Carotid Sinus Nerve Stimulator (NCD 160.6)

Transcription

1 Policy Number Reimbursement Policy Approved By UnitedHealthcare Medicare Reimbursement Policy Committee Current Approval Date 05/28/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies use Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general resource regarding UnitedHealthcare s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee s benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT copyright 2010 (or such other date of publication of CPT) American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Table of Contents Application...1 Summary...2 Overview...2 Reimbursement Guidelines...2 CPT/HCPCS Codes...2 ICP/PCS Codes...2 References Included (but not limited to):...17 CMS NCD...17 CMS Benefit Policy Manual...17 UnitedHealthcare Medicare Advantage Coverage Summaries...17 Others...17 History...17 Application This reimbursement policy applies to services reported using the Health Insurance Claim Form CMS-1500 or its electronic equivalent or its successor form, and services reported using facility claim form CMS-1450 or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians, and other health care professionals. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing UnitedHealthcare. It is not enough to link the procedure code to a correct, payable Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 1

2 ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. Compliance with the provisions in this policy is subject to monitoring by pre-payment review and/or post-payment data analysis and subsequent medical review. The effective date of changes/additions/deletions to this policy is the committee meeting date unless otherwise indicated. CPT codes and descriptions are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS restrictions apply to Government use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Current Dental Terminology (CDT), including procedure codes, nomenclature, descriptors, and other data contained therein, is copyright by the American Dental Association, 2002, All rights reserved. CDT is a registered trademark of the American Dental Association. Applicable FARS/DFARS apply. Summary Overview Implantation of the carotid sinus nerve stimulator is indicated for relief of angina pectoris in carefully selected patients who are refractory to medical therapy and who after undergoing coronary angiography study either are poor candidates for or refuse to have coronary bypass surgery. In such cases, Medicare reimbursement may be made for this device and for the related services required for its implantation. Reimbursement Guidelines However, the use of the carotid sinus nerve stimulator in the treatment of paroxysmal supraventricular tachycardia is considered investigational and is not in common use by the medical community. The device and related services in such cases cannot be considered as reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member as required by 1862(a)(1) of the Act. CPT/HCPCS Codes Code Description Unlisted procedure, nervous system ICP/PCS Codes ICP Code Description PCS Code Description Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable 0JH60MZ 0JH63MZ 0JH70MZ 0JH73MZ 0JH80MZ 0JH83MZ into Chest Subcutaneous Tissue and Fascia, Open into Chest Subcutaneous Tissue and Fascia, Percutaneous into Back Subcutaneous Tissue and Fascia, Open into Back Subcutaneous Tissue and Fascia, Percutaneous into Abdomen Subcutaneous Tissue and Fascia, Open into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 2

3 03HK0MZ 03HK3MZ 03HK4MZ 03HL0MZ 03HL3MZ Insertion of Stimulator Lead into Right Internal Carotid Artery, Open Insertion of Stimulator Lead into Right Internal Carotid Artery, Percutaneous Insertion of Stimulator Lead into Right Internal Carotid Artery, Percutaneous Endoscopic Insertion of Stimulator Lead into Left Internal Carotid Artery, Open Insertion of Stimulator Lead into Left Internal Carotid Artery, Percutaneous Implantation or replacement of carotid sinus stimulation lead(s) only Implantation or replacement of carotid sinus stimulation pulse generator only 03HL4MZ 03HK0MZ 03HK3MZ 03HK4MZ 03HL0MZ 03HL3MZ 03HL4MZ 0JH60MZ 0JH63MZ 0JH70MZ 0JH73MZ Insertion of Stimulator Lead into Left Internal Carotid Artery, Percutaneous Endoscopic Insertion of Stimulator Lead into Right Internal Carotid Artery, Open Insertion of Stimulator Lead into Right Internal Carotid Artery, Percutaneous Insertion of Stimulator Lead into Right Internal Carotid Artery, Percutaneous Endoscopic Insertion of Stimulator Lead into Left Internal Carotid Artery, Open Insertion of Stimulator Lead into Left Internal Carotid Artery, Percutaneous Insertion of Stimulator Lead into Left Internal Carotid Artery, Percutaneous Endoscopic into Chest Subcutaneous Tissue and Fascia, Open into Chest Subcutaneous Tissue and Fascia, Percutaneous into Back Subcutaneous Tissue and Fascia, Open into Back Subcutaneous Tissue and Fascia, Percutaneous Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 3

4 39.84 Revision of carotid sinus stimulation lead(s) only Revision of carotid sinus stimulation pulse generator Removal of carotid sinus stimulation device, total system Removal of carotid sinus stimulation lead(s) only Removal of carotid sinus stimulation pulse generator only 0JH80MZ 0JH83MZ 03WY0MZ 03WY3MZ 03WY4MZ 0JWT0MZ 0JWT3MZ 0JWTXMZ 0JPT0MZ 0JPT3MZ 03PY0MZ 03PY3MZ 03PY4MZ 03PY0MZ 03PY3MZ 03PY4MZ 0JPT0MZ into Abdomen Subcutaneous Tissue and Fascia, Open into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Revision of Stimulator Lead in Upper Artery, Open Revision of Stimulator Lead in Upper Artery, Percutaneous Revision of Stimulator Lead in Upper Artery, Percutaneous Endoscopic Revision of Stimulator Generator in Trunk Subcutaneous Tissue and Fascia, Open Revision of Stimulator Generator in Trunk Subcutaneous Tissue and Fascia, Percutaneous Revision of Stimulator Generator in Trunk Subcutaneous Tissue and Fascia, External Removal of Stimulator Generator from Trunk Subcutaneous Tissue and Fascia, Open Removal of Stimulator Generator from Trunk Subcutaneous Tissue and Fascia, Percutaneous Removal of Stimulator Lead from Upper Artery, Open Removal of Stimulator Lead from Upper Artery, Percutaneous Removal of Stimulator Lead from Upper Artery, Percutaneous Endoscopic Removal of Stimulator Lead from Upper Artery, Open Removal of Stimulator Lead from Upper Artery, Percutaneous Removal of Stimulator Lead from Upper Artery, Percutaneous Endoscopic Removal of Stimulator Generator from Trunk Subcutaneous Tissue and Fascia, Open Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 4

5 39.89 Other operations on carotid body, carotid sinus and other vascular bodies 0JPT3MZ 0G560ZZ 0G563ZZ 0G564ZZ 0G570ZZ 0G573ZZ 0G574ZZ 0G580ZZ 0G583ZZ 0G584ZZ 0G590ZZ 0G593ZZ 0G594ZZ 0G5B0ZZ 0G5B3ZZ 0G5B4ZZ 0G5C0ZZ 0G5C3ZZ 0G5C4ZZ 0G5D0ZZ 0G5D3ZZ 0G5D4ZZ Removal of Stimulator Generator from Trunk Subcutaneous Tissue and Fascia, Percutaneous Destruction of Left Carotid Body, Open Destruction of Left Carotid Body, Percutaneous Destruction of Left Carotid Body, Percutaneous Endoscopic Destruction of Right Carotid Body, Open Destruction of Right Carotid Body, Percutaneous Destruction of Right Carotid Body, Percutaneous Endoscopic Destruction of Bilateral Carotid Bodies, Open Destruction of Bilateral Carotid Bodies, Percutaneous Destruction of Bilateral Carotid Bodies, Percutaneous Endoscopic Destruction of Para-aortic Body, Open Destruction of Para-aortic Body, Percutaneous Destruction of Para-aortic Body, Percutaneous Endoscopic Destruction of Coccygeal Glomus, Open Destruction of Coccygeal Glomus, Percutaneous Destruction of Coccygeal Glomus, Percutaneous Endoscopic Destruction of Glomus Jugulare, Open Destruction of Glomus Jugulare, Percutaneous Destruction of Glomus Jugulare, Percutaneous Endoscopic Destruction of Aortic Body, Open Destruction of Aortic Body, Percutaneous Destruction of Aortic Body, Percutaneous Endoscopic Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 5

6 0G5F0ZZ 0G5F3ZZ 0G5F4ZZ 0G9600Z 0G960ZX 0G960ZZ 0G9630Z 0G963ZX 0G963ZZ 0G9640Z 0G964ZX 0G964ZZ 0G9700Z 0G970ZX 0G970ZZ 0G9730Z 0G973ZX 0G973ZZ 0G9740Z 0G974ZX Destruction of Paraganglion Extremity, Open Destruction of Paraganglion Extremity, Percutaneous Destruction of Paraganglion Extremity, Percutaneous Endoscopic Drainage of Left Carotid Body with Drainage Device, Open Drainage of Left Carotid Body, Open, Drainage of Left Carotid Body, Open Drainage of Left Carotid Body with Drainage of Left Carotid Body, Percutaneous, Drainage of Left Carotid Body, Percutaneous Drainage of Left Carotid Body with Endoscopic Drainage of Left Carotid Body, Percutaneous Endoscopic, Drainage of Left Carotid Body, Percutaneous Endoscopic Drainage of Right Carotid Body with Drainage Device, Open Drainage of Right Carotid Body, Open, Drainage of Right Carotid Body, Open Drainage of Right Carotid Body with Drainage of Right Carotid Body, Percutaneous, Drainage of Right Carotid Body, Percutaneous Drainage of Right Carotid Body with Endoscopic Drainage of Right Carotid Body, Percutaneous Endoscopic, Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 6

7 0G974ZZ 0G9800Z 0G980ZX 0G980ZZ 0G9830Z 0G983ZX 0G983ZZ 0G9840Z 0G984ZX 0G984ZZ 0G9900Z 0G990ZX 0G990ZZ 0G9930Z 0G993ZX 0G993ZZ 0G9940Z 0G994ZX 0G994ZZ 0G9B00Z Drainage of Right Carotid Body, Percutaneous Endoscopic Drainage of Bilateral Carotid Bodies with Drainage Device, Open Drainage of Bilateral Carotid Bodies, Open, Drainage of Bilateral Carotid Bodies, Open Drainage of Bilateral Carotid Bodies with Drainage of Bilateral Carotid Bodies, Percutaneous, Drainage of Bilateral Carotid Bodies, Percutaneous Drainage of Bilateral Carotid Bodies with Endoscopic Drainage of Bilateral Carotid Bodies, Percutaneous Endoscopic, Drainage of Bilateral Carotid Bodies, Percutaneous Endoscopic Drainage of Para-aortic Body with Drainage Device, Open Drainage of Para-aortic Body, Open, Drainage of Para-aortic Body, Open Drainage of Para-aortic Body with Drainage of Para-aortic Body, Percutaneous, Drainage of Para-aortic Body, Percutaneous Drainage of Para-aortic Body with Endoscopic Drainage of Para-aortic Body, Percutaneous Endoscopic, Drainage of Para-aortic Body, Percutaneous Endoscopic Drainage of Coccygeal Glomus with Drainage Device, Open Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 7

8 0G9B0ZX 0G9B0ZZ 0G9B30Z 0G9B3ZX 0G9B3ZZ 0G9B40Z 0G9B4ZX 0G9B4ZZ 0G9C00Z 0G9C0ZX 0G9C0ZZ 0G9C30Z 0G9C3ZX 0G9C3ZZ 0G9C40Z 0G9C4ZX 0G9C4ZZ 0G9D00Z 0G9D0ZX 0G9D0ZZ Drainage of Coccygeal Glomus, Open, Drainage of Coccygeal Glomus, Open Drainage of Coccygeal Glomus with Drainage of Coccygeal Glomus, Percutaneous, Drainage of Coccygeal Glomus, Percutaneous Drainage of Coccygeal Glomus with Endoscopic Drainage of Coccygeal Glomus, Percutaneous Endoscopic, Drainage of Coccygeal Glomus, Percutaneous Endoscopic Drainage of Glomus Jugulare with Drainage Device, Open Drainage of Glomus Jugulare, Open, Drainage of Glomus Jugulare, Open Drainage of Glomus Jugulare with Drainage of Glomus Jugulare, Percutaneous, Drainage of Glomus Jugulare, Percutaneous Drainage of Glomus Jugulare with Endoscopic Drainage of Glomus Jugulare, Percutaneous Endoscopic, Drainage of Glomus Jugulare, Percutaneous Endoscopic Drainage of Aortic Body with Drainage Device, Open Drainage of Aortic Body, Open, Drainage of Aortic Body, Open Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 8

9 0G9D30Z 0G9D3ZX 0G9D3ZZ 0G9D40Z 0G9D4ZX 0G9D4ZZ 0G9F00Z 0G9F0ZX 0G9F0ZZ 0G9F30Z 0G9F3ZX 0G9F3ZZ 0G9F40Z 0G9F4ZX 0G9F4ZZ 0GB60ZX 0GB60ZZ 0GB63ZX 0GB63ZZ 0GB64ZX Drainage of Aortic Body with Drainage of Aortic Body, Percutaneous, Drainage of Aortic Body, Percutaneous Drainage of Aortic Body with Endoscopic Drainage of Aortic Body, Percutaneous Endoscopic, Drainage of Aortic Body, Percutaneous Endoscopic Drainage of Paraganglion Extremity with Drainage Device, Open Drainage of Paraganglion Extremity, Open, Drainage of Paraganglion Extremity, Open Drainage of Paraganglion Extremity with Drainage of Paraganglion Extremity, Percutaneous, Drainage of Paraganglion Extremity, Percutaneous Drainage of Paraganglion Extremity with Endoscopic Drainage of Paraganglion Extremity, Percutaneous Endoscopic, Drainage of Paraganglion Extremity, Percutaneous Endoscopic Excision of Left Carotid Body, Open, Excision of Left Carotid Body, Open Excision of Left Carotid Body, Percutaneous, Excision of Left Carotid Body, Percutaneous Excision of Left Carotid Body, Percutaneous Endoscopic, Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 9

10 0GB64ZZ 0GB70ZX 0GB70ZZ 0GB73ZX 0GB73ZZ 0GB74ZX 0GB74ZZ 0GB80ZX 0GB80ZZ 0GB83ZX 0GB83ZZ 0GB84ZX 0GB84ZZ 0GB90ZX 0GB90ZZ 0GB93ZX 0GB93ZZ 0GB94ZX 0GB94ZZ 0GBB0ZX 0GBB0ZZ 0GBB3ZX Excision of Left Carotid Body, Percutaneous Endoscopic Excision of Right Carotid Body, Open, Excision of Right Carotid Body, Open Excision of Right Carotid Body, Percutaneous, Excision of Right Carotid Body, Percutaneous Excision of Right Carotid Body, Percutaneous Endoscopic, Excision of Right Carotid Body, Percutaneous Endoscopic Excision of Bilateral Carotid Bodies, Open, Excision of Bilateral Carotid Bodies, Open Excision of Bilateral Carotid Bodies, Percutaneous, Excision of Bilateral Carotid Bodies, Percutaneous Excision of Bilateral Carotid Bodies, Percutaneous Endoscopic, Excision of Bilateral Carotid Bodies, Percutaneous Endoscopic Excision of Para-aortic Body, Open, Excision of Para-aortic Body, Open Excision of Para-aortic Body, Percutaneous, Excision of Para-aortic Body, Percutaneous Excision of Para-aortic Body, Percutaneous Endoscopic, Excision of Para-aortic Body, Percutaneous Endoscopic Excision of Coccygeal Glomus, Open, Excision of Coccygeal Glomus, Open Excision of Coccygeal Glomus, Percutaneous, Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 10

11 0GBB3ZZ 0GBB4ZX 0GBB4ZZ 0GBC0ZX 0GBC0ZZ 0GBC3ZX 0GBC3ZZ 0GBC4ZX 0GBC4ZZ 0GBD0ZX 0GBD0ZZ 0GBD3ZX 0GBD3ZZ 0GBD4ZX 0GBD4ZZ 0GBF0ZX 0GBF0ZZ 0GBF3ZX 0GBF3ZZ 0GBF4ZX 0GBF4ZZ Excision of Coccygeal Glomus, Percutaneous Excision of Coccygeal Glomus, Percutaneous Endoscopic, Excision of Coccygeal Glomus, Percutaneous Endoscopic Excision of Glomus Jugulare, Open, Excision of Glomus Jugulare, Open Excision of Glomus Jugulare, Percutaneous, Excision of Glomus Jugulare, Percutaneous Excision of Glomus Jugulare, Percutaneous Endoscopic, Excision of Glomus Jugulare, Percutaneous Endoscopic Excision of Aortic Body, Open, Excision of Aortic Body, Open Excision of Aortic Body, Percutaneous, Excision of Aortic Body, Percutaneous Excision of Aortic Body, Percutaneous Endoscopic, Excision of Aortic Body, Percutaneous Endoscopic Excision of Paraganglion Extremity, Open, Excision of Paraganglion Extremity, Open Excision of Paraganglion Extremity, Percutaneous, Excision of Paraganglion Extremity, Percutaneous Excision of Paraganglion Extremity, Percutaneous Endoscopic, Excision of Paraganglion Extremity, Percutaneous Endoscopic Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 11

12 0GJS0ZZ 0GJS3ZZ 0GJS4ZZ 0GN60ZZ 0GN63ZZ 0GN64ZZ 0GN70ZZ 0GN73ZZ 0GN74ZZ 0GN80ZZ 0GN83ZZ 0GN84ZZ 0GN90ZZ 0GN93ZZ 0GN94ZZ 0GNB0ZZ 0GNB3ZZ 0GNB4ZZ 0GNC0ZZ 0GNC3ZZ 0GNC4ZZ 0GND0ZZ 0GND3ZZ 0GND4ZZ Inspection of Endocrine Gland, Open Inspection of Endocrine Gland, Percutaneous Inspection of Endocrine Gland, Percutaneous Endoscopic Release Left Carotid Body, Open Release Left Carotid Body, Percutaneous Release Left Carotid Body, Percutaneous Endoscopic Release Right Carotid Body, Open Release Right Carotid Body, Percutaneous Release Right Carotid Body, Percutaneous Endoscopic Release Bilateral Carotid Bodies, Open Release Bilateral Carotid Bodies, Percutaneous Release Bilateral Carotid Bodies, Percutaneous Endoscopic Release Para-aortic Body, Open Release Para-aortic Body, Percutaneous Release Para-aortic Body, Percutaneous Endoscopic Release Coccygeal Glomus, Open Release Coccygeal Glomus, Percutaneous Release Coccygeal Glomus, Percutaneous Endoscopic Release Glomus Jugulare, Open Release Glomus Jugulare, Percutaneous Release Glomus Jugulare, Percutaneous Endoscopic Release Aortic Body, Open Release Aortic Body, Percutaneous Release Aortic Body, Percutaneous Endoscopic Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 12

13 0GNF0ZZ 0GNF3ZZ 0GNF4ZZ 0GQ60ZZ 0GQ63ZZ 0GQ64ZZ 0GQ70ZZ 0GQ73ZZ 0GQ74ZZ 0GQ80ZZ 0GQ83ZZ 0GQ84ZZ 0GQ90ZZ 0GQ93ZZ 0GQ94ZZ 0GQB0ZZ 0GQB3ZZ 0GQB4ZZ 0GQC0ZZ 0GQC3ZZ 0GQC4ZZ 0GQD0ZZ 0GQD3ZZ 0GQD4ZZ Release Paraganglion Extremity, Open Release Paraganglion Extremity, Percutaneous Release Paraganglion Extremity, Percutaneous Endoscopic Repair Left Carotid Body, Open Repair Left Carotid Body, Percutaneous Repair Left Carotid Body, Percutaneous Endoscopic Repair Right Carotid Body, Open Repair Right Carotid Body, Percutaneous Repair Right Carotid Body, Percutaneous Endoscopic Repair Bilateral Carotid Bodies, Open Repair Bilateral Carotid Bodies, Percutaneous Repair Bilateral Carotid Bodies, Percutaneous Endoscopic Repair Para-aortic Body, Open Repair Para-aortic Body, Percutaneous Repair Para-aortic Body, Percutaneous Endoscopic Repair Coccygeal Glomus, Open Repair Coccygeal Glomus, Percutaneous Repair Coccygeal Glomus, Percutaneous Endoscopic Repair Glomus Jugulare, Open Repair Glomus Jugulare, Percutaneous Repair Glomus Jugulare, Percutaneous Endoscopic Repair Aortic Body, Open Repair Aortic Body, Percutaneous Repair Aortic Body, Percutaneous Endoscopic Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 13

14 0GQF0ZZ 0GQF3ZZ 0GQF4ZZ 0GT60ZZ 0GT64ZZ 0GT70ZZ 0GT74ZZ 0GT80ZZ 0GT84ZZ 0GT90ZZ 0GT94ZZ 0GTB0ZZ 0GTB4ZZ 0GTC0ZZ 0GTC4ZZ 0GTD0ZZ 0GTD4ZZ 0GTF0ZZ 0GTF4ZZ 0GC60ZZ 0GC63ZZ 0GC64ZZ Repair Paraganglion Extremity, Open Repair Paraganglion Extremity, Percutaneous Repair Paraganglion Extremity, Percutaneous Endoscopic Resection of Left Carotid Body, Open Resection of Left Carotid Body, Percutaneous Endoscopic Resection of Right Carotid Body, Open Resection of Right Carotid Body, Percutaneous Endoscopic Resection of Bilateral Carotid Bodies, Open Resection of Bilateral Carotid Bodies, Percutaneous Endoscopic Resection of Para-aortic Body, Open Resection of Para-aortic Body, Percutaneous Endoscopic Resection of Coccygeal Glomus, Open Resection of Coccygeal Glomus, Percutaneous Endoscopic Resection of Glomus Jugulare, Open Resection of Glomus Jugulare, Percutaneous Endoscopic Resection of Aortic Body, Open Resection of Aortic Body, Percutaneous Endoscopic Resection of Paraganglion Extremity, Open Resection of Paraganglion Extremity, Percutaneous Endoscopic Extirpation of Matter from Left Carotid Body, Open Extirpation of Matter from Left Carotid Body, Percutaneous Extirpation of Matter from Left Carotid Body, Percutaneous Endoscopic Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 14

15 0GC70ZZ 0GC73ZZ 0GC74ZZ 0GC80ZZ 0GC83ZZ 0GC84ZZ 0GC90ZZ 0GC93ZZ 0GC94ZZ 0GCB0ZZ 0GCB3ZZ 0GCB4ZZ 0GCC0ZZ 0GCC3ZZ 0GCC4ZZ 0GCD0ZZ 0GCD3ZZ 0GCD4ZZ 0GCF0ZZ Extirpation of Matter from Right Carotid Body, Open Extirpation of Matter from Right Carotid Body, Percutaneous Extirpation of Matter from Right Carotid Body, Percutaneous Endoscopic Extirpation of Matter from Bilateral Carotid Bodies, Open Extirpation of Matter from Bilateral Carotid Bodies, Percutaneous Extirpation of Matter from Bilateral Carotid Bodies, Percutaneous Endoscopic Extirpation of Matter from Paraaortic Body, Open Extirpation of Matter from Paraaortic Body, Percutaneous Extirpation of Matter from Paraaortic Body, Percutaneous Endoscopic Extirpation of Matter from Coccygeal Glomus, Open Extirpation of Matter from Coccygeal Glomus, Percutaneous Extirpation of Matter from Coccygeal Glomus, Percutaneous Endoscopic Extirpation of Matter from Glomus Jugulare, Open Extirpation of Matter from Glomus Jugulare, Percutaneous Extirpation of Matter from Glomus Jugulare, Percutaneous Endoscopic Extirpation of Matter from Aortic Body, Open Extirpation of Matter from Aortic Body, Percutaneous Extirpation of Matter from Aortic Body, Percutaneous Endoscopic Extirpation of Matter from Paraganglion Extremity, Open Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 15

16 0GCF3ZZ 0GCF4ZZ 0GHS02Z 0GHS03Z 0GHS32Z 0GHS33Z 0GHS42Z 0GHS43Z 0GPS00Z 0GPS02Z 0GPS03Z 0GPS30Z 0GPS32Z 0GPS33Z 0GPS40Z 0GPS42Z 0GPS43Z 0GWS00Z Extirpation of Matter from Paraganglion Extremity, Percutaneous Extirpation of Matter from Paraganglion Extremity, Percutaneous Endoscopic Insertion of Monitoring Device into Endocrine Gland, Open Insertion of Infusion Device into Endocrine Gland, Open Insertion of Monitoring Device into Insertion of Infusion Device into Insertion of Monitoring Device into Endoscopic Insertion of Infusion Device into Endoscopic Removal of Drainage Device from Endocrine Gland, Open Removal of Monitoring Device from Endocrine Gland, Open Removal of Infusion Device from Endocrine Gland, Open Removal of Drainage Device from Removal of Monitoring Device from Removal of Infusion Device from Removal of Drainage Device from Endoscopic Removal of Monitoring Device from Endoscopic Removal of Infusion Device from Endoscopic Revision of Drainage Device in Endocrine Gland, Open Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 16

17 0GWS02Z 0GWS03Z 0GWS30Z 0GWS32Z 0GWS33Z 0GWS40Z Revision of Monitoring Device in Endocrine Gland, Open Revision of Infusion Device in Endocrine Gland, Open Revision of Drainage Device in Revision of Monitoring Device in Revision of Infusion Device in Revision of Drainage Device in Endoscopic 0GWS42Z Revision of Monitoring Device in Endoscopic 0GWS43Z Revision of Infusion Device in Endoscopic References Included (but not limited to): CMS NCD NCD Carotid Sinus Nerve Stimulator CMS Benefit Policy Manual Chapter 15 Covered Medical and Other Health Services UnitedHealthcare Medicare Advantage Coverage Summaries Carotid Procedures and Testing Others Social Security Act (Title XVIII): 1862(a)(1), U.S. Social Security Administration Website History Date Revisions 05/28/14 Annual review, no changes 05/22/13 A2970 and L8499 expired and no longer applicable to this policy Administrative updates Proprietary information of UnitedHealthcare. Copyright 2014 United HealthCare Services, Inc. Page 17