OUTPATIENT SERVICES PRIOR AUTHORIZATION LIST - CONNECTICUT MEDICARE APRIL 2012

Transcription

1 The information contained in this listing pertains to Wellcare of Connecticut Medicare authorization requirements only. The codes contained on this list are limited to Current Procedural Terminology (CPT codes) and do not include HCPCS codes. Separate authorization requirements may apply for HCPCPS codes. is always required for the following services: Services rendered by non-participating providers and facilities Inpatient confinements including: Elective Inpatient, Acute Inpatient, Skilled Nursing Facility, Behavioral Health, Rehabilitation and Long-term/Sub-acute care services Advanced Radiological, Diagnostic Cardiac, Musculoskeletal (Pain Management) and Diagnostic Sleep services managed by CareCore National: Behavioral Health managed by CompCare: Durable Medical Equipment (DME) Refer to the DME and O/P List for details Orthotics/Prosthetics (O/P) Refer to the DME and O/P List for details Home Health Care Ophthalmology services Select Pharmaceuticals Skilled Therapy Services: Occupational, Physical and Speech Therapy services Transplant services We encourage you to verify member eligibility and confirm benefits prior to rendering services. Reimbursement for these services will be in accordance with the terms and conditions of your agreement. authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 1 of 101

2 ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED S ON THE SPINE AND SPINAL CORD; DIAGNOSTIC ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED S ON THE SPINE AND SPINAL CORD; THERAPEUTIC 1991 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); OTHER THAN THE PRONE POSITION 1992 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PROVIDER); PRONE POSITION FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE No No ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) No No INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNC No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 2 of 101

3 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNC INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE DEBRIDEMENT; SKIN, PARTIAL THICKNESS DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 3 of 101

4 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; EACH REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 4 of 101

5 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1. EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETE EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETE EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETE EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETE EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETE EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIP EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIP No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 5 of 101

6 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 6 of 101

7 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL; BIOPSY OF NAIL UNIT (EG, PLATE, BED, MATRIX, HYPONYCHIUM, PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE ) WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL) INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS INJECTION, INTRALESIONAL; MORE THAN 7 LESIONS INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT No No No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 7 of 101

8 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 8 of 101

9 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEF ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS GRAFT; DERMA-FAT-FASCIA BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 9 of 101

10 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS THAN 10 SQ CM DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (PROUD FLESH, SINUS OR FISTULA) DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 10 of 101

11 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR C MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING GUIDANCE (SEPARATE ) REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; SIMPLE INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR "FASCIA") INJECTION(S); SINGLE TENDON ORIGIN/INSERTION INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1OR 2 MUSCLE(S) INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S) ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL JOINT OR BURSA (EG, FINGERS, TOES) ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 11 of 101

12 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) (SEPARATE ) EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVISE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); THORACIC No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 12 of 101

13 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVISE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); LUMBAR EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO FOR PRIMARY ) PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; ONE OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO FOR PRIMARY ) CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITHOUT MANI CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL; WITHOUT MANIPULATION No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 13 of 101

14 CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]); WITHOUT MANIPULATION REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITHOUT MANIPULATION CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITHOUT MANIPULATION, EACH BONE CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 14 of 101

15 CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITHOUT MANIPULATION, CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITHOUT MANIPULATION, EACH INJECTION FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITHOUT MANIPULATION CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDI CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND) FASCIOTOMY, FOOT AND/OR TOE EXCISION, TUMOR, FOOT; SUBCUTANEOUS TISSUE No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 15 of 101

16 REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE ) CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT MANIPULATION, EACH CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT MANIPULATION CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITHOUT MANIPULATION, EACH ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD ) ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH OR WITHOUT CORACOACRO ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 16 of 101

17 ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE ) ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE ) ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL) ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL) ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 17 of 101

18 EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD LAVAGE BY CANNULATION; MAXILLARY SINUS (ANTRUM PUNCTURE OR NATURAL OSTIUM) LAVAGE BY CANNULATION; SPHENOID SINUS NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE ) NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY SINUSOSCOPY (VIA INFERIOR MEATUS OR CANINE FOSSA PUNCTURE) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE ) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, PARTIAL (ANTERIOR) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTERIOR) No No No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 18 of 101

19 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS EXPLORATION, WITH OR WITHOUT REMOVAL OF TISSUE FROM FRONTAL SINUS NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE ) LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; DIAGNOSTIC, EXCEPT NEWBORN LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; DIAGNOSTIC, WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 19 of 101

20 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, WITH STROBOSCOPY BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; DIAGNOSTIC, WITH OR WITHOUT CELL WASHING (SEPARATE BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRUSHING OR PROTECTED BRUSHINGS BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL ALVEOLAR LAVAGE BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), T INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); VENTRICULAR No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 20 of 101

21 INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING SINGLE LEAD INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS 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) INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS 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) 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 FOR PRIMARY ) authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 21 of 101

22 REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; MULTIPLE LEAD SYSTEM INSERTION OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS INSERTION OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS INSERTION OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING SINGLE LEAD INSERTION OR REPLACEMENT OF PERMANENT PACING CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER REMOVAL OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR; SINGLE LEAD SYSTEM REMOVAL OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 22 of 101

23 REMOVAL OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN) SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINU INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) INTRODUCTION OF NEEDLE AND/OR CATHETER, ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (GRAFT/FISTULA); INITIAL ACCESS WITH COMPLETE RAD INTRODUCTION OF NEEDLE AND/OR CATHETER, ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (GRAFT/FISTULA); ADDITIONAL ACCESS FOR THERAPEUTI INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 23 of 101

24 37765 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; STAB INCISIONS BONE MARROW; ASPIRATION ONLY BIOPSY OF LIP EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z-PLASTY) TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12 TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12 TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER ADENOIDECTOMY, SECONDARY; YOUNGER THAN AGE 12 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE P No No No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 24 of 101

25 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF FOREIGN BODY UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; DIAG UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 25 of 101

26 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MUL No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 26 of 101

27 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDU SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE ) SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR W COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAU COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE T COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY F COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNI ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 27 of 101

28 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG, RUBBER BAND) ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE ) DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER S DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, LIGATION OF INTERNAL HEMORRHOIDS; MULTIPLE S BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE) INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY) INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON) CHANGE OF CYSTOSTOMY TUBE; SIMPLE BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME) SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 28 of 101

29 COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT) COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH URETHRAL PRESSURE PROFILE STUDIES (IE, URETHRAL CLOSURE PRESSUR COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE), ANY TE COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE) AND URE SIMPLE UROFLOWMETRY (UFR) (EG, STOP- WATCH FLOW RATE, MECHANICAL UROFLOWMETER) COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT) URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE PRESSURE PROFILE), ANY TECHNIQUE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF BULBOCAVERNOSUS REFLEX LATENCY TIME) VOIDING PRESSURE STUDIES (VP); BLADDER VOIDING PRESSURE, ANY TECHNIQUE No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 29 of 101

30 VOIDING PRESSURE STUDIES (VP); INTRA- ABDOMINAL VOIDING PRESSURE (AP) (RECTAL, GASTRIC, INTRAPERITONEAL) (LIST SEPARATELY I MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING CYSTOURETHROSCOPY (SEPARATE ) CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, UR CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESI CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; MALE CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL SYNDROME WITH ANY OR ALL OF THE FOLLOWING: URETHRAL MEATOTOMY, URET CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE ); TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE THERMOTHERAPY No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 30 of 101

31 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; NEONATE (28 DAYS OF AGE OR LESS) INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) (EG, PAPAVERINE, PHENTOLAMINE) FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE ), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S) BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS LYSIS OF LABIAL ADHESIONS DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 31 of 101

32 DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) BIOPSY OF VULVA OR PERINEUM (SEPARATE ); ONE LESION COLPOSCOPY OF THE VULVA; DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE ) IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT FOR TREATMENT OF BACTERIAL, PARASITIC, OR FUNGOID DISEASE INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE PELVIC EXAMINATION UNDER ANESTHESIA COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; No No No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 32 of 101

33 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURETTAGE COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE ) ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE) CAUTERY OF CERVIX; ELECTRO OR THERMAL CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT CAUTERY OF CERVIX; LASER ABLATION DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE ) ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), No No No No No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 33 of 101

34 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) REMOVAL OF INTRAUTERINE DEVICE (IUD) CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALP HYSTEROSCOPY, DIAGNOSTIC (SEPARATE ) HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION) HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS AMNIOCENTESIS; DIAGNOSTIC FETAL NON-STRESS TEST CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); GASSERIAN GANGLION No No No No No No No No No No No No No No No No No No No No authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 34 of 101

35 CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); TRIGEMINAL MEDULLARY TRACT PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1DAY INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL) authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 35 of 101

36 DECOMPRESSION, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, ANY METHOD UTILIZING NEEDLE BASED TECHNIQUE TO REMOVE DISC MATERIAL UNDER FLUOROSCOPIC IMAGING OR OTHER FORM OF INDIRECT VISUALIZATION, WITH THE USE OF AN ENDOSCOPE, WITH DISCOGRAPHY AND/OR EPIDURAL INJECTION(S) AT THE TREATED LEVEL(S), WHEN PERFORMED, SINGLE OR MULTIPLE LEVELS, LUMBAR INJECTION FOR DISCOGRAPHY, EACH LEVEL; LUMBAR INJECTION FOR DISCOGRAPHY, EACH LEVEL; CERVICAL OR THORACIC INJECTION FOR CHEMONUCLEOLYSIS, INCLUDING DISCOGRAPHY, INTERVERTEBRAL DISC, SINGLE OR MULTIPLE LEVELS, LUMBAR INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR authorization requirements. does not guarantee claims payment. All services and procedures are subject to benefit coverage, limitations, and exclusions as described in the applicable Plan coverage guidelines. (Effective April 1, 2012) Page 36 of 101