W, R172M)

CPT (81121 eff. 01/01/2018)

12/12/2017

Ilizarov bone lengthening technique

CPT (20690, 20692, 20693, 20694, 20696, 20697)

1/12/2018

Imaging — tactile breast by computer-aided tactile sensors

(E.g., Breastview Visual Mapping System, iBreastExam)

CPT (0422T)

8/11/2017

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.

6/9/2017

(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

CPT (62350, 62351, 62355, 62360, 62360, 62361,62362, 62365, 62367,

62368, 62369, 62370, 95990, 95991, 96523)

HCPCS (E0782, E0783, E0785, E0786, A4220)

SEE NOTE

7/14/2017

Implantable Miniature Telescope™ for macular degeneration

CPT (0308T)

7/14/2017

Immune cell function assays

(E.g., Lymphocyte Stimulation, ImmuKnow®, CYLEX®, CU Index®, iSpot Lyme™)

CPT (86352)

9/8/2017

Inflow™ intraurethral valve pump

HCPCS (A4335)

8/11/2017

Infrared heating pad system and replacement pads

HCPCS (A4639, E0221)

8/8/2017

Injectable autologous myoblast cells for fecal incontinence

(See also Fecal Incontinence Treatment)

CPT (0277T, 0377T, 11950, 11951, 11952, 11954)

HCPCS (L8605, L8699)

7/14/2017

Injectable autologous mesenchymal stem cells for fecal incontinence

CPT (0277T, 0377T, 11950, 11951, 11952, 11954)

HCPCS (L8605, L8699)

7/14/2017

Injectable autologous white blood cell concentrate (autologous protein

solution), any site, including image guidance, harvesting and preparation

CPT (0481T eff. 01/01/2018)

12/12/2017

Injectable bulking agents for fecal incontinence

(E.g., Solesta®)

(See also Fecal Incontinence Treatment)

CPT (0377T)

HCPCS (J3490, L8605)

10/13/2017

Injectable bulking agents for vocal cord medialization

HCPCS (L8607)

7/14/2017

Injection, Alemtuzumab

(See also Alemtuzumab [Campath®] or Alemtuzumab [Lemtrada™])

HCPCS (J0202)

7/14/2017

Injection, isavuconazonium sulfate

HCPCS (J1833)

7/14/2017

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

SEE NOTE

2/9/2018

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)

SEE NOTE

2/9/2018

Insulin — internal insulin pumps

CPT (49419 [also used for morphine and chemotherapeutic agents

administration, only deny for a diabetic indication])

8/11/2017

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)

8/11/2017

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)

8/11/2017

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®])

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)

CPT (0403T)

1/12/2018

Interferential current stimulator

CPT (S8130, S8131)

8/11/2017

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)

1/12/2018

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 FDA-

approved 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

SEE NOTE

7/14/2017

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™)

HCPCS (Q1004, Q1005)

8/11/2017

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)

1/19/2017

Intra-oral bone conduction prosthetic hearing devices (e.g., SoundBite™)

(See also Bone anchored hearing aids)

CPT (L9900)

3/10/2017

Intrapulmonary percussive ventilators (IPV)

(See also High Frequency Chest Wall Oscillation Devices and

Intrapulmonary Percussive Ventilators)

HCPCS (E0481)

6/9/2017

Intrathecal opioid therapy for chronic non-malignant pain

CPT (62350, 62351, 62355, 62360, 62361, 62362, 62365, 62367, 62368)

HCPCS (E0785, J3490)

7/14/2017

Irreversible electroporation (IRE) for tumors

(E.g., NanoKnife System)

CPT (No specific code)

1/12/2018

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)

2/10/2017

Know error® system (Strand Diagnostics) to confirm surgical biopsy

samples through bar coding

CPT (81265, 81266)

8/11/2017

Koning Breast CT System (KBCT)

CPT (76497)

8/11/2017

Kyphoplasty

CPT (22513, 22514, 22515)

7/14/2017

Lacrimal duct angioplasty

(E.g., Lacricath®)

CPT (68816)

7/14/2017

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)

3/10/2017

Laser — ablative, non-contact, full field and fractional ablation, open

wound

CPT (0491T, 0492T eff. 01/01/2018)

12/12/2017

Laser — benign prostatic hypertrophy/interstitial laser coagulation (ILC)

(E.g., Indigo®)

CPT (52647)

7/14/2017

Laser — coronary angioplasty

CPT (No specific code)

8/11/2017

Laser — in situ for keratomileusis (LASIK)

HCPCS (S0800)

8/11/2017

Laser — laparoscopic CO2 laser ablation for endometriosis

CPT (58578)

7/14/2017

Laser — low level laser therapy / cold laser

CPT (S8948)

8/11/2017

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)

9/21/2017

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)

9/21/2017

Laser — prostate ablation

CPT (52647, 52648)

7/14/2017

Laser — pulsed dye for cutaneous vascular lesions

CPT (17106, 17107, 17108)

5/12/2017

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

SEE NOTE

7/14/2017

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)

CPT (36478, 36479)

3/23/2017

Laser-induced thermotherapy for liver cancers

No specific CPT (47399)

8/11/2017

Liquid-based cervical cytology

(E.g., Thin Prep)

CPT (88141, 88142)

HCPCS (G0123, G0124)

7/14/2017

Lumason contrast agent

HCPCS (Q9950)

7/14/2017

Lung volume reduction surgery (reduction pneumoplasty)

CPT (32491)

HCPCS (G0302, G0303, G0304, G0305)

8/11/2017

Magnetic Mini Mover Procedure (3MP) for the treatment of pectus

excavatum

(See also Surgical Correction of Chest Wall Deformities)

CPT (No specific code)

10/13/2017

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)

SEE NOTE

2/9/2018

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

SEE NOTE

8/11/2017

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)

HCPCS (S8035)

7/17/2017

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.

3/10/2017

Mammography — digital

CPT (77065, 77066, 77067)

HCPCS (G0202, G0204, G0206 [del. 01/01/2018])

7/14/2017

Measurement of spirometric forced expiratory flows and lung volumes

for infants or children < 2yrs of age

CPT (94010, 94011, 94012, 94013)

8/11/2017

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])

10/13/2017

Meniett device for Ménière’s disease

CPT (69433)

HCPCS (E2120, A4638)

8/11/2017

Merci® Retriever/Merci® Retrieval System for ischemic stroke

CPT (No specific code)

8/11/2017

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)

10/13/2017

Microprocessor-controlled prosthetic knees (e.g., C-Leg/ Compact)

(See also Noridian Medicare Local Coverage Determination (LCD) —

Lower Limb Prostheses

HCPCS (L5856, L5857, L5858)

7/14/2017

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

death

CPT (93025)

7/14/2017

Microwave thermotherapy for chest wall recurrence of breast cancer

CPT ([0301T del. 01/01/2018], 19499)

8/11/2017

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)

9/8/2017

Molecular Intelligence (Caris Life Sciences) tumor profiling

(See also Gene Expression Profiling)

CPT (81599, 81479)

1/12/2018

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)

8/11/2017

MRI-guided focal laser ablation for prostate cancer

(E.g., Visualase Laser Ablation System)

CPT (No specific code)

8/11/2017

My5-FU™ (Saladax Biomedical) (formerly OnDose™ [Myriad]) for 5-

fluorouracil (5-FU) dosing guidance

(See also Gene Expression Profiling)

CPT ([84999, prior 01/01/2018], [81232, 81346 eff. 01/01/2018])

HCPCS (S3722)

9/8/2017

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)

8/11/2017

Nasal endoscopy, surgical; balloon dilation of eustachian tube

(E.g., ACCLARENT AERA™ Eustachian Tube Balloon Dilation System)

CPT (69799)

9/8/2017

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)

8/11/2017

Near-infrared spectroscopy studies of lower extremity wounds

(E.g., for oxyhemoglobin measurement)

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

8/11/2017

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)

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

case basis.

CPT (64575, 64580, 64585, 64590, 64595)

HCPCS (C1778, C1816, L8680, L8681, L8682, L8683, L8684, L8685, L8686,

L8687, L8688,L8689)

SEE NOTE

8/11/2017

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)

8/11/2017

Nerve blocks for primary or secondary headache

(E.g., cluster, migraine, cervicogenic [i.e., occipital neuralgia], posttraumatic, etc.)

(See also Pain Management)

CPT (64405)

1/12/2018

Neulasta® Onpro™ kit

CPT (96377)

1/19/2017

NeuraGen Nerve Guide and NeuraWrap Nerve Protector

CPT (64910, 64911)

8/11/2017

Neuroendocrine lab testing of saliva/urine for evaluating

neurotransmitters/hormones

CPT (No Specific Code)

2/9/2018

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)

8/11/2017

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)

1/12/2018

Noncontact normothermic wound therapy (e.g., Warm-Up®)

CPT (97610)

HCPCS (A6000, E0231, E0232)

8/11/2017

Noninvasive physiologic study of implanted wireless pressure sensor in

aneurysmal sac following endovascular repair, complete study

(E.g., Endosure Wireless Implantable System)

CPT (93982)

8/11/2017

Nonpenetrating deep sclerectomy

CPT (66999)

8/11/2017

Nuchal translucency screening in 1st trimester pregnancies

CPT (76813, 76814)

6/9/2017

Occipital nerve stimulation (ONS) /percutaneous electrical nerve

stimulation (PENS) for occipital neuralgia/cervicogenic headache

CPT (64999, 64555, 64575)

8/11/2017

Ocular — blood flow measurement

(See also Medicare Local Coverage Article: Ocular Blood Flow Tests)

CPT (0198T [by repetitive intraocular pressure sampling], 92499 [when

8/11/2017

used to report ocular flow measurement by other technique])

Ocular — intraocular pressure monitoring ≥ 24 hours

(E.g., SENSIMED Triggerfish®)

CPT (0329T)

8/11/2017

Ocular — intraocular tear film imaging

(E.g., Ophtha Vision Imaging System, Tearscope-Plus, LipiView®)

CPT (0330T)

8/11/2017

OncoVantage™ Solid Tumor Mutation Analysis (Quest)

(See also Gene Expression Profiling)

CPT (81445)

9/8/2017

OP-1™ implant (bone morphogenic protein 1) for recalcitrant long bone

non-union fractures

CPT (No specific code)

7/14/2017

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)

8/11/2017

Opioid antagonists under heavy sedation or general anesthesia as a

technique for opioid detoxification (ultra rapid detoxification [UROD])

CPT (No specific code)

HCPCS (H0047)

8/11/2017

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)

2/9/2018

Optical coherence tomography — intravascular, coronary native vessel or

graft, diagnostic evaluation and/or therapeutic intervention

(E.g., C7 Xr® Imaging System)

CPT (92978, 92978)

2/9/2018

Optical coherence tomography — middle ear, interpretation and report

CPT (0485T, 0486T eff. 01/01/2018)

12/12/2017

Oral appliance therapy for obstructive sleep apnea

(See also Obstructive Sleep Apnea Diagnosis and Treatment)

CPT (E0485, E0486)

2/9/2018

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)

8/11/2017

Osteochondral allografting of the talus

(See also Osteochondral Grafting)

CPT (28446)

1/12/2018

OV-Watch®/ovulation predictor kit

CPT/HCPCS (No specific code)

8/11/2017

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)

9/8/2017

Ovarian cancer — proteomic analysis testing

(E.g., OvaCheck™ [Quest Diagnostics]; OvaSure™ [withdrawn by LabCorp])

CPT (83789, 81503)

8/11/2017

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)

2/9/2018

Pancreatic islet cell transplantation for chronic pancreatitis

CPT (48160, 48550)

10/13/2017

Pancreatic islet cell transplantation for Type 1 diabetes

HCPCS (G0341, G0342, G0343)

8/11/2017

Percutaneous sacral augmentation (sacroplasty) (injection with balloon

or mechanical device)

CPT (0200T, 0201T)

8/11/2017

Percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis

(DVT)/pulmonary embolism (PE)

CPT (37187, 37188)

9/8/2017

Peripheral nerve blocks for diabetic neuropathy

(See also Medicare LCD: Peripheral Nerve Blocks)

8/11/2017

CPT (64400-64450)

Periurethral bulking agents for urinary incontinence

CPT (51715)

HCPCS (L8603, L8604, L8606)

5/12/2017

Pervenio™ Lung RS test (Life Technologies)

(See also Gene Expression Profiling)

CPT (84999)

8/11/2017

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)

SEE NOTE

8/11/2017

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)

1/12/2018

Pharmacogenetic testing — BRAF mutation analysis for the treatment of

unresectable or metastatic melanoma, metastatic colon cancer, non-

small 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)

10/13/2017

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)

2/9/2018

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)

8/11/2017

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])

(See also Epidermal Growth Factor Receptor Mutation Analysis for

Patients with Non-Small-Cell Lung Cancer)

CPT (81275, 81276, 81235, 81479)

1/12/2018

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)

7/14/2017

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)

8/11/2017

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)

8/11/2017

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)

8/11/2017

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])

8/11/2017

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)

8/11/2017

Pharmacogenetic testing — genotyping for CYP2C19 polymorphisms for

members who have been prescribed clopidogrel (Plavix)

Note: One allowable per lifetime

CPT (81225)

8/11/2017

Pharmacogenetic testing — genotyping for CYP2D6 polymorphisms for

members who have been prescribed doses of tetrabenazine (Xenazine) >

50 mg per day

8/11/2017

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)

Note: One allowable per lifetime

CPT (81226)

8/11/2017

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)

SEE NOTE

8/11/2017

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)

10/13/2017

Pharmacogenetic testing — HLA-B*5701 screening for members infected

with HIV-1 prior to commencing treatment with abacavir (Ziagen)

CPT (81381)

8/11/2017

Pharmacogenetic testing — HLA-B*1502 genotyping for members of

Asian ancestry prior to commencing treatment with carbamazepine

(Tegretol)

CPT (81381)

8/11/2017

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)

10/13/2017

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)

7/14/2017

Pharmacogenetic testing — MGMT (O(6)-methylguanine-DNA

7/14/2017

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)

(See also Keytruda® [pembrolizumab])

CPT (81301)

8/11/2017

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)

7/14/2017

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)

8/11/2017

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)

7/14/2017

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)

9/21/2017

Photodynamic Therapy — Visudyne® Ocular

CPT (67221, 67225)

HCPCS (J3396)

9/8/2017

Photoscreening (MTI Photoscreener™) for the detection of eye disorders

in children

CPT (99174, 99177)

7/14/2017

Photoselective vaporization of the prostate

(E.g., GreenLight PVP®)

CPT (52648)

7/14/2017

Phrenic nerve stimulation for central sleep apnea

8/11/2017

CPT (64575, 64590)

HCPCS (L8680, L8682, L8683)

Physical therapy post TMJ surgery

CPT (No specific code)

HCPCS (E1700, E1701, E1702)

7/14/2017

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)

2/9/2018

Plethysmography — cardiac (as part of enhanced external

counterpulsation)

CPT (No specific code)

7/14/2017

Plethysmography — lung (as an adjunct to pulmonary function testing)

NOTE: Total body plethysmography is appropriate for this indication.

CPT (94726, 94750)

7/14/2017

Plethysmography — penile (for cavernous nerve evaluation prior to

nerve-sparing prostatic or colorectal cancer procedures)

CPT (54240)

8/11/2017

Plethysmography (air-displacement) — total body for determining body

composition

CPT (94726, 94750)

7/14/2017

Pontocerebellar Hypoplasia Panel

CPT (81479)

2/9/2018

Procalcitonin (PCT) measurement

CPT (84145)

2/99/2018

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

SEE NOTE

7/14/2017

Positron emission tomography (PET)/magnetic resonance imaging (MRI)

— combined scanning

CPT (70540, 71550, 72195, 73218, 73718, 74181, 78812)

7/14/2017

Positron emission tomography (PET) — NaF-18 scan to identify bone

8/11/2017

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

CPT (88313, 88346, 88350, 88323, 88399)

7/14/2017

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)

5/12/2017

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)

9/8/2017

Praxis Extended RAS Panel (Illumina) next generation sequencing (NGS)

to determine Vetibix treatment eligibility for colorectal cancer patients

CPT (81311, 81275, 81276)

7/14/2017

Prolotherapy — all indications

(Aka proliferant therapy, proliferation therapy, joint sclerotherapy, or reconstructive

ligament therapy)

CPT (No specific code)

2/9/2018

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)

7/14/2017

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)

10/13/2017

Prophylactic mastectomy

5/12/2017

(See also Risk-Reduction Mastectomy)

CPT (19303, 19304)

Prophylactic (risk-reduction) oophorectomy

CPT (58940, 58661)

7/14/2017

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)

1/19/2017

Proove Opioid Risk Test (Proove Biosciences)

(See also Gene Expression Profiling)

CPT (81291, 81479)

9/8/2017

Prostatic artery embolization (PAE) for benign prostatic hypertrophy

(BPH)

CPT (53899, 37242, 75894)

1/12/2018

Prostatic urethral lift (PUL) implant for benign prostatic hypertrophy

(BPH)

(E.g., UroLift System)

(See also Medicare LCD: Prostatic Urethral Lift)

CPT (52441, 52442)

7/14/2017

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

7/14/2017

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)

SEE NOTE

8/11/2017

Proton beam (particle beam) therapy for various

(See also Stereotactic Radiosurgery and Proton Beam Therapy)

CPT (77520, 77522, 77523, 77525)

HCPCS (S8030)

1/12/2018

Proton beam (particle beam) therapy for prostate cancer

(See also Stereotactic Radiosurgery and Proton Beam Therapy

CPT (77520, 77522, 77523, 77525)

HCPCS (S8030)

1/12/2018

Pudendal nerve decompression surgery

CPT (64722)

8/11/2017

Pulmonary artery pressure monitoring — wireless

(E.g., CardioMEMS HF System)

CPT (No specific code)

8/11/2017

Quantitative pupillometry

(E.g., NPi™-100 Pupillometer, VIP™-200 Pupillometer)

CPT (0341T)

8/11/2017

Quantitative sensory testing (QST) to assess nerve fiber sensation

(multiple stimuli)

CPT (0106T, 0107T, 0108T, 0109T, 0110T)

8/11/2017

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)

9/21/2017

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)

8/11/2017

Radiofrequency — handheld radiofrequency spectroscopy for

intraoperative assessment of surgical margins during breast-conserving

surgery

(E.g. MarginProbe®)

CPT (19499)

HCPCS (A4649)

8/11/2017

Radiofrequency ablation — Barrett’s Esophagus

(E.g., BÂRRX System)

CPT (43229, 43270)

5/12/2017

Radiofrequency ablation — benign bone tumors

(See also Radiofrequency Ablation of Tumors)

CPT (20982)

5/12/2017

Radiofrequency ablation — cardiac (for atrial fibrillation)

7/14/2017

(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)

CPT (77003, 64635, 64636, 64633, 64634)

10/13/2017

Radiofrequency ablation — cooled/pulsed for sacroiliac joint pain

(See also Radiofrequency Ablation for Spinal Pain)

CPT (64999)

1/12/2018

Radiofrequency ablation — endometrial

CPT (58353, 58563, 58999)

7/14/2017

Radiofrequency ablation — fecal incontinence

(E.g., Secca® procedure)

(See also Fecal Incontinence Treatment)

CPT (46999)

HCPCS (L8699)

7/14/2017

Radiofrequency ablation — hepatic cancer

(See also Radiofrequency Ablation of Tumors)

CPT (47370, 47380, 47382, 76940, 77013, 77022)

5/12/2017

Radiofrequency ablation — lung cancer

(See also Radiofrequency Ablation of Tumors)

CPT (32998)

5/12/2017

Radiofrequency ablation — MRI-guided ultrasound/RFA ablation of

uterine fibroids

(E.g., Acessa™ System, ExAblate®, VizAblate®)

CPT (0071T, 0072T, 0404T, 58674)

8/11/2017

Radiofrequency ablation (coblation/microtenotomy) — plantar fasciitis

CPT (No specific code; possible codes: 28899, 64640, 29893)

8/11/2017

Radiofrequency ablation — renal cancer

(See also Cryosurgical and Radiofrequency Ablation for Renal Tumors)

CPT (50592)

6/9/2017

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)

1/12/2018

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

8/11/2017

(53860)

Remote real-time interactive video-conferenced critical care evaluation

and management

CPT (0188T, 0189T)

2/24/2017

Radiofrequency ablation — trigeminal neuralgia

CPT (64600, 64605, 64610)

7/14/2017

Radiofrequency ablation — varicosities

(See also Varicose Vein Treatment)

CPT (36475, 36476)

3/23/2017

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)

2/19/2018

Radiofrequency tissue volume reduction somnoplasty for upper airway

obstruction

(See also Obstructive Sleep Apnea Diagnosis and Treatment)

CPT (41530)

2/9/2018

Radiostereometric analysis

CPT (0347T, 0348T, 0349T, 0350T)

8/11/2017

Red blood cell long chain fatty acid chromatography analysis

CPT (0111T)

8/11/2017

Relizorb™ point-of-care digestive enzyme cartridge

(Aka enteral feeding in-line cartridge [EFIC])

HCPCS (B9998)

2/9/2018

ReShape® Integrated Dual Balloon System for obesity

(See also Bariatric Surgery)

CPT (No specific code)

3/10/2017

Rhinomanometry/acoustic rhinometry

CPT (92512)

8/11/2017

Rhizotomy (dorsal) for spastic cerebral palsy

(See also Selective Dorsal Rhizotomy for Cerebral Palsy)

CPT (63185, 63190)

7/14/2017

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.

7/14/2017

Retinal polarization scan, ocular screening with on-site automated

results, bilateral

(CPT 0469T [new eff. 07/01/17])

7/14/2017

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.

7/14/2017

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.

7/14/2017

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.

7/14/2017

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.

7/14/2017

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.

7/14/2017

Sacral nerve stimulators for fecal incontinence, urinary urge

7/14/2017

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.

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)

2/9/2018

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)

8/11/2017

Sclera fistulization for glaucoma

CPT (66999)

8/11/2017

Sclerotherapy for esophageal varices

CPT (43204, 43243)

7/14/2017

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)

3/23/2017

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)

4/21/2017

Selective internal radiation therapy (SIRT) for primary hepatocellular

carcinoma, hepatoma or metastatic liver tumors

SIR-Spheres®

CPT (37243, 75894, 79445, 77778)

9/8/2017

SelectMDx for prostate cancer (MDxHealth Inc.)

(See also Gene Expression Profiling)

CPT (81479)

8/11/2017

Sentinel lymph node biopsy for breast cancer

CPT (38792, 38500, 38525, 38530, 78195)

7/14/2017

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.

7/14/2017

Serum markers for liver disease

(E.g., ASH FibroSURE™, FibroMAX™, FIBROSpect II®, HCV FibroSURE™ [Quest], FibroTest +

ActiTest, HepaScore™, NASH FibroSURE™)

CPT (No specific code)

7/14/2017

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)

8/11/2017

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)

2/9/2018

Sleeve gastrectomy

(See also Bariatric Surgery)

CPT (43775)

3/10/2017

SpaceOar System — rectal protection from radiation therapy for prostate

cancer

CPT (45999)

HCPCS (A4649)

8/11/2017

Spectroscopy — intravascular catheter-based coronary vessel or graft

(E.g., infrared)

CPT (0205T)

8/11/2017

Spectroscopy — multi-wavelength fluorescent measurement of advanced

glycation products (AGE) to replace skin biopsy for risk assessment

CPT (88749)

8/11/2017

Spectroscopy — real time spectral analysis of prostate tissue by

fluorescence spectroscopy

(E.g., Precision Biopsy ClariCore Optical Biopsy System®)

CPT (0443T)

2/9/2018

Speculoscopy for the screening or diagnosis of cervical cancer

(Aka cervicography; e.g., PapSure®)

2/9/2018

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)

Note: CPT 22858 is covered for Medicaid only

9/8/2017

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)

9/8/2017

Spinal — cervical traction (e.g., freestanding over-the-door mechanism or

attached to headboard)

HCPCS (E0840, E0849, E0850)

7/14/2017

Spinal — continuous or intermittent traction for low back pain

HCPCS (E0830)

7/14/2017

Spinal — dynamic spinal visualization (including

cineradiography/videoradiography)

CPT (76120, 76125)

8/11/2017

Spinal — endoscopy (epiduroscopy)

(See also “Spinal minimally invasive” below)

CPT ([20939 eff. 01/01/2018], 64999)

8/11/2017

Spinal — interspinous distraction devices

(E.g. X-Stop® Interspinous Process Decompression System)

CPT (22867, 22868, 22869, 22870)

5/12/2017

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)

3/10/2017

Spinal — intrafacet implant(s), single/multi-level (inclusive of imaging

and bone graft/device placement)

(E.g., NuFix, TruFUSE®)

CPT (0219T, 0220T, 0221T, 0222T)

8/11/2017

Spinal — lumbar fusion

(See also Lumbar Fusion and Intervertebral Fusion Devices for covered

fusion procedures and covered CPT coding)

SEE NOTE

3/10/2017

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)

CPT (62290, 72295)

7/14/2017

Spinal — manipulation under anesthesia for acute spinal injury

(E.g., vertebral fracture, complete dislocation or acute traumatic incomplete dislocation

[subluxation])

CPT (22505, 00640)

7/14/2017

Spinal — manipulation under anesthesia when services rendered by a

chiropractor

CPT (22505, 00640)

8/11/2017

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 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.

 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)

8/11/2017

Spinal — sacroiliac joint (SIJ) fusion (open)

CPT (27280, 27299)

6/9/2017

Spinal — sacroiliac joint (SIJ) fusion (minimally invasive)

(E.g., iFuse Implant System® [SI-BONE])

CPT (27279)

6/9/2017

Spinal — vertebral axial decompression devices/mechanical spinal

8/11/2017

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)

8/11/2017

Spinal — vertebroplasty

CPT (22510, 22511, 22512, 22513, 22514, 22515)

7/14/2017

SPOT-Light® HER2 CISH™ Kit for breast cancer to determine Herceptin®

treatment candidacy

(See also Genetic Counseling and Testing)

CPT (88368)

3/10/2017

ST2 Assay as a prognostic indicator for acute dyspnea and acute or

chronic heart failure

CPT (83520)

8/11/2017

Stereotactic placement of infusion catheter(s) in the brain for delivery of

therapeutic agent(s)

CPT (64999)

8/11/2017

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)

1/12/2018

Subfascial endoscopic perforator surgery for chronic venous insufficiency

(SEPS)

(See also Varicose Vein Treatment)

CPT (37500)

3/23/2017

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)

2/9/2018

Sural nerve graft with radical prostatectomy

CPT (64999, 55840, 55842, 55845)

8/11/2017

Surface electromyography for the evaluation of segmental spinal joint

dysfunction and muscle tone

CPT (96002, 96004)

HCPCS (S3900)

8/11/2017

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

8/11/2017

neuropathy syndromes due to insufficient evidence of therapeutic value.

Sympathectomy/ endoscopic thoracic sympathectomy for hyperhidrosis

CPT (32664)

5/12/2017

Target Now™ molecular profiling test

(Aka MI Profile, MI Profile X)

(See also Gene Expression Profiling)

CPT (88360, 88368, 81599)

9/8/2017

Tear osmolarity measurement for the dry eye diagnosis (e.g., TearLab®

Osmolarity System)

CPT (83861)

7/14/2017

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)

8/11/2017

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)

8/11/2017

Thermography (indications other than breast)

CPT (93740)

8/11/2017

Thermography — breast

(See also FDA Consumer Posting — Breast Cancer Screening: Thermogram

No Substitute for Mammogram)

CPT (No specific code)

10/27/2017

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)

8/11/2017

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)

2/9/2018

TOP2A FISH (topoisomerase II Alpha) pharmDX (Dako Agilent

Technologies company) for breast cancer prognosis

(See also Genetic Counseling and Testing)

CPT (88365, 88368)

3/10/2017

Topical oxygen wound therapy (TOWT) (aka continuous diffusion of

9/8/2017

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-of-

Heterozygosity Based Topographic Genotyping with PathfinderTG ®)

CPT (81479)

9/8/2017

Total ankle replacement

(E.g., Scandinavian Total Ankle Replacement System [STAR Ankle] or any other FDA-

approved device)

CPT (27702, 27703)

9/8/2017

Trabeculectomy for glaucoma (ab externo)

(See also Glaucoma Surgery)

CPT (65820, 66170, 66172)

5/12/2017

Trabectome® for glaucoma (ab interno)

(See also Glaucoma Surgery)

CPT (65820, 65850, 66999)

5/12/2017

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])

SEE NOTE

5/12/2017

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)

6/9/2017

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.

8/11/2017

Transendoscopic therapies for dysphagia and gastrointestinal reflux

8/11/2017

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)

7/14/2017

Transilluminated powered phlebectomy (TriVex System) for varicosities

(See also Varicose Vein Treatment)

CPT (No specific code)

3/23/2017

Transmyocardial revascularization

CPT (33140, 33141)

7/14/2017

Transperineal implantation of permanent adjustable balloon

continence device, with cystourethroscopy, when performed

and/or fluoroscopy, when performed

CPT (No specific code)

9/8/2017

Tranpupillary thermotherapy for retinoblastoma

CPT (67299)

1/19/2017

Transtelephonic spirometry for monitoring pulmonary function following

lung or heart-lung transplantation. CPT (94014, 94015, 94016)

8/11/2017

Transurethral microwave thermotherapy

CPT (53850)

7/14/2017

Transurethral needle ablation of the prostate

CPT (53852)

7/14/2017

Transvascular Autonomic Modulation (TVAM) for the treatment of

autonomic dysfunction using balloon angioplasty devices

(See also FDA MedWatch Safety Alert)

CPT (No specific code)

3/10/2017

Tremor analysis device

(E.g., Physiologic recording of tremor using accelerometers)

CPT (95999)

8/11/2017

Triggerfish® System for continuous intraocular pressure monitoring for

glaucoma (Sensimed)

CPT (0329T)

6/9/2017

Tropism testing for HIV

(E.g., Trofile™ co-receptor assay for HIV [Monogram Biosciences], HIV-1 Coreceptor Tropism

Testing [Quest Diagnostics]

10/13/2017

(See also Genetic Counseling and Testing)

CPT (No specific code)

Ultrasound — intravascular noncoronary vessel

CPT (37252, 37253)

7/14/2017

Ultrasound — low frequency for wounds

(E.g., MIST Therapy System)

CPT (97610)

8/11/2017

Ultrasound — obstetric

(See also Obstetric Ultrasonography for coding and criteria)

11/10/2017

Ultrasound-guided ligation of hemorrhoidal vascular bundle(s)

CPT (0249T)

8/11/2017

Ultrasound-guided spinal injection(s), single/multilevel),

diagnostic/therapeutic agent

(See also Pain Management)

CPT (0213T, 0214T, 0215T)

1/12/2018

Unicondylar interpositional spacer

(E.g., UniSpacer™ Knee System)

CPT (No specific code)

8/11/2017

Urine cytology for bladder cancer screening or as a primary detection

modality (without cystoscopy)

(E.g., UroVysion™)

CPT (88112, 88120, 88121)

8/11/2017

Uterine artery embolization for symptomatic fibroids

CPT (37243)

7/8/2017

Vacuum-Assisted Socket System™ for artificial limbs

HCPCS (L5781, L5782)

7/14/2017

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)

2/9/2018

Vacuum bell for treatment of pectus excavatum

(See also Surgical Correction of Chest Wall Deformities)

CPT (No specific code)

10/13/2017

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)

SEE NOTE

07/14/2017

Vagus nerve stimulation — epilepsy

5/12/2017

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.)

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)

2/9/2018

Venoplasty for relapsing remitting multiple sclerosis

CPT (36901, 36902, 36903, 36904, 36905, 36906)

8/11/2017

VerifyNow™ Aspirin Plus Assay (point-of-care platelet aggregation device)

(Accumetrics)

CPT (85576)

8/11/2017

VeriStrat® proteomic expression profiling for non-small cell lung cancer

treatment (Biodesix)

(See also Medicare Coverage Article: Biomarkers for Oncology)

CPT (84999, 81538)

7/14/2017

Vertical expandable prosthetic titanium rib

(See also Vertical Expandable Prosthetic Titanium Rib [VEPTR])

CPT (No specific code)

3/10/2017

Viadur® (leuprolide acetate implant) for advanced prostate cancer

CPT (11981, 11982, 11983)

HCPCS (J9219)

7/14/2017

Virtual colonoscopy

CPT codes ([74261, 74262 for diagnostic], [74263 for screening])

1/12/2018

Viscocanalostomy

(See also Canaloplasty and Viscocanalostomy)

CPT (66174, 66175)

4/21/2017

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)

CPT (0464T)

7/14/2017

Visual field assessment — real time, remote surveillance data

transmission

(E.g., ForeseeHome™ AMD Monitoring Program)

CPT (0378T, 0379T)

8/11/2017

Vitamin D Deficiency Testing

(See Vitamin D Deficiency Testing for coding)

6/26/2017

Water-induced thermotherapy

CPT (55899)

7/14/2017

Waterjet ablation — prostate, transurethral

(E.g. PROCEPT Aquablation™ System)

CPT (0421T)

8/11/2017

Wireless Esophageal pH Monitoring (Bravo™ System)

CPT (91035)

7/14/2017

Xofigo® (radium Ra 223 dichloride injection)

CPT (79101)

HCPCS (A9606)

1/12/2018

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])

U400 Med Tech Database1

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