Prominence Health Plan: Cardiology CPT Code List

Transcription

1 CID Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial CID Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular CID Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular CID Insertion of pacemaker pulse generator only; with existing single lead CID Insertion of pacemaker pulse generator only; with existing dual leads CID Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new generator) CID Insertion of pacemaker pulse generator only; with existing multiple leads CID Prominence Health Plan: Cardiology CPT Code List Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) CID Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket revision) (list separately in addition to code for primary procedure) CID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system CID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system CID Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system CID Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads Updated: 4/8/2018

2 CID Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads CID Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead CID Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber CID Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; single lead system CID Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; dual lead system CID Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator; multiple lead system CID Implantation of heart valve (pulmonary) to lungs, accessed through the skin MRI M R I T M J CT C T Head Without Contrast CT C T Head With Contrast CT C T Head Without & With Contrast CT C T Orbit Without Contrast CT C T Orbit With Contrast CT C T Orbit Without & With Contrast CT C T Maxillofacial Without Contrast CT C T Maxillofacial With Contrast CT C T Maxillofacial Without & With Contrast CT C T Soft Tissue Neck Without Contrast CT C T Soft Tissue Neck With Contrast CT C T Soft Tissue Neck Without & With Contrast CT C T Angiography Head CT C T Angiography Neck MRI M R I Orbit, Face,Neck and/or Without Contrast MRI M R I Face, Orbit, Neck With Contrast MRI M R I Face, Orbit, Neck With & Without Contrast MRA M R A Head Without Contrast MRA M R A Head With Contrast MRA M R A Head With & Without Contrast MRA M R A Neck Without Contrast Updated: 4/8/2018

3 MRA M R A Neck With Contrast MRA M R A Neck With & Without Contrast MRI M R I Head Without Contrast MRI M R I Head With Contrast MRI M R I Head With & Without Contrast MRI MRI Brain, functional MRI MRI MRI Brain, functional MRI, requiring physician CT C T Thorax Without Contrast CT C T Thorax With Contrast CT C T Thorax Without & With Contrast CT C T Angiography Chest Without Contrast Material, Followed by Contrast Material and Further Sections,Including Image Postprocessing MRI M R I Chest Without Contrast MRI M R I Chest With Contrast MRI M R I Chest With & Without Contrast MRA M R A Chest (Excluding Myocardium) With Or Without Contrast CT C T Cervical Spine Without Contrast CT C T Cervical Spine With Contrast CT C T Cervical Spine Without & With Contrast CT C T Thoracic Spine Without Contrast CT C T Thoracic Spine With Contrast CT C T Thoracic Spine Without & With Contrast CT C T Lumbar Spine Without Contrast CT C T Lumbar Spine With Contrast CT C T Lumbar Spine Without & With Contrast MRI M R I Cervical Spine Without Contrast MRI M R I Cervical Spine With Contrast MRI M R I Thoracic Spine Without Contrast MRI M R I Thoracic Spine With Contrast MRI M R I Lumbar Spine Without Contrast MRI M R I Lumbar Spine With Contrast MRI M R I Cervical Spine With & Without Contrast MRI M R I Thoracic Spine With & Without Contrast Updated: 4/8/2018

4 MRI M R I Lumbar Spine With & Without Contrast MRA M R A Spinal Canal With Or Without Contrast CT C T Angiography Pelvis CT C T Pelvis Without Contrast CT C T Pelvis With Contrast CT C T Pelvis Without & With Contrast MRI M R I Pelvis Without Contrast MRI M R I Pelvis With Contrast MRI M R I Pelvis With & Without Contrast MRA M R A Pelvis With Or Without Contrast CT C T Upper Extremity Without Contrast CT C T Upper Extremity With Contrast CT C T Upper Extremity Without & With Contrast CT C T Angiography Upper Extremity MRI M R I Upper Extremity Without Contrast MRI M R I Upper Extremity With Contrast MRI M R I Upper Extremity With & Without Contrast MRI M R I Upper Extremity Joint Without Contrast MRI M R I Upper Extremity Joint With Contrast MRI M R I Upper Extremity Joint With & Without Contrast MRA M R A Upper Extremity With Or Without Contrast CT C T Lower Extremity Without Contrast CT C T Lower Extremity With Contrast CT C T Lower Extremity Without & With Contrast CT C T Angiography Lower Extremity MRI M R I Lower Extremity Without Contrast MRI M R I Lower Extremity With Contrast MRI M R I Lower Extremity With & Without Contrast MRI M R I Lower Extremity Joint Without Contrast MRI M R I Lower Extremity Joint With Contrast MRI M R I Lower Extremity Joint With & Without Contrast MRA M R A Lower Extremity With Or Without Contrast CT C T Abdomen Without Contrast Updated: 4/8/2018

5 CT C T Abdomen With Contrast CT C T Abdomen Without & With Contrast CT CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT C T Angiography Abdomen CT C T Abdomen And Pelvis Without Contrast CT CT Abdomen And Pelvis With Contrast CT Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(S) And Further Sections In One Or Both Body Regions MRI M R I Abdomen Without Contrast MRI M R I Abdomen With Contrast MRI M R I Abdomen With & Without Contrast MRA M R A Abdomen With Or Without Contrast CT Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material CT Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed CT Computed tomographic (CT) colonography, screening, including image postprocessing MRI Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation MRI Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) CMRI Cardiac magnetic resonance imaging for morphology and function without contrast material CMRI CMRI CMRI CMRI Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging Cardiac magnetic resonance imaging for velocity flow mapping (list separately in addition to code for primary procedure) Updated: 4/8/2018

6 CCTA Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium CCTA Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3d image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) CCTA Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3d image postprocessing, assessment of lv cardiac function, rv structure and function and evaluation of venous structures, if performed) CCTA Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3d image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT C T Angiography Abdominal Aorta 3DI D Rendering W/O Postprocessing 3DI D Rendering W Postprocessing CT C T Limited Or Localized Follow-Up Study MRI M R I Spectroscopy CT Unlisted computed tomography procedure MRI Unlisted MRI Procedure DGUS Us Echoencephalography DGUS Us Soft Tissue Head And Neck DGUS Us Chest Real Time With Image Documentation DGUS Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete DGUS Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited DGUS Ultrasound Abdominal Real Time With Image Documentation DGUS U/S Single Organ DGUS Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) DGUS Ultrasound,Retroperotonral,Real Time With Image Documentation;Complete DGUS Us Echo Limited Updated: 4/8/2018

7 DGUS Ultrasound, Transplanted Kidney, Real Time And Duplex Doppler With Image Documentation DGUS Us Echo Spinal Canal OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Single Or First Gestation OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, First Trimester less than 14 Weeks Each Additional Gestation OB-US Ultrasound Obstetrical Pelvis, Pregnant Uterus, B-Scan OB-US Ultrasound Obstetrical Pelvis Complete, Multiple Gestation After 1st Trimester OB-US Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Single Or First Gestation OB-US Ultrasound Pregnant Uterus Fetal & Maternal Evaluation Plus Fetal Anatomic Evaluation Transabdominal Each Additional Gestation OB-US Ultrasound, pregnant uterus, real time with image documentation OB-US Ultrasound, pregnant uterus, real time with image documentation OB-US Ultrasound Obstetrical Pelvis Limited (Gestational Age, Heart Beat, Emergency) OB-US Ultrasound Obstetrical Pelvis Follow Up Or Repeat OB-US Ultrasound Pregnant Uterus Transvaginal OB-US Fetal Biophysical Profile OB-US Fetal Biophysical Profile Without Stress Non Stress OB-US Doppler Velocimetry, Fetal; Umbilical Artery OB-US Doppler Velocimetry, Fetal; Middle Cerebral Artery OB-US Ultrasound Obstetrical Echocardiography, Fetal, Cardiovascular System OB-US Follow Up Or Repeat Study OB-US Doppler Echocardiography Fetal Complete OB-US Follow Up Or Repeat Study DGUS U/S Transvaginal DGUS Hysterosonography W Or W/O Col DGUS Ultrasound Pelcic Real Time With Image Documentation;Complete DGUS Us Pel Lim Or F/U DGUS Us Echo Scrotum DGUS U/S Transrectal DGUS Ultrasound, complete joint (i.e., joint space and peri-articular soft tissue structures) real-time with image documentation Updated: 4/8/2018

8 DGUS Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g., joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation DGUS Us Echo, Infant Hips Realtime DGUS Us,Infant Hips,Real Time;Limited, Static DGUS Us Study Follow Up DGUS Ultrasound Gastrointestinal, Endoscopic DGUS Echo Examination Procedure CT Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation CT Ct Guide Plcmnt Radiation MRI M R I Guidance For Needle Placement MRI Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation BMRI M R I Breast With And/Or Without Contrast BMRI M R I Breast Bilateral CT Computed Tomography, bone mineral density study, 1 or more sites; axial skeleton MRI Magnetic resonance (eg, proton) imaging, bone marrow blood supply NUC MED Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) NUC MED Thyroid imaging (including vascular flow, when performed) NUC MED Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) NUC MED Thyroid Met Imaging NUC MED Thyroid Met Imaging With Additional Studies NUC MED Thyroid Scan Whole Body NUC MED Thyroid Carcinoma Metastases Uptake NUC MED Parathyroid planar imaging (including subtraction, when performed) NUC MED Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) NUC MED NUC MED Adrenal Nuclear Imaging Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization Updated: 4/8/2018

9 NUC MED Bone Marrow Imaging, Limited NUC MED Bone Marrow Imaging, Multiple NUC MED Bone Marrow Imaging, Whole Body NUC MED Labeled Red Cell Sequestration NUC MED Spleen Imaging With & Without Vascular Flow NUC MED Lymph System Imaging NUC MED Liver Imaging NUC MED Liver Imaging With Flow NUC MED Liver Imaging SPECT (3D) NUC MED Liver Imaging SPECT With Vasulcar Flow NUC MED Liver & Spleen Imaging NUC MED Liver & Spleen Imaging With Flow NUC MED Hepatobiliary system imaging, including gallbladder when present; NUC MED Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed NUC MED Salivary Gland Imaging NUC MED Serial Salivary Gland NUC MED Salivary Gland Function Exam NUC MED Esophogus Motility Study NUC MED Gastric Mucosa Imaging NUC MED Gastroesophageal Reflux Exam NUC MED Gastric Emptying Study NUC MED Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit NUC MED Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days NUC MED GI Bleeder Scan NUC MED Meckels Diverticulum Imaging NUC MED Leveen Shunt Patency Exam NUC MED Bone Or Joint Imaging Limited NUC MED Bone Or Joint Imaging Multiple NUC MED Bone Scan Whole Body NUC MED Bone Scan 3 Phase Study NUC MED Bone Joint Imaging Tomo Test SPECT Updated: 4/8/2018

10 NUC MED Non-Imaging Heart Function NUC MED Cardiac Shunt Imaging NUC MED Radionuclide Venogram Non-Cardiac NUC CARD myocardial perfusion imaging, tomographic (spect) including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) NUC CARD NUC CARD NUC CARD Myocardial perfusion imaging, tomographic (spect) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection NUC MED Venous Thrombosis Imaging Unilateral NUC MED Venous Thrombosis Images, Bilateral CPET Myocardial imaging, positron emission tomography (pet), metabolic evaluation NUC MED Myocardial Infarction Scan NUC MED Heart Infarct Image Ejection Fraction NUC MED Heart Infarct Image 3D SPECT NUC MED Cardiac Bloodpool Img, Single NUC MED Cardiac Bloodpool Img, Multi NUC MED Heart First Pass Single NUC MED Cardiac Blood Pool Imaging -- Multiple CPET Myocardial imaging, positron emission tomography (pet), perfusion; single study at rest or stress CPET Myocardial imaging, positron emission tomography (pet), perfusion; multiple studies at rest and/or stress NUC MED Cardiac Blood Pool Imaging, SPECT NUC MED Cardiac Blood Pool Imaging - Single Rest Updated: 4/8/2018

11 NUC MED Unlisted Cardiovascular Procedure NUC MED Pulmonary ventilation imaging (eg, aerosol or gas) NUC MED Pulmonary perfusion imaging (eg, particulate) NUC MED Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging NUC MED Pulmonary Perfusion With Washout With Or Without Single Breath NUC MED Quantitative differential pulmonary perfusion, including imaging when performed NUC MED Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed NUC MED Brain Imaging Limited Static NUC MED Brain Limited Imaging And Flow NUC MED Brain Imaging Complete NUC MED Brain Imaging Complete With Flow NUC MED Brain Imaging 3D PET Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation PET Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation NUC MED Brain Flow Imaging Only NUC MED Cisternogram (Cerebrospinal Fluid Flow) NUC MED Cerebrospinal Ventriculography NUC MED CSF Shunt Evaluation NUC MED Cerebrospinal Fluid Scan (Tomographic) SPECT NUC MED C S F Leakage Detection And Localization NUC MED Radiopharmaceutical Dacryocystography Unlisted Unlisted Nuclear Medicine Procedure NUC MED Kidney Imaging Morphology NUC MED Kidney Imaging With Vascular Flow NUC MED Kidney Imaging With Vascular Flow & Function Single Study Without Pharmacological Intervention NUC MED Kidney Imaging Single Study With Pharmacological Intervention NUC MED Kidney Imaging - Multiple Studies Without & With Pharmacological Intervention NUC MED Kidney Imaging - Tomographic (SPECT) NUC MED Kidney Function Study - Non-Imaging Radioisotopic NUC MED Urinary Bladder Residual Study NUC MED Ureteral Reflux Study Updated: 4/8/2018

12 NUC MED Testicular Imaging With Vascular Flow NUC MED Radiopharm Localization Of Tumor, Limited Area NUC MED Radiopharm Localization Of Tumor, Multiple Areas NUC MED Radiopharm Localization Of Tumor, Whole Body NUC MED Radiopharm Localization Of Tumor Tomographic (SPECT) NUC MED Radiopharm Localization Of Tumor, Whole Body NUC MED Radiopharm Localization Of Abscess, Limited Area NUC MED Radiopharm Localization Of Abscess, Whole Body NUC MED Radiopharm Localization Of Abscess, Tomographic SPECT PET Tumor Imaging, Positron Emission Tomography (Pet); Limited Area (Eg, Chest, Head/Neck) PET Tumor Imaging, Positron Emission Tomography (Pet); Skull Base To Mid-Thigh PET Positron Emission Tomography (Pet); Whole Body PETCT Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Limited Area (Eg Chest, Head/Neck) PETCT PETCT Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Skull Base To Mid-Thigh Tumor Imaging, Positron Emission Tomography (Pet) With Concurrently Acquired Computer Tomography (Ct) For Attenuation Correction And Anatomical Localization; Whole Body ECHO Transthoracic echocardiography for congenital cardiac anomalies; complete ECHO Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study ECHO Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography ECHO Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; complete ECHO Echocardiography, transthoracic, real-time with image documentation (2d) with or without m-mode recording; follow-up or limited study ECHO TEE 2D;Incl Probe Placement, Imaging/Interp/Report Updated: 4/8/2018

13 ECHO Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M- mode recording); placement of transesophageal probe only ECHO Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M- mode recording); image acquisition, interpretation and report only ECHO Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report ECHO Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only ECHO Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only ECHO Echo transesophageal intraop ECHO Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete ECHO Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study ECHO Doppler echocardiography color flow velocity mapping XSE XSE XSE DHC DHC DHC DHC Echocardiography, transthoracic, real-time with image documentation (2d), with or without m-mode recording, during rest and cardiovascular stress test, with interpretation and report Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure) RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation Updated: 4/8/2018

14 DHC Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography DHC Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization DHC Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization DHC DHC DHC Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed DHC Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography DHC Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure) DHC RIGHT HEART CATHETERIZATION (CHD) DHC RIGHT/LEFT HEART CATHETERIZATION (CHD) DHC RIGHT/LEFT HEART CATHETERIZATION (CHD-TS) Updated: 4/8/2018

15 DHC RIGHT/LEFT HEART CATHETERIZATION (CAD-ASD) DGUS Duplex Scan Extracranial Arter DGUS Duplex Scan Extracranial Arter DGUS Transcranial Doppler Study Int DGUS Transcranial Doppler Study Int DGUS Transcranial Doppler Vasoreactivity Study DGUS Transcranial Doppler Study Of The Intracranial Arteries; Emboli Detection Without Intravenous Microbubble Injection DGUS Transcranial Doppler Study Of The Intracranial Arteries; Emboli Detection With Intravenous Microbubble Injection DGUS Non-Invasive Physiologic Studi DGUS Non-Invasive Physiologic Studi DGUS Non-Invasive Physiologic Studi DGUS Duplex Scan Low Ext. Art. Or A DGUS Duplex Scan Low Ext. Art. Or A DGUS Duplex Scan Up Ext. Art. Or Ar DGUS Duplex Scan Up Ext. Art. Or Ar DGUS Duplex Scan Ext. Veins, Comple DGUS Duplex Scan Ext. Veins, Unilat DGUS Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study DGUS Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study DGUS Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study DGUS Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; cunilateral or limited study DGUS Duplex scan of arterial inflow and venous outflow of penile vessels; complete study DGUS Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study DGUS Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) DGUS Unlisted Noninvasive Vascular Diagnostic Study CT 0042T CT Perfusion Brain Updated: 4/8/2018

16 Computer-aided detection, including computer algorithm analysis of MRI image data for lesion CT 0159T detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) CID 0319T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode CID 0387T Implantation or replacement of permanent ventricular pacemaker CID 0388T Removal of permanent ventricular pacemaker NUC CARD 0399T Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics) (List separately in addition to code for primary procedure) CPET CCTA CCTA CCTA CCTA 0482T 0501T 0502T 0503T 0504T Absolute quantitation of myocardial blood flow, positron emission tomography (PET), rest and stress (List separately in addition to code for primary procedure) Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordantdata, interpretation and report Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report MRA C8900 MRA Abdomen with contrast Updated: 4/8/2018

17 MRA C8901 MRA Abdomen without contrast MRA C8902 MRA Abdomen with and w/o contrast MRI C8903 MRI Breast w/ contrast, unilateral MRI C8904 MRI Breast w/o contrast, unilateral MRI C8905 MRI Breast w. and w/o contrast, unilateral MRI C8906 MRI Breast Bilateral W/ Contrast MRI C8907 MRI Breast Bilateral W/O Contrast MRI C8908 MRI Breast Bilateral W/ And W/O Contrast MRA C8909 MRA chest w/contrast (excluding myocardium) MRA C8910 MRA chest w/o contrast (excluding myocardium) MRA C8911 MRA chest (excluding myocardium) MRA C8912 MRA lower extremity w/ contrast MRA C8913 MRA lower extremity w/o contrast MRA C8914 MRA lower extremity w/ and w/o contrast MRA C8918 MRA pelvis w/ contrast MRA C8919 MRA pelvis w/o contrast MRA C8920 MRA pelvis w/ and w/o contrast ECHO C8921 Transthoracic echocardiography w/contrast for congenital cardiac anomalies; complete ECHO C8922 Transthoracic echocardiography w/contrast for congenital cardiac anomalies; f/u or limited study ECHO ECHO ECHO ECHO C8923 C8924 C8928 C8929 Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording; complete Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording; f/u or limited study Transthoracic echocardiography w/contrast, real-time w/image documentation (2d), w/wo m-mode recording, during rest and cardiovascular stress test, w/interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, realtime with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Updated: 4/8/2018

18 ECHO C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, realtime with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision MRA C8931 MRA, W/Dye, Spinal Canal MRA C8932 MRA, W/O Dye, Spinal Canal MRA C8933 MRA, W/O&W/Dye, Spinal Canal MRA C8934 MRA, W/Dye, Upper Extremity MRA C8935 MRA, W/O Dye, Upper Extr MRA C8936 MRA, W/O&W/Dye, Upper Extr DGUS C9744 ULTRASOUND, ABDOMINAL, WITH CONTRAST PET G0219 Pet Imaging Whole Body; Melanoma For Non-Covered Indications PET G0235 Pet Imaging, Any Site, Not Otherwise Specified PET G0252 Pet Imaging, Full And Partial-Ring Pet Scanners Only For Initial Diagnosis Of Breast Cancer And/Or Surgical Planning For Breast Cancer CT G0297 Low-dose Computed Tomography For Lung Cancer Screening DGUS G0389 Ultrasound B-Scan And/Or Real Time With Image Documentation; For Abdominal Aortic Aneurysm (Aaa) Screening CT S8032 Low-dose Computed Tomography For Lung Cancer Screening MRI S8037 Magnetic resonance cholangiopancreato-graphy (MRCP) MRI S8042 Magnetic Resonance Imaging (Mri), Low-Field CT S8080 Scintimammography (Radioimmunoscintigraphy Of The Breast), Unilateral, Including Supply Of Radiopharmaceutical PET S8085 Fluorine-18 Fluorodeoxyglucose (F-18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non-Dedicated Pet Scan) CT S8092 Electron Beam Computed Tomography (Also Known As Ultrafast Ct, Cinet) Cardiology NON-INVASIVE PHSIOLOGIC STUDI Ultrasound 0439T Myocardial Perfusion Echo CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Updated: 4/8/2018

19 Product CPT Code CPT Code Description Requires PA Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Prominence Health Plan: Lab CPT Code List BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) Laboratory BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant Laboratory BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis Laboratory BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant Laboratory Laboratory Laboratory CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence CP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) Updated: 6/20/2018 Effective: 7/1/2018

20 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Laboratory Laboratory Laboratory CP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (eg, bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis) Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities Laboratory CP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) Laboratory CP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) Laboratory DPD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) Laboratory F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence Laboratory G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence Laboratory HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) Laboratory HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence Laboratory HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants Laboratory IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs variant Updated: 6/20/2018 Effective: 7/1/2018

21 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis Laboratory MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) Laboratory MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis Laboratory MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants Laboratory MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis Laboratory MSH2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants Laboratory MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis Laboratory MSH6 (muts homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants Laboratory PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) Laboratory PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis Laboratory PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants Laboratory PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis Laboratory PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant Laboratory PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis Laboratory SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis Updated: 6/20/2018 Effective: 7/1/2018

22 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) Laboratory TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) Laboratory TMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) Laboratory VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -1639G>A, c c>t) Laboratory HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) Laboratory HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) Laboratory HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence Laboratory Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) Laboratory Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) Laboratory Molecular pathology procedure, Level 3 Laboratory Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Laboratory Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/ deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) Laboratory Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of exons, regionally targeted cytogenomic array analysis) Updated: 6/20/2018 Effective: 7/1/2018

23 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Molecular pathology procedure, Level 7 (eg, analysis of exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of exons, cytogenomic array analysis for neoplasia) Laboratory Molecular pathology procedure, Level 8 Laboratory Molecular pathology procedure, Level 9 Laboratory Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MH11, ACTA2, SLC2A10, SMAD3, and MLK Laboratory Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MH11, and COL3A1 Laboratory Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1 Laboratory Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RR2, and SCN5A Laboratory Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 Laboratory Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Laboratory Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for primary procedure) Updated: 6/20/2018 Effective: 7/1/2018

24 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) Laboratory Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), cirulating cell-free fetal DNA in maternal blood Laboratory Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis Laboratory Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure) Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome) Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MO7A, MO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, alwaysincluding BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, ES, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A Updated: 6/20/2018 Effective: 7/1/2018

25 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTH, PTEN, SMAD4, and STK11 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes, (eg, DSG2, MBPC3, MH7, PKP2, and TTN) Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TMP Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed Updated: 6/20/2018 Effective: 7/1/2018

26 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) Laboratory Laboratory Laboratory Laboratory Laboratory Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mrna expression levels, if performed Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 Laboratory X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 Laboratory Unlisted molecular pathology procedure Updated: 6/20/2018 Effective: 7/1/2018

27 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Laboratory Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score Coronary artery disease, mrna, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores Oncology (breast), mrna, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalinfixed paraffin embedded tissue, algorithm reported as recurrence score Oncology (breast), mrna gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score Oncology (breast), mrna, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis Oncology (colon), mrna, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedure) Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hk2]), utilizing plasma or serum, prognostic algorithm reported as a probability score Updated: 6/20/2018 Effective: 7/1/2018

28 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory Oncology (tumor of unknown origin), mrna, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalinfixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype Laboratory Oncology (prostate), mrna gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a diseasespecific mortality risk score Laboratory Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) Laboratory Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy Laboratory Cardiology (heart transplant), mrna, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score Laboratory Unlisted multianalyte assay with algorithmic analysis Laboratory Unlisted chemistry procedure Laboratory 0001U Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported Laboratory 0004M Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score Laboratory 0005U Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score Laboratory 0006M Oncology (hepatic), mrna expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier Laboratory 0007M Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index Updated: 6/20/2018 Effective: 7/1/2018

29 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory 0011M Oncology, prostate cancer, mrna expression assay of 12 genes (10 content and 2 housekeeping), RT- PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk Laboratory Laboratory Laboratory 0012M 0012U 0013M Oncology (urothelial), mrna, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s) Oncology (urothelial), mrna, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma Laboratory 0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s) Laboratory 0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome nextgeneration sequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s) Laboratory 0018U Oncology (thyroid), microrna profiling by RT-PCR of 10 microrna sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy Laboratory 0019U Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents Laboratory Laboratory 0022U 0026U Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider Oncology (thyroid), DNA and mrna of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") Updated: 6/20/2018 Effective: 7/1/2018

30 Laboratory Laboratory Laboratory Laboratory Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA 0028U 0029U 0030U 0031U CP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, copy number variants, common variants with reflex to targeted sequence analysis Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CP1A2, CP2C19, CP2C9, CP2D6, CP3A4, CP3A5, CP4F2, SLCO1B1, VKORC1 and rs ) Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CP2C9, CP4F2, VKORC1, rs ) CP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) Laboratory 0032U COMT (catechol-o-methyltransferase)(drug metabolism) gene analysis, c.472g>a (rs4680) variant Laboratory 0033U HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5- hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs [c t>c], HTR2C rs [c.- 759C>T] and rs [c c>g]) Laboratory 0034U TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15*3, *4, *5) Laboratory Laboratory Laboratory Laboratory 0036U 0037U 0045U 0047U Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden Oncology (breast ductal carcinoma in situ), mrna, gene expression profiling by realtime RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score - Effective 7/1/2018 Oncology (prostate), mrna, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score - Effective 7/1/2018 Updated: 6/20/2018 Effective: 7/1/2018

31 Laboratory Laboratory Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA 0048U 0050U Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancerassociated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) - Effective 7/1/2018 Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements - Effective 7/1/2018 Laboratory 0053U Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade - Effective 7/1/2018 Laboratory Laboratory Laboratory 0055U 0057U 0060U Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma - Effective 7/1/2018 Oncology (solid organ neoplasia), mrna, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffinembedded tissue, algorithm reported as a normalized percentile rank - Effective 7/1/2018 Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in maternal blood - Effective 7/1/2018 Laboratory G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) Laboratory S3800 Genetic testing for amyotrophic lateral sclerosis (als) Laboratory S3840 Dna analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 Laboratory S3841 Genetic testing for retinoblastoma Laboratory S3842 Genetic testing for von hippel-lindau disease Laboratory S3845 Genetic testing for alpha-thalassemia Laboratory S3846 Genetic testing for hemoglobin e beta-thalassemia Laboratory S3852 Dna analysis for apoe epsilon 4 allele for susceptibility to alzheimer's disease Laboratory S3854 Gene expression profiling panel for use in the management of breast cancer treatment Updated: 6/20/2018 Effective: 7/1/2018

32 Prominence Health Plan: Lab CPT Code List Product CPT Code CPT Code Description Requires PA Laboratory S3861 Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (scn5a) and variants for suspected brugada syndrome Laboratory S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy Laboratory S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (hcm) in an individual with a known hcm mutation in the family Laboratory Laboratory 0056U S3870 Hematology (acute myelogenous leukemia), DNA, whole genome nextgeneration sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s) Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability 1.CPT Coyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2. Any CPT code within the range of and G0452-S3854 included with a required prior authorizationcode will be reviewed and those results are binding. 3. Please review list regularly as codes are subject to change. Updated: 6/20/2018 Effective: 7/1/2018

33 Prominence Health Plan: Lab Claims CPT Code List Product CPT Code CPT Code Description = Also Requires PA Laboratory HPA-1 genotyping gene analysis common variant Laboratory HPA-2 genotyping gene analysis common variant Laboratory HPA-3 genotyping gene analysis common variant Laboratory HPA-4 genotyping gene analysis common variant Laboratory HPA-5 genotyping gene analysis common variant Laboratory HPA-6 genotyping gene analysis common variant Laboratory HPA-9 genotyping gene analysis common variant Laboratory HPA-15 genotyping gene analysis common variant Laboratory IDH1 common variants Laboratory IDH2 common variants Laboratory DMD DUPLICATION/DELETION ANALSIS Laboratory BRCA1&BRCA2 FULL SEQ ANALS/FULL DUP/DEL ANALS Laboratory ABL1 GENE ANALSIS KINASE DOMAIN VARIANTS Laboratory ASXL1 gene analysis full gene sequence Laboratory ASXL1 gene analysis targeted seq sequence Laboratory ASPA GENE ANALSIS COMMON VARIANTS Laboratory APC GENE ANALSIS FULL GENE SEQUENCE Laboratory APC GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory APC GENE ANALSIS DUPLICATION/DELETION VARIANTS Laboratory BCKDHB GENE ANALSIS COMMON VARIANTS Laboratory BCR/ABL1 MAJOR BREAKPNT QUALITATIVE/QUANTITATIVE Laboratory BCR/ABL1 MINOR BREAKPNT QUALITATIVE/QUANTITATIVE Laboratory BCR/ABL1 OTHER BREAKPNT QUALITATIVE/QUANTITATIVE Laboratory BLM GENE ANALSIS 2281DEL6INS7 VARIANT Laboratory BRAF GENE ANALSIS V600 VARIANT(S) Updated: 6/20/2018 Effective: 7/1/2018

34 Product CPT Code CPT Code Description = Also Requires PA Laboratory BRCA1&BRCA2 FULL SEQ ANALS/COMM DUP/DEL BRCA Laboratory BRCA1&BRCA2 ANAL 185DELAG5385INSC/6174DELT Laboratory BRCA1&BRCA2 ANAL UNCOMMON DUP/DEL VARIANTS Laboratory BRCA1 FULL SEQ ANAL&COMMON DUP/DEL VARIANTS Laboratory BRCA1 GENE ANALSIS KNOWN FAMILIAL VARIANT Laboratory BRCA2 GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory BRCA2 GENE ANALSIS KNOWN FAMILIAL VARIANT Laboratory CEBPA GENE ANALSIS FULL GENE SEQUENCE Laboratory CALR GENE ANALSIS COMMON VARIANTS IN EXON 9 Laboratory CFTR GENE ANALSIS COMMON VARIANTS Laboratory CFTR GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory CFTR GENE ANALSIS DUPLICATION/DELETION VARIANTS Laboratory CFTR GENE ANALSIS FULL GENE SEQUENCE Laboratory CFTR GENE ANALSIS INTRON 8 POL-T ANALSIS Laboratory CP2C19 GENE ANALSIS COMMON VARIANTS Laboratory CP2D6 GENE ANALSIS COMMON VARIANTS Laboratory CP2C9 GENE ANALSIS COMMON VARIANTS Laboratory CTOGENOM CONST MICROARRA COP NUMBER VARIANTS Laboratory CTOGENOM CONST MICROARRA COP NUMBER&SNP VAR Laboratory CP3A4 gene analysis common variants Laboratory CP3A5 gene analysis common variants Laboratory DPD gene analysis common variants Laboratory EGFR GENE ANALSIS COMMON VARIANTS Laboratory F9 full gene sequence Laboratory F2 GENE ANALSIS 20210G >A VARIANT Laboratory F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT Laboratory FANCC GENE ANALSIS COMMON VARIANT Laboratory FMR1 ANALSIS EVAL TO DETECT ABNORMAL ALLELES Laboratory FMR1 GENE ANALSIS CHARACTERIZATION OF ALLELES Laboratory FLT3 GENE ANALSIS INTERNAL TANDEM DUP VARIANTS Laboratory FLT3 GENE ANLS TROSINE KINASE DOMAIN VARIANTS Laboratory G6PD gene analysis common variants Updated: 6/20/2018 Effective: 7/1/2018

35 Product CPT Code CPT Code Description = Also Requires PA Laboratory G6PD gene analysis familial variants Laboratory G6PD gene analysis full gene sequence Laboratory G6PC GENE ANALSIS COMMON VARIANTS Laboratory GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS Laboratory GJB2 GENE ANALSIS FULL GENE SEQUENCE Laboratory GJB2 GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory GJB6 GENE ANALSIS COMMON VARIANTS Laboratory HEXA GENE ANALSIS COMMON VARIANTS Laboratory HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS Laboratory HBA1/HBA2 gene analysis common deletions/variant Laboratory HBA1/HBA 2 gene analysis known familial variant Laboratory HBA1/HBA 2 gene analysis full gene sequence Laboratory IKBKAP GENE ANALSIS COMMON VARIANTS Laboratory IGH@ REARRANGE ABNORMAL CLONAL POP AMPLIFIED Laboratory IGH@ REARRANGE ABNORMAL CLONAL POP DIRECT PROBE Laboratory IGH@ VARIABLE REGION SOMATIC MUTATION ANALSIS Laboratory IGK@ GENE REARRANGE DETECT ABNORMAL CLONAL POP Laboratory COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC Laboratory COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN Laboratory CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION Laboratory CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA Laboratory HBA1/HBA 2 gene analysis dup/del variants Laboratory JAK2 GENE ANALSIS P.VAL617PHE VARIANT Laboratory KIT GENE ANALSIS TARGETED SEQUENCE ANALSIS Laboratory KIT GENE ANALSIS D816 VARIANT(S) Laboratory KRAS GENE ANALSIS VARIANTS IN EXON 2 Laboratory KRAS GENE ANALSIS ADDITIONAL VARIANT(S) Laboratory LONG QT SNDROME GENE ANALSIS FOR DETECTION OF KNOWN FAMILIAL SEQUENCE VARIANT Laboratory IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs variant Laboratory MGMT METHLATION ANALSIS Updated: 6/20/2018 Effective: 7/1/2018

36 Product CPT Code CPT Code Description = Also Requires PA Laboratory MLH1 GENE ANALSIS PROMOTER METHLATION ANALSIS Laboratory MCOLN1 MUCOLIPIN1 GENE ANALSIS COMMON VARIANTS Laboratory MTHFR GENE ANALSIS COMMON VARIANTS Laboratory MLH1 GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory MLH1 GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory MLH1 GENE ANALSIS DUPLICATION/DELETION VARIANTS Laboratory MSH2 GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory MSH2 GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory MSH2 GENE ANALSIS DUPLICATION/DELETION VARIANTS Laboratory MSH6 GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory MSH6 GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory MSH6 GENE ANALSIS DUPLICATION/DELETION VARIA Laboratory MICROSATELLITE INSTAB ANAL MISMATCH REPAIR DEF Laboratory MECP2 GENE ANALSIS FULL SEQUENCE Laboratory MECP2 GENE ANALSIS KNOWN FAMILIAL VARIANT Laboratory MECP2 GENE ANALSIS DUPLICATION/DELETION VARIANT Laboratory NPM1 NUCLEOPHOSMIN GENE ANAL EXON 12 VARIANTS Laboratory NRAS GENE ANALSIS VARIANTS IN EXON 2&3 Laboratory PCA3/KLK3 PROSTATE SPECIFIC ANTIGEN RATIO Laboratory PDGFRA GENE ANALS TARGETED SEQUENCE ANALS Laboratory PML/RARALPHA COMMON BREAKPOINTS QUAL/QUANT Laboratory PML/RARALPHA SINGLE BREAKPOINT QUAL/QUAN Laboratory PMS2 GENE ANALSIS FULL SEQUENCE Laboratory PMS2 GENE ANALSIS KNOWN FAMILIAL VARIANTS Laboratory PMS2 GENE ANALSIS DUPLICATION/DELETION VARIANTS Laboratory PTEN GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory PTEN GENE ANALSIS KNOWN FAMILIAL VARIANT Laboratory PTEN GENE ANALSIS DUPLICATION/DELETION VARIANT Laboratory PMP22 GENE ANAL DUPLICATION/DELETION ANALSIS Laboratory PMP22 GENE ANALSIS FULL SEQUENCE ANALSIS Laboratory PMP22 GENE ANALSIS KNOWN FAMILIAL VARIANT Laboratory SEPT9 METHLATION ANALSIS Updated: 6/20/2018 Effective: 7/1/2018

37 Product CPT Code CPT Code Description = Also Requires PA Laboratory SLCO1B1 gene analysis common variants Laboratory SMPD1 GENE ANALSIS COMMON VARIANTS Laboratory SNRPN/UBE3A METHLATION ANALSIS Laboratory SERPINA1 GENE ANALSIS COMMON VARIANTS Laboratory RUNX1 gene analysis targeted sequence analysis Laboratory TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) Laboratory TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD Laboratory TRB@ REARRANGEMENT ANAL DIRECT PROBE METHODOLOG Laboratory TRG@ GENE REARRANGEMENT ANALSIS Laboratory TMS gene analysis common variants Laboratory UGT1A1 GENE ANALSIS COMMON VARIANTS Laboratory VKORC1 GENE ANALSIS COMMON VARIANT(S) Laboratory HBB common variants Laboratory HBB known familial variants Laboratory HBB duplication/deletion variants Laboratory HBB full gene sequence Laboratory HLA CLASS I&II LOW HLA-A -B -C -DRB1/3/4/5&DQB Laboratory HLA I&LI LOW RESOLUTION HLA-A -B&-DRB1 Laboratory HLA CLASS I TPING LOW RESOLUTION COMPLETE Laboratory HLA CLASS I TPING LOW RESOLUTION ONE LOCUS EACH Laboratory HLA I LOW RESOLUTION ONE ANTIGEN EQUIVALENT EACH Laboratory HLA II LOW RESOLUTION HLA-DRB1/3/4/5 AND -DQB1 Laboratory HLA CLASS II TPING LOW RESOLUTION ONE LOCUS EA Laboratory HLA II LOW RESOLUTION ONE ANTIGEN EQUIVALENT EA Laboratory HLA I&II HIGH RESOLUTION HLA-A -B -C AND -DRB1 Laboratory HLA CLASS I TPING HIGH RESOLUTION COMPLETE Laboratory HLA CLASS I TPING HIGH RESOLUTION ONE LOCUS EA Laboratory HLA I TPING HIGH RESOLUTION 1 ALLELE/ALLELE GRP Laboratory HLA CLASS II TPING HIGH RESOLUTION ONE LOCUS EA Laboratory HLA II HIGH RESOLUTION 1 ALLELE/ALLELE GROUP Laboratory Molecular pathology procedure level 1 Updated: 6/20/2018 Effective: 7/1/2018

38 Product CPT Code CPT Code Description = Also Requires PA Laboratory Molecular pathology procedure level 2 Laboratory MOLECULAR PATHOLOG PROCEDURE LEVEL 3 Laboratory Molecular pathology procedure level 4 Laboratory Molecular pathology procedure level 5 Laboratory Molecular pathology procedure level 6 Laboratory Molecular pathology procedure level 7 Laboratory MOLECULAR PATHOLOG PROCEDURE LEVEL 8 Laboratory MOLECULAR PATHOLOG PROCEDURE LEVEL 9 Laboratory AORTIC DSFUNCTION/DILATION GENOMIC SEQ ANALSIS Laboratory AORTIC DSFUNCTION/DILATION DUP/DEL ANALSIS Laboratory ASHKENAZI JEWISH ASSOC DSRDRS GEN SEQ ANAL 9 GEN Laboratory CAR ION CHNNLPATH GENOMIC SEQ ALS INC 10 GNS Laboratory CAR ION CHNNLPATH DUP/DEL GN ALS PANEL 2 GENES Laboratory EXOME SEQUENCE ANALSIS Laboratory EXOME SEQUENCE ANALSIS EACH COMPARATOR EXOME Laboratory EXOME RE-EVAL OF PREVIOUSL OBTAINED EXOME SEQ Laboratory FETAL CHROMOSOMAL ANEUPLOID GENOMIC SEQ ANALS Laboratory FETAL CHROMOSOMAL MICRODELTJ GENOMIC SEQ ANALS Laboratory GENOME SEQUENCE ANALSIS Laboratory GENOME SEQUENCE ANALSIS EACH COMPARATOR GENOME Laboratory GENOME RE-EVALUATION OF PREC OBTAINED GENOME SEQ Laboratory HEARING LOSS GENOMIC SEQUENCE ANALSIS 60 GENES Laboratory HEARING LOSS DUP/DEL ANALSIS Laboratory Hereditary brst ca-related gen seq analys 10 gen Laboratory HEREDITAR BRST CA-RELATED DUP/DEL ANALSIS Laboratory HEREDITAR RETINAL DSRDRS GEN SEQ ANALS 15 GEN Laboratory HEREDITAR COLON CA DSRDRS GEN SEQ ANALS 10 GEN Laboratory HEREDITAR COLON CA DSRDRS DUP/DEL ANALS 5 GEN Laboratory HEREDTR NURONDCRN TUM DSRDRS GEN SEQ ANAL 6 GEN Laboratory HEREDTR NURONDCRN TUM DSRDRS DUP/DEL ANALSIS Laboratory Hereditary cardiomyopathy gen seq analys 5 gen Laboratory NUCLEAR MITOCHONDRIAL 100 GENE GENOMIC SEQ Updated: 6/20/2018 Effective: 7/1/2018

39 Product CPT Code CPT Code Description = Also Requires PA Laboratory NOONAN SPECTRUM DISORDERS GEN SEQ ANALS 12 GEN Laboratory GEN SEQ ANALS SOLID ORGAN NEOPLASM 5-50 GENE Laboratory Hereditary peripheral neuropathy gen seq pnl Laboratory GEN SEQ ANALS HEMATOLMPHOID NEO 5-50 GENE Laboratory GEN SEQ ANALS SOL ORG/HEMTOLMPHOID NEO 51/> GEN Laboratory WHOLE MITOCHONDRIAL GENOME Laboratory WHOLE MITOCHONDRIAL GENOME ANALSIS PANEL Laboratory X-LINKED INTELLECTUAL DBLT GENOMIC SEQ ANALS Laboratory X-LINKED INTELLECTUAL DBLT DUP/DEL GENE ANALS Laboratory UNLISTED MOLELCULAR PATHOLOG PROCEDURE Laboratory AUTOIMMUNE RHEUMATOID ARTHRTS ANALS 12 BIOMRKRS Laboratory COR ART DISEASE MRNA GENE EXPRESSION 23 GENES Laboratory ONCO (OVARIAN) BIOCHEMICAL ASSA TWO PROTEINS Laboratory ONCO (OVARIAN) BIOCHEMICAL ASSA FIVE PROTEINS Laboratory ONCOLOG TISSUE OF ORIGIN SIMILAR SCOR ALGORITHM Laboratory ENDOCRINOLOG BIOCHEMICAL ASSA SEVEN ANAL Laboratory FETAL ANEUPLOID SEQ ANAL TRISOM RISK Laboratory FETAL CONGENITAL ABNOR ASSA TWO PROTEINS Laboratory FETAL CONGENITAL ABNOR ASSA 3 PROTEINS Laboratory FETAL CONGENITAL ABNOR ASSA THREE ANAL Laboratory FETAL CONGENITAL ABNOR ASSA FOUR ANAL Laboratory FETAL CONGENITAL ABNOR ASSA FIVE ANAL Laboratory ONCOLOG BREAST MRNA GENE EXPRESSION 21 GENES Laboratory Onc breast mrna gene xprsn prfl hybrd 58 genes Laboratory Onc breast mrna microra gene xprsn prfl 70 genes Laboratory ONCOLOG COLON MRNA GENE EXPRESSION 12 GENES Laboratory ONCOLOG COLORECTAL SCREENING QUAN 10 DNA MARKRS Laboratory ONCOLOG GNE LIVE TUM CELL CLTR&CHEMO RESP 1ST Laboratory ONCOLOG GNE LIVE TUM CELL CLTR&CHEMO RESP ADD Laboratory ONCOLOG LUNG MS 8-PROTEIN SIGNATURE Laboratory ONCOLOG PROSTATE BIOCHEMICAL ASSA 4 PROTEINS Laboratory ONCOLOG TUM UNKNOWN ORIGIN MRNA 92 GENES Updated: 6/20/2018 Effective: 7/1/2018

40 Product CPT Code CPT Code Description = Also Requires PA Laboratory ONC prst8 mrna gene xprsn prfl rt-pcr 46 genes Laboratory ONCOLOG THROID GENE EXPRESSION 142 GENES Laboratory ONC prst8 prmtr methylation prfl r-t pcr 3 genes Laboratory CARDIOLOG HRT TRNSPL MRNA GENE EXPRESS 20 GENES Laboratory UNLISTED MULTIANALTE ASSA ALGORITHMIC ANALSIS Laboratory UNLISTED CHEMISTR PROCEDURE Laboratory CELL ENUMERATION IMMUNE SELECTJ & ID FLUID SPEC Laboratory CELL ENUMERATION IMMUNE SELECTJ & ID PHS INTERP Laboratory CULTURE TPING NUCLEIC ACID PROBE DIR EA ORGANSM Laboratory CULTP NUC ACID AMP PRB CULT/ISOLATE EA ORGNISM Laboratory CULTURE TPING IDENTIFJ PULSE FIELD GEL TPING Laboratory CULTP NUCLEIC ACID SEQUENCING METH EA ISOLATE Laboratory IADNA BARTONELLA AMPLIFIED PROBE TECHNIQUE Laboratory IADNA BARTONELLA HENSELAE&QUINTANA QUANTJ Laboratory IADNA BORRELIA BURGDORFERI DIRECT PROBE TQ Laboratory IADNA BORRELIA BURGDORFERI AMPLIFIED PROBE TQ Laboratory IADNA CANDIDA SPECIES DIRECT PROBE TQ Laboratory IADNA CANDIDA SPECIES AMPLIFIED PROBE TQ Laboratory IADNA CANDIDA SPECIES QUANTIFICATION Laboratory CNS DNA/RNA AMP PROBE MULTIPLE SUBTPES Laboratory IADNA CHLAMDIA PNEUMONIAE DIRECT PROBE TQ Laboratory IADNA CHLAMDIA PNEUMONIAE AMPLIFIED PROBE TQ Laboratory IADNA CHLAMDIA PNEUMONIAE QUANTIFICATION Laboratory IADNA CHLAMDIA TRACHOMATIS DIRECT PROBE TQ Laboratory IADNA CHLAMDIA TRACHOMATIS AMPLIFIED PROBE TQ Laboratory IADNA CHLAMDIA TRACHOMATIS QUANTIFICATION Laboratory INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE Laboratory IADNA CTOMEGALOVIRUS DIRECT PROBE TQ Laboratory IADNA CTOMEGALOVIRUS AMPLIFIED PROBE TQ Laboratory IADNA CTOMEGALOVIRUS QUANTIFICATION Laboratory IADNA ENTEROVIRUS AMPLIF PROBE & REVRSE TRNSCRIP Laboratory INFECTIOUS AGENT DNA/RNA VANCOMCIN RESISTANCE Updated: 6/20/2018 Effective: 7/1/2018

41 Product CPT Code CPT Code Description = Also Requires PA Laboratory INFECTIOUS AGENT DNA/RNA INFLUENZA EA TPE Laboratory INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TPES Laboratory NFCT AGENT DNA/RNA INFLUENZA >2 TPES EA ADDL Laboratory NFCT AGENT DNA/RNA GASTROINTESTINAL PATHOGEN Laboratory IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ 6-11 Laboratory IADNA-DNA/RNA GI PTHGN MULTIPLEX PROBE TQ Laboratory IADNA GARDNERELLA VAGINALIS DIRECT PROBE TQ Laboratory IADNA GARDNERELLA VAGINALIS AMPLIFIED PROBE TQ Laboratory IADNA GARDNERELLA VAGINALIS QUANTIFICATION Laboratory IADNA HEPATITIS B VIRUS AMPLIFIED PROBE TQ Laboratory IADNA HEPATITIS B VIRUS QUANTIFICATION Laboratory IADNA HEPATITIS C DIRECT PROBE TECHNIQUE Laboratory IADNA HEPATITIS C AMPLIFIED PROBE&REVRSE TRANSCR Laboratory IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION Laboratory IADNA HEPATITIS G DIRECT PROBE TECHNIQUE Laboratory IADNA HEPATITIS G AMPLIFIED PROBE TECHNIQUE Laboratory IADNA HEPATITIS G QUANTIFICATION Laboratory IADNA HERPES SIMPLX VIRUS DIRECT PROBE TQ Laboratory IADNA HERPES SOMPLX VIRUS AMPLIFIED PROBE TQ Laboratory IADNA HERPES SOMPLX VIRUS QUANTIFICATION Laboratory IADNA HERPES VIRUS-6 DIRECT PROBE TQ Laboratory IADNA HERPES VIRUS-6 AMPLIFIED PROBE TQ Laboratory IADNA HERPES VIRUS-6 QUANTIFICATION Laboratory IADNA HIV-1 DIRECT PROBE TECHNIQUE Laboratory IADNA HIV-1 AMPLIFIED PROBE & REVERSE TRANSCRPJ Laboratory IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION Laboratory IADNA HIV-2 DIRECT PROBE TECHNIQUE Laboratory IADNA HIV-2 AMPLIFIED PROBE & REVERSE TRANSCRIPJ Laboratory IADNA HIV-2 QUANT & REVERSE TRANSCRIPTION Laboratory IADNA LEGIONELLA PNEUMOPHILA DIRECT PROBE TQ Laboratory IADNA LEGIONELLA PNEUMOPHILA AMPLIFIED PROBE TQ Laboratory IADNA LEGIONELLA PNEUMOPHILA QUANTIFICATION Updated: 6/20/2018 Effective: 7/1/2018

42 Product CPT Code CPT Code Description = Also Requires PA Laboratory IADNA MCOBACTERIA SPECIES DIRECT PROBE TQ Laboratory IADNA MCOBACTERIA SPECIES AMPLIFIED PROBE TQ Laboratory IADNA MCOBACTERIA SPECIES QUANTIFICATION Laboratory IADNA MCOBACTERIA TUBERCULOSIS DIR PRB Laboratory IADNA MCOBACTERIA TUBERCULOSIS AMP PRB Laboratory IADNA MCOBACTERIA TUBERCULOSIS QUANTIFICATION Laboratory IADNA MCOBACTERIA AVIUM-INTRACLRE DIR PRB Laboratory IADNA MCOBACTERIA AVIUM-INTRACLRE AMP PRB Laboratory IADNA MCOBACTERIA AVIUM-INTRACELLULARE QUANT Laboratory IADNA MCOPLSM PNEUMONIAE DIRECT PROBE TQ Laboratory IADNA MCOPLSM PNEUMONIAE AMPLIFIED PROBE TQ Laboratory IADNA MCOPLSM PNEUMONIAE QUANTIFICATION Laboratory IADNA NEISSERIA GONORRHOEAE DIRECT PROBE TQ Laboratory IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ Laboratory IADNA NEISSERIA GONORRHOEAE QUANTIFICATION Laboratory IADNA HUMAN PAPILLOMAVIRUS LOW-RISK TPES Laboratory IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TPES Laboratory IADNA HUMAN PAPILLOMAVIRUS TPES 16 & 18 ONL Laboratory IADNA RESPIRATR PROBE & REV TRNSCR 3-5 TARGETS Laboratory IADNA RESPIRATR PROBE & REV TRNSCR 6-11 TARGETS Laboratory IADNA RESPIRATR PROBE & REV TRNSCR TARGET Laboratory Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique Laboratory IADNA S AUREUS AMPLIFIED PROBE TQ Laboratory IADNA S AUREUS METHICILLIN RESIST AMP PROBE TQ Laboratory IADNA STREPTOCOCCUS GROUP A DIRECT PROBE TQ Laboratory IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ Laboratory IADNA STREPTOCOCCUS GROUP A QUANTIFICATION Laboratory IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ Laboratory IADNA TRICHOMONAS VAGINALIS DIRECT PROBE TQ Laboratory IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH Laboratory Zika virus igm antibody Updated: 6/20/2018 Effective: 7/1/2018

43 Product CPT Code CPT Code Description = Also Requires PA Laboratory IADNA NOS DIRECT PROBE TQ EACH ORGANISM Laboratory IADNA NOS AMPLIFIED PROBE TQ EACH ORGANISM Laboratory IADNA NOS QUANTIFICATION EACH ORGANISM Laboratory IADNA MULTIPLE ORGANISMS DIRECT PROBE TQ Laboratory IADNA MULTIPLE ORGANISMS AMPLIFIED PROBE TQ Laboratory NFCT AGT DRUG SUSCEPT PHENOTPE PREDICTION Laboratory NFCT GEXP NUCLEIC ACID HIV REV TRNSCR&PROTEAS Laboratory NFCT AGNT GENOTP NUCLEIC ACID HEPATITIS C VIRUS Laboratory NFCT PHEXP RESIST TISS CUL HIV FIRST 1-10 DRUGS Laboratory NFCT PHEXP RESIST TISS CUL HIV EA ADDL DRUG Laboratory NFCT GEXP DNA/RNA HIV 1 OTHER REGION Laboratory NFCT AGT GENOTPE NUCLEIC ACID CTOMEGALOVIRUS Laboratory NFCT AGENT GENOTPE HEPATITIS B VIRUS Laboratory CTP INSITU HBRID URINE SPEC 3-5 PROBES EA MNL Laboratory CTP INSITU HBRID URNE SPEC 3-5 PROBES CPTR EA Laboratory FLOW CTOMETR CELL CCLE/DNA ANALSIS Laboratory FLOW CTOMETR CELL SURF MARKER TECHL ONL 1ST Laboratory FLOW CTOMETR CELL SURF MARKER TECHL ONL EA Laboratory FLOW CTOMETR INTERPJ 2-8 MARKERS Laboratory FLOW CTOMETR INTERPJ 9-15 MARKERS Laboratory FLOW CTOMETR INTERPRETATION 16/> MARKERS Laboratory UNLISTED CTOPATHOLOG PROCEDURE Laboratory TISS CUL NON-NEO DISORDERS LMPHOCTE Laboratory TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX Laboratory TISS CUL NON-NEO DISORDERS AMNIOTIC/CHORNC CELLS Laboratory TISS CUL NEO DISORDERS BONE MARROW BLOOD CELLS Laboratory TISS CUL NEO DISORDERS SOLID TUMOR Laboratory CROPRSRV FRZING&STORAGE CELLS EA CELL LINE Laboratory THAWING&EXPANSION FROZEN CELLS EACH ALIQUOT Laboratory CHRMSM BREAKAGE BASELINE SISTER CLL Laboratory CHRMSM BREAKAGE BASELINE BREAKAGE CLL Laboratory CHRMSM BREAKAGE SNDS SCORE 100 CLL Updated: 6/20/2018 Effective: 7/1/2018

44 Product CPT Code CPT Code Description = Also Requires PA Laboratory CHRMSM COUNT 5 CELL 1KAROTPE BANDING Laboratory CHRMSM COUNT CLL 2KAROTP BANDING Laboratory CHRMSM COUNT 45 CELL MOSAICISM 2KAROTPE Laboratory CHRMSM ANALZE CELLS Laboratory CHRMSM ALS AMNIOTIC/VILLUS 15 CELL 1KAROTPE Laboratory CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KAROTP Laboratory MOLECULAR CTOGENETICS DNA PROBE EACH Laboratory MOLECULAR CTOGENETICS CHRMOML ISH 3-5 CELLS Laboratory MOLECULAR CTOGENETICS CHRMOML ISH CLL Laboratory MOLECULAR CTOGENETICS INTERPHASE ISH CLL Laboratory MOLEC CTG INTERPHASE ISH ANALZE CLL Laboratory CHRMSM ANALSIS ADDL KAROTP EACH STUD Laboratory CHRMSM ANALSIS ADDL SPECIALIZED BANDING Laboratory CHRMSM ANALSIS ADDL CELLS COUNTED EACH STUD Laboratory CHRMSM ANALSIS ADDL HIGH RESOLUTION STUD Laboratory CTOGENETICS&MOLEC CTOGENETICS INTERP&REP Laboratory UNLISTED CTOGENETIC STUD Laboratory IMHISTOCHEM/CTCHM EA ADDL ANTIBOD SLIDE Laboratory IMHISTOCHEM/CTCHM 1ST ANTIBOD STAIN PROCEDURE Laboratory IMHISTOCHEM/CTCHM EA MULTIPLEX ANTIBOD SLIDE Laboratory M/PHMTRC ALS TUMOR IMHCHEM EA ANTIBOD MANUAL Laboratory M/PHMTRC ALS TUMOR IMHCHEM EA ANTBD CMPTR ASST Laboratory IN SITU HBRIDIZATION EA ADDL PROBE STAIN Laboratory IN SITU HBRIDIZATION 1ST PROBE STAIN Laboratory IN SITU HBRIDIZATION EA MULTIPLEX PROBE STAIN Laboratory M/PHMTRC ALS ISH CPTR-ASST TECH 1ST PROBE STAIN Laboratory M/PHMTRC ALS IN SITU HBRIDIZATION EA PROBE MNL Laboratory M/PHMTRC ALS ISH QUANT/SEMIQ MNL PER SPEC EACH Laboratory M/PHMTRC ALS ISH QUANT/SEMIQ CPTR PER SPEC EACH Laboratory M/PHMTRC ALS ISH QUANT/SEMIQ CPTR EACH MULTIPRB Laboratory M/PHMTRC ALS ISH QUANT/SEMIQ MNL EACH MULTIPRB Laboratory MICRODISSECTION PREP IDENTIFIED TARGET LASER Updated: 6/20/2018 Effective: 7/1/2018

45 Product CPT Code CPT Code Description = Also Requires PA Laboratory MICRODISSECTION PREP IDENTIFIED TARGET MANUAL Laboratory MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA Laboratory MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE Laboratory 0001M INFECTIOUS DIS HCV 6 ASSAS Laboratory 0001U RBC DNA HEA 35 AG 11 BLD GRP Laboratory 0002M LIVER DIS 10 ASSAS W/ASH Laboratory 0003M LIVER DIS 10 ASSAS W/NASH Laboratory 0004M SCOLIOSIS DNA ALS Laboratory 0005U ONCO PRST8 3 GENE UR ALG Laboratory 0006M ONCOLOG HEP MRNA 161 GENES RISK CLASSIFIER Laboratory 0007M ONCOLOG GASTRO 51 GENES NOMOGRAM DISEASE INDEX Laboratory 0008U HPLORI DETCJ ABX RSTNC DNA Laboratory 0009M FETAL ANEUPLOID, T21 AND T18 Laboratory 0009U ONC BRST CA ERBB2 AMP/NONAMP Laboratory 0010U NFCT DS STRN TP WHL GEN SEQ Laboratory 0011M PR CA MRNA 12 G BL PLSM UR ALG Laboratory 0012M UROTH CA RISK MRNA 5 G UR ALG Laboratory 0012U GERMLN DO GENE REARGMT DETCJ Laboratory 0013M UROTH CA RECR MRNA 5 G UR ALG Laboratory 0013U ONC SLD ORG NEO GENE REARGMT Laboratory 0014U HEM HMTLMF NEO GENE REARGMT Laboratory 0016U ONC HMTLMF NEO RNA BCR/ABL1 Laboratory 0017U ONC HMTLMF NEO JAK2 MUT DNA Laboratory 0018U ThyraMIR, Interpace Diagnostics Laboratory 0019U OncoTarget/ OncoTreat, Columbia University Department of Pathology and Cell Biology, Darwin Health Laboratory 0022U Oncomine Dx, Target Test, Thermo Fisher Scientific Laboratory 0023U LeukoStrat CDx FLT3 Mutation Assay, LabPMM LLC, an Invivoscribe Technologies Inc. company Laboratory 0026U ONC THR DNA&MRNA 112 GENES FNA NDUL ALG ALS Laboratory 0027U JAK2 GENE ANALSIS TRGT SEQ ALS EXONS Laboratory 0028U CP2D6 GENE COP NUMBER CMN VRNTS TRGT SEQ ALS Updated: 6/20/2018 Effective: 7/1/2018

46 Product CPT Code CPT Code Description = Also Requires PA Laboratory 0029U RX METAB ADVRS RX RXN & RSPSE TRGT SEQ ALS Laboratory 0030U RX METAB WARFARIN RX RESPONSE TRGT SEQ ALS Laboratory 0031U CP1A2 GENE ANALSIS COMMON VARIANTS Laboratory 0032U COMT GENE ANALSIS C.472G>A VARIANT Laboratory 0033U HTR2A HTR2C GENE ANALSIS COMMON VARIANTS Laboratory 0034U TPMT NUDT15 GENE ANALSIS COMMON VARIANTS Laboratory 0036U XOME TUM & NML SPEC SEQ ALS Laboratory 0037U TRGT GEN SEQ DNA 324 GENES Laboratory 0040U BCR/ABL1 GENE MAJOR BP QUAN Laboratory 0045U ONC BRST DUX CARC IS 12 GENE Laboratory 0046U FLT3 GENE ITD VARIANTS QUAN Laboratory 0047U ONC PRST8 MRNA 17 GENE ALG Laboratory 0048U ONC SLD ORG NEO DNA 468 GENE Laboratory 0049U NPM1 GENE ANALSIS QUAN Laboratory 0050U TRGT GEN SEQ DNA 194 GENES Laboratory 0053U ONC PRST8 CA FISH ALS 4 GEN Laboratory 0055U CARD HRT TRNSPL 96 DNA SEQ Laboratory 0056U HEM AML DNA GENE REARGMT Laboratory 0057U ONC SLD ORG NEO MRNA 51 GENE Laboratory 0060U TWN ZG GEN SEQ ALS CHRMS2 Laboratory 0500T Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus (HPV) for five or more separately reported highrisk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping) Laboratory G0452 MOLECULAR PATHOLOG INTERPR Laboratory G0476 HPV COMBO ASSA CA SCREEN Laboratory G9143 WARFARIN RESPONSIVENESS TESTING Laboratory S3722 DOSE OPTIMIZATION AUC - 5FU Laboratory S3800 GENETIC TESTING ALS Laboratory S3840 DNA ANALSIS RET-ONCOGENE Laboratory S3841 GENE TEST RETINOBLASTOMA Laboratory S3842 GENE TEST HIPPEL-LINDAU Laboratory S3844 DNA ANALSIS DEAFNESS Updated: 6/20/2018 Effective: 7/1/2018

47 Product CPT Code CPT Code Description = Also Requires PA Laboratory S3845 GENE TEST ALPHA-THALASSEMIA Laboratory S3846 GENE TEST BETA-THALASSEMIA Laboratory S3849 GENE TEST NIEMANN-PICK Laboratory S3850 GENE TEST SICKLE CELL Laboratory S3852 DNA ANALSIS APOE ALZHEIMER Laboratory S3853 GENE TEST MO MUSCLR DST Laboratory S3854 GENE PROFILE PANEL BREAST Laboratory S3861 GENETIC TEST BRUGADA Laboratory S3865 COMP GENET TEST HP CARDIOM Laboratory S3866 SPEC GENE TEST HP CARDIOM Laboratory S3870 CGH TEST DEVELOPMENTAL DELA ** Some of the codes listed require Prior Authorization. ** CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. **Code(s) under management are subject to change. Please regularly consult the website or current documents. Updated: 6/20/2018 Effective: 7/1/2018

48 Prominence Health Plan: Comprehensive CPT Code List Product CPT Code CPT Code Description Alternate Description Drug Admin Technique Medical Oncology J0202 Alemtuzumab Campath INJECTABLE Medical Oncology J0640 Leucovorin - inj INJECTABLE Medical Oncology J0641 Levoleucovorin Fusilev INJECTABLE Medical Oncology J0894 Decitabine Dacogen INJECTABLE Medical Oncology J1930 Lanreotide Sumatuline Depot INJECTABLE Medical Oncology J2353 Octreotide depot Sandostatin INJECTABLE Medical Oncology J2354 Octreotide non-depot Sandostatin INJECTABLE Medical Oncology J3315 Triptorelin Pamoate Trelstar INJECTABLE Medical Oncology J3490 Atezolizumab Tecentriq INJECTABLE Medical Oncology J3490 Bendamustine HCL Bendeka INJECTABLE Medical Oncology J3490 Daratumumab Darzalex INJECTABLE Medical Oncology J3490 Dinutuximab Unituxin INJECTABLE Medical Oncology J3490 Elotuzumab Empliciti INJECTABLE Medical Oncology J3490 Irinotecan Liposome Onivyde INJECTABLE Medical Oncology J3490 Necitumumab Portrazza INJECTABLE Medical Oncology J3490 Peginterferon, alfa-2a Pegasys INJECTABLE Medical Oncology J3490 Peginterferon, alfa-2b PegIntron INJECTABLE Medical Oncology J3490 Talimogene Laherparepvec Imlygic INJECTABLE Medical Oncology J3490 Trabectedin ondelis INJECTABLE Updated: mm/dd/yyyy CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.