INVESTIGATIONAL NOT COVERED

Transcription

1 Acoustic Heart Sound Recorder (93799) Actigraphy for Sleep Disturbances (95803) Anoscopy with Thermal Energy (46999) Aqueous Drainage Devices for Glaucoma (0253T, 0449T, 0450T, and 0474T ) Effective 10/01/17 Arthrex Mini Tightrope Implant Arthroereisis - Ankle / Subtalar (S2117/ 28899) (Will be denied as ineligible) Arterial Pressure Waveform Analysis (93050) Artificial Discs (Total Disc Arthroplasty) ie: Thoracic, Lumbar (0163T 0165T, 22857, 22862, 22865) Artificial Pancreas (S1034, S1035, S1036, S1037) Automated Breast Ultrasound (76999*) Automated Percutaneous Lumbar Diskectomy (APLD) (multi)(62287, C2614) Bio-engineered Skin and Skin Substitutes. Deny as Ineligible. o Q4100 Skin substitute, not otherwise specified o Q4108 Skin substitute, Integra matrix, per sq cm o Q4110 Skin substitute, PriMatrix, per sq cm o Q4111 Skin substitute, GammaGraft, per sq cm o Q4112 Cymetra, injectable, 1 cc o Q4113 GRAFTJACKET XPRESS, injectable, 1cc o Q4114 Integra flowable wound matrix, injectable, 1 cc o Q4115 AlloSkin, per sq cm o Q4117 HYALOMATRIX, per sq cm o Q4118 MatriStem micromatrix, 1 mg o Q4121 TheraSkin, per sq cm o Q4122 DermACELL, per sq cm o Q4123 AlloSkin RT, per sq cm o Q4124 Oasis ultra tri-layer wound matrix, per sq cm o Q4125 Arthroflex, per sq cm o Q4126 MemoDerm, per sq cm o Q4127 Talymed, per sq cm o Q4130 Strattice TM, per sq cm o Q4131 EpiFix, per sq cm o Q4132 Grafix core, per sq cm o Q4133 Grafix prime, per sq cm o Q4134 hmatrix, per sq cm o Q4135 Mediskin, per sq cm o Q4136 E-Z Derm, per sq cm o Q4137 Amnioexcel or biodexcel, per sq cm o Q4138 Biodfence dryflex, per sq cm INVESTIGATIONAL NOT COVERED o Q4139 Amniomatrix or biodmatrix, injectable, 1 cc o Q4140 Biodfence, per sq cm o Q4141 Alloskin AC, per sq cm o Q4142 XCM biologic tissue matrix, per sq cm o Q4143 Repriza, per sq cm o Q4145 Epifix, injectable, 1 mg o Q4146 Tensix, per sq cm o Q4147 Architect extracellular matrix, per sq cm o Q4148 Neox 1k, per sq cm o Q4149 Excellagen, 0.1 cc o Q4150 Allowrap DS or dry, per sq cm o Q4151 Amnioband or guardian, per sq cm o Q4152 Dermapure, per sq cm o Q4153 Dermavest and Plurivest, per sq cm o Q4154 Biovance, per sq cm o Q4155 Neoxflo or clarixflo 1 mg o Q4156 Neox 100, per sq cm o Q4157 Revitalon, per sq cm o Q4158 Marigen, per sq cm o Q4159 Affinity, per sq cm o Q4160 Nushield, per square centimeter o Q4161 Bio-ConneKt wound matrix, per sq cm o Q4162 AmnioPro Flow, BioSkin Flow, BioRenew Flow, WoundEx Flow, Amniogen-A, Amniogen-C, 0.5 cc o Q4163 AmnioPro, BioSkin, BioRenew, WoundEx, Amniogen-45, Amniogen-200, per sq cm o Q4164 Helicoll, per sq cm o Q4165 Keramatrix, per sq cm o Q4166 Cytal o Q4167- Truskin o Q4168- AmnioBand, 1 mg o Q4169- Artacent wound, per sq cm o Q4170- Cygnus, per sq cm o Q4171- Interfyl, 1 mg o Q4172- PuraPly or PuraPly AM, per sq cm o Q4173- PalinGen or PalinGen XPlus, per sq cm o Q4174- PalinGen or ProMatrX, 0.36 mg per 0.25 cc o Q4175- Miroderm, per sq cm o Q4176 Neopatch Per Square CM ( ) o Q4177 Floweramnioflo 0.1 cc ( ) o Q4178 Floweramniopatch per square CM ( ) o Q4179 Flowerderm per square CM ( ) * Code is for multiple procedure/test usage; non-specific for this procedure/test Page 1 of 6

2 o Q4180 Revita per square CM ( ) o Q4181 Amnio wound per square CM ( ) o Q4182 Transcyte per square CM ( ) o C9358 Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm o C9360 Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm o C9364 Porcine implant, Permacol, per sq cm Bioimpedance Spectroscopy ( ) Bone Growth Stimulation for Cervical Spinal Fusion Breast Thermography (93740)Bronchial Thermoplasty (31660, 31661) Calypso positional tracking for radiation (77387, G ) Carotid Sinus Baroreceptor Stimulation (0266T 0273T) Cefaly transcutaneous supraorbital neurostimulation (tsns) device for headaches Cerebral Thermal Perfusion Common Carotid Intima-Media (IMT) Study (0126T, 93895) Computer Aided Detection Chest X-Rays (0174T, 0175T) Computer Assisted Imaging in Orthopedic Procedures (20985, 0054T, 0055T) Deny as Ineligible. Corneal Collagen Cross-Linking (0402T) Coronary CT Calcium Scoring (75571) Coronary Spectroscopy (0205T) Correlated audioelectric cardiography (93799) endomechanical ablative approach (e.g., ClariVein Catheter) Endobronchial and Intrabronchial Valves (31647, 31648, 31649, 31651) Endothelial Function Assessment (0337T) Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method (0505T) Envoy prosthetic hearing restoration (S2230, V5095) EpiFlo topical HBO mobile unit Eustachian Tube Balloon Dilation for the treatment of Eustachian Tube Dysfunction in Adults (C9745) Evacuation Meibomian Glands (0207T) (LipiFlow procedure) Excimer Laser for Treatment of Psoriasis and all other dermatologic conditions WITH THE EXCEPTION OF REFRACTORY VITILIGO (* 96920, * 96921, * 96922) **SEE ALSO UNDER NEW TECHNOLOGY UTILIZATION WITH LIMITATIONS Extracorporeal Shockwave Therapy-Plantar Fasciitis (28890) Extracorporeal Shockwave for Wound Healing *(28899) Helios II Ablation Catheter Hemodynamic Monitor / Atrial Hemi-Cap System re/to Toe Joint Arthroplasty (System Only) Hypoglossal Nerve Stimulation for Sleep Apnea - *64999* (Hayes D2) o Apnex o IMThera o Inspire Inferential Nerve Stimulators Intradiscal Electrothermal Therapy (IDET) also known as Intradiscal Electrothermal Annuloplasty or Thermal Intradiscal Procedure (TIPs) (22526, 22527, 22899) Intraocular pressure monitoring for 24 hours (0329T) Laboratory Testing o Assay of Calprotectin, Fecal (CPT 83993) o Acu-Gen (test for baby gender) o AmniSure Test (CPT 84112) o Avise PG o CPT Proprietary Lab Analyses: PreciseType HEA Test (0001U), PolypDX (0002U), Overa(OVA1 Next Generation ) ( 0003U), Gram- Negative Bacterial Resistance Gene PCR Panel (0004U), ExosomeDX Prostate (0005U), Aegis Drug-Drug Interaction Test (0006U), ToxProtect (0007U), AmHPR Helicobacter pylori Antibiotic Resistance Next Generation Sequencing Panel (0008U), DEPArray HER2 (0009U), Bacterial Typing by Whole Genome Sequencing (0010U), Cordant CORE ( 0011U ), MatePair Targeted Rearrangements,Congenital (0012U), MatePair Targeted Rearrangements, Oncology ( 0013U), MatePair Targeted Rearrangements, Hematologic (0014U), OneOme RightMed Pharmacogenomic Test (0015U), BCR-ABL1 major and minor breakpoint fusion transcripts (0016U), JAK2 Mutation (0017U) 0045U, The Oncotype DX Breast DCIS Score TM Test 0047U, Oncotype DX Genomic Prostate Score 0048U, MSK-IMPACT (Integrated Mutation Profiling of Actionable Cancer Targets) 0053U, Prostate Cancer Risk Panel * Code is for multiple procedure/test usage; non-specific for this procedure/test Page 2 of 6

3 0057U, RNA-Sequencing by NGS-Solid NanoKnife Ablation Organ Neoplasm Profiling Near-infrared dual imaging of meibomian glands 0058U, Merkel SmT Oncoprotein Antibody (0507T) Titer Near Infrared Spectroscopy (NIRS) of Lower 0059U, Merkel Virus VP1 Capsid Antibody Extremity Wounds (76499) 0060U, Twins Zygosity Near Infrared Vascular Imaging (AccuVein/Vein 0061U, Transcutaneous measurement of Viewer) five biomarkers Nerve Repair w/nerve Allograft (64912, 64913) o Human Epididymus Protein (HE4) (86305) NTI Tension Suppression System o Non-invasive Hemoglobin (88738) Ocular blood flow by repetitive intraocular pressure o Oncoprotein (DCP) , sampling (0198T) o Placental alpha microglobulin-1 for detection of Optical Coherence Tomography (OCT) ( ) Rupture of Fetal Membranes (PAMG-1) (IVUS covered) o Procalcitonin (PCT) Palatal Stiffening Procedures (cautery assisted or o Salivary Hormone Tests implants such as Pillar Device) (C9727) o VAP-Expanded Lipid Profile Testing *83701, Percutaneous Intradiscal Radiofrequency *84478 Thermocoagulation (PIRFT) 22526, 22527, S2348 o Vectra DA panel (81490) Permanent Leadless Pacemakers (0387T, 0388T, o Videssa Testing 0389T, 0390T, 0391T) Laser-assisted palatoplasty (LAUP)(S2080) Phonophoresis Laser-assisted spine surgery (62287) Platelet Rich Plasma - (Injection) (0232T) Laser - Onychomycosis Posturography (92548) Liver Elastography (91200) Power Pumper Pediatric Rehab Device Low Level Laser S8948 Pressure Sensor Monitor for AICD (0294T) (also noted under limitations) Prolotherapy (M0076) o Service by Chiropractor Exp/Inv ProstaScint - (78801)* o Service by other practitioners no PA med nec needed Pulmonary Artery Pressure Sensor (Wireless version only) (C2624, C9741) (Cardio MEMS) Ligation of Perforator Vein (37761) Pulse-echo ultrasound bone density measurement Lumbar stabilization devices, Sacroplasty (Presacral resulting in indicator of axial bone mineral density, Arthrodesis), Intradiscal stabilization devices - ie: tibia (0508T) AxiaLIF, XLIF, Dynesys, Stabilimax NZ, X-stop (0219T to 0222T) (0195T to 0196T) (22586), Coflex ( Pulsed radiofrequency facet ablation ) Reflectance Confocal Microscopy (RCM) (96931, Lymphedema Pump for chest/trunk applications 96932, 96933, 96934, 96935, 96936) E0656, E0657 Renal Sympathetic Denervation (Transcatheter) Macular pigment optical density measurement (0338T, 0339T) (0506T) Retinal Prosthesis Systems (0100T, C1841, C1842, Magnetic Resonance-Guided Focused Ultrasound 0472T-effective 07/01/17, 0473T- effective 07/01/17 Therapy - (ExAblate and InSightec, Ltd.) for uterine ) fibroids (0071T, 0072T) and palliation of painful bone Sacroilliac Joint Fusions (27279, 27280) metastases (no specific codes) Sclerotherapy plus ligation of saphenofemoral Mediator Release Testing for food allergies (*83516, junction *83518, *83519, *83520, *86807, *86808) Scrambler Therapy (0278T) Medigus US Surgical Endostapler Sensory Nerve Conduction Test (SNCT) G0255 Melafind computerized light to find melanomas Sinus Implant (Drug Eluting Device) (Mometasone Microwave Probe for Breast Tumor furoate sinus implant, 370 micrograms) S1090 MRI-Guided Focused Ultrasound of the Uterus (0406T, 0407T) (0071T, 0072T, C9734) Skin advanced glycation endproducts (AGE) Myocardial Sympathetic Innervation Imaging (0331T, Sphenopalatine nerve blocks (64505) 0332T) Spectroscopy of Expired Gases (94799 misc) Stem cells for Spinal Fusion (20939) * Code is for multiple procedure/test usage; non-specific for this procedure/test Page 3 of 6

4 Sub-mucosal Ablation for Sleep Disturbances (41530) Subtalar Joint Implant - Talotarsal (Extra-osseous) (0335T) Tear Film Imaging (0330T) Thyroid Cancer Tumor Ablation with ETOH Tongue Base Suspension for Sleep Disturbances (i.e.: Repose Device) (41512) TOPAZ Radiofrequency Procedure (Coblation Musculoskeletal Procedures) Total Facet Arthroplasty System (0202T) Transcatheter Placement of Heart Mitral Valve (33418, 33419, 0345T) Transilluminated powered phlebectomy (TIPP, TriVex) Transforaminal epidural, with ultrasound other than lumbar/sacral (0228T, 0229T, 0230T, 0231T) Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy (Rezum system) (C9748) (This will be denied as ineligible.) Transurethral/Transvaginal RF SurX Transvaginal System, Renessa Transurethral RF System (53860) Ultrasonic plantar fascial debridement under ultrasound guidance(*28899) Ultrasound for Hemorrhoid Banding (0249T) Ultrasound, Low Frequency Non-Thermal (97610) Uterine Fibroid Ablation (58674) Vax-D (S9090) Vacuum-assisted socket system (VASS) for Limb Prosthetics Vaginal Weights (noted in misc code 99070) VBLOC Vagal Blocking Therapy for Obesity Visual Evoke Potential (0333T) VisionCare Opththalmic implantable telescope WheezeRATE GENETIC TESTING NOT COVERED EXPERIMENTAL / INVESTIGATIONAL 5-Fluorouracil Pharmacogenetics - DPYD, MTHFR, and TYMS Genes (A-0665) (S3722) Amyotrophic Lateral Sclerosis (ALS) - SOD1 Gene (A-0591) (S3800) (*81404) Arrhythmogenic Right Ventricular Cardiomyopathy - ARVC Genes (A-0627) Ataxia-Telangiectasia - ATM Gene (A-0593) Autism Genetic Test S3870 Bloom Syndrome - BLM Gene (A-0682) (81209) Cancer of Unknown Primary: Molecular Profiling - Pathwork Tissue of Origin (A-0673) CancerTYPE ID (biotheranostics Inc. Carrier Screening Tests o Good Start Genetics Carrier Screening Test o Universal Genetic Test (i.e. Counsyl Carrier Screen) COMT - Catechol-O-Methyltransferase enzyme (81479*) Chemoresistance or Chemosensitive Assays - (Chemo Fx Assay) Clopidogrel Pharmacogenetics - CYP2C19 Gene (A- 0631) (81225) Colon Cancer Gene Expression Assays - (OncoDefender-CRC and OncoType DX Colon Cancer Assay. Note this Oncotype is different than Oncotype DX) (A-0651) Coronary Artery Disease - 9p21 Allele (A-0657) Coronary Artery Disease - KIF6 Gene (A-0656) Coronary Artery Disease Gene Expression Testing - (CardioDX / Corus) (A-0652) Coronary Artery Disease Genetic Panel (A-0658) Crohn Genetic Test-Prometheus Lab-Anser IFX CYP2B6 liver enzyme (81479*) DecisionDX (specific names below) o DecisionDX-EC o DecisionDX-G-CIMP o DecisionDX-GBM o DecisionDX-Melanoma o DecisionDX-Thymoma o DecisionDX-UM Diabetes Mellitus - HNF4A, GCK, HNF1A, PDX1, HNF1B, NEUROD1, KLF11, CEL, PAX4, INS, BLK, ABCC8, EIF2AK3, FOXP3, KCNJ11, and PTF1A Genes (A-0598) Drug Metabolizing Enzyme Genotyping Facilitated Glucose Transporter 1 gene testing (Glut1and/or SLC2A1 gene ) FoundationOne genetic assay testing. (Panel type testing for over 200 genes examples include EGFR, BRAF, FLT3, KRAS) Gaucher Disease - GBA Gene (A-0603) (81251) Genecept Assay GeneSight panel (Assurex Health) Genetic Testing Panels (see note below) * Code is for multiple procedure/test usage; non-specific for this procedure/test Page 4 of 6

5 Genome-Wide Association Studies (A-0531) Heart Transplant Rejection Gene Expression Profiling (AlloMap) (A-0623) Hemoglobinopathies, Thalassemias and Sickle Cell Disease - HBA1, HBA2, and HBB Genes (A-0604) (81257) Hyperhomocysteinemia - MTHFR Gene (A-0629) (eg, hereditary hypercoagulability) igene Cancer Panel JAK2 Exon (note different than JAK 2) Lesch-Nyhan Syndrome - HPRT1 Gene (A-0606) Li-Fraumeni Syndrome - TP53 Gene (A-0584) Long QT Syndromes - ANK2, ANKB, CACNA1C, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, SCN4B, and SCN5A Genes (A-0607) ( ) Macula Risk PGx Test (Artic Medical Laboratories) Hayes D2 Rating Malignant Melanoma, Familial BAP1, CDK4 and CDKN2A Genes (A-0601) Maple Syrup Urine Disease - BCKDHA, BCKDHB, and DBT Genes (A-0681) (81205) Melanoma Gene Expression Profiling (A-0670) Muscular Dystrophies (Duchenne, Becker) - DMD Gene (A-0608) (81161) Neuroblastoma - ALK, MYCN, and PHOX2B Genes and Gene Expression Profiling (A-0610) Neurofibromatosis - NF1 and NF2 Genes (A-0581) Niemann-Pick Disease (Acid Sphingomyelinase Deficiency) - SMPD1, NPC1, and NPC2 Genes (A- 0611) (81330) nucseek Comprehensive Sequence Analysis of Nuclear Mitochondrial Exome OPRM1 - gene (81479*) Paraganglioma-Pheochromocytoma Syndromes, Hereditary - SDHB, SDHC, SDHD, and TMEM127 Genes (A-0535) Parkinson Disease - ATP13A2, GBA, LRRK2, MAPT, PARK2, PARK7, PINK1, and SNCA genes (A-0671) Prometheus IBD sgi Diagnostic (83520* x 8, 82397* x 3, 86140* x 1, *x 1, 88350* x 1, 81479* x 4 ) Prostate Cancer - Genetic Profiles, BRCA2, HOXB13, MMR, PCA3, PTEN, and TMPRSS-ETS Fusion Genes (A-0612) (S3721) PCA3/KLK3 Ratio ( ) Proteomics (VeriStrat) (A-0693) Psychotropic Medication Pharmacogenetic Testing (A-0692) Retinoblastoma - RB1 Gene (A-0586) (S3841) Selective Serotonin Reuptake Inhibitors (SSRIs) - Cytochrome P450 Polymorphism Testing (A-0625) Tamoxifen Pharmacogenetics - CYP2D6 Gene (A- 0647) (81226) Telomere Analysis (A-0672) Topographic Genotyping - PathFinderTG (A-0632) UGT2B15 liver enzyme (81479*) Viral DNA Testing for Colds Von Hippel-Lindau Syndrome - VHL Gene (A-0583) (S3842) Von Willebrand Disease - VWF Gene (A-0688) Warfarin Dosing - CYP2C9, VKORC1, and CYP4F2 Genes (A-0587) (G9143)(81227, 81355) Wilms Tumor - WT1, WT2, and WTX Genes (A-0615) Note: Genetic Testing Panels to pre-screen or prevent cardiac disease, diabetes, metabolic syndrome, fatty liver disease, etc. are considered experimental. There is a lack of validity of these test panels. Examples include but not limited to: Laboratories: Health Diagnostic Laboratory Inc. True Health Diagnostics Tests: Cardiovascular Disease Risk Test * Code is for multiple procedure/test usage; non-specific for this procedure/test Page 5 of 6

6 DURABLE MEDICAL EQUIPMENT (DME) ITEMS NOT COVERED (UNLESS SPECIFIED IN INDIVIDUAL SPD**) AED (non-wearable) (E0617) Air purifier (E1399) Any hygienic item, device (A9286) Auditory osseointegrated devices (BAHA) (L8690, L8691, L8692, L8693) (L8694, L8625) Automatic Blood Pressure Machine (A4670) Bath Bench (E0245) Batteries (other than for covered, purchased items) (V5266, L7360, L7364, L7362, L7366-L7368, L8621-L8624) Bed Wedge (E0190, E0315) Bedwetting Alarm (S8270) Belly bra for maternity (E1399) Bras following Breast reduction (E1399) Cholesterol screening strips (E1399) Cochlear Implants (L8614-L8629) Commode Chair, Electric (E0170, E0171, E0172) Commode Pail (E0167) Corrective footwear devices (including orthopedic shoes and shoe inserts) (L2232, L2320, L2330, L3000-L3100, L3201-L3265, L3300-L3649, A5500-A5513) Cryocuff/Cold Therapy (E0218) Dehumidifier (E1399) Egg crate mattresses (E0181, E0184-E0187, E0196-E0198, E0271-E0272, E0199) Electric Heating Pads (E0210, E0215) Electronic Medication Compliance Device (T1505) Exercise Equipment (including theraband and tubegauze) (A9300, E1399) *Food / Food Supplements / Special diets (B4100-B4104, B4149-B4162, S9434, S9435) Grossan nasal irrigator tips Hearing Aids (L8690-L8693, V5008-V5299) Heat and/or Cold Wrap any type (A9273) Heat Lamps (E0200, E0205) Heel or Elbow Protectors (E0191) Humidifier (E0605) Hydrocollator Units (E0225, E0239) Incontinence Supplies (A4520, T4521-T4544) Jaw Motion Rehab System (E1700-E1702) Lift Chair (E0621, E0625, E0627, E0629) Male Vacuum Erection System (L7900) Effective Motorized Tri-cart (E1230) Nerve Stimulation for Tx of N & V (E0765) Nondisposable Underpads (A4553) Ostomy deodorant (A4394-A4395) Powered operated vehicles (E1230, K0800-K0812) Rollabout Chair (E1031) Segmental Pneumatic Pumps Trunk and Chest (E0656-E0657) Sentry (watch)/life Alert (E1399) Shower chairs (E0240) SNaP - Negative Pressure Wound Therapy System (Spiracon) (A9272) Sock Aid (E1399) Spa / whirlpool (E1300, E1310) Static Progressive Stretching Devices (E1801, E1806, E1811, E1816, E1818, E1821, E1831, E1841) Ted hose (A4490, A4495, A4500, A4510) Toilet Riser / Grab Bars / Rails (E0241-E0246) Transfer Device (E0705) Transport Chair (E1037-E1039) Water Circulating Pads (E0217-E0218, E0236, E0249) Waterpiks (E1399) Wheelchair Service (A0130) * HMO Plans covered if meets plan requirements. ** This list is NOT all-inclusive and is for reference only. Other DME items may also not be covered.